[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1781 Introduced in Senate (IS)]
111th CONGRESS
1st Session
S. 1781
To provide for a demonstration program to reduce frequent use of health
services by Medicaid beneficiaries with chronic illnesses by providing
coordinated care management and community support services.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
October 14, 2009
Mrs. Shaheen (for herself, Mr. Brown, and Mr. Menendez) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To provide for a demonstration program to reduce frequent use of health
services by Medicaid beneficiaries with chronic illnesses by providing
coordinated care management and community support services.
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 ``Reducing Emergency Department
Utilization through Coordination and Empowerment Demonstration Program
Act'' or the ``REDUCE Demonstration Program''.
SEC. 2. DEFINITIONS.
In this Act:
(1) Chronic condition.--The term ``chronic condition''
means a chronic medical condition that is life-threatening or
may result in permanent disability, including--
(A) asthma;
(B) cancer;
(C) chronic obstructive pulmonary disease;
(D) congestive heart failure or arrhythmia;
(E) diabetes;
(F) HIV/AIDS;
(G) liver disease;
(H) post-traumatic stress disorder;
(I) renal failure;
(J) rheumatologic disease;
(K) severe mental illness;
(L) substance abuse disorder;
(M) thromboembolic disease;
(N) traumatic brain injury resulting in cognitive
impairment;
(O) chronic pain; and
(P) any other chronic medical condition that has
been identified by a State and approved by the
Secretary for inclusion under the REDUCE demonstration
program.
(2) Frequent user of health services.--The term ``frequent
user of health services'' means an individual who uses the
emergency department, is admitted to the hospital, or uses
other inpatient services frequently.
(3) Medicaid.--The term ``Medicaid'' means the Federal and
State medical assistance program established under title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.).
(4) Participating state.--The term ``participating State''
means a State with an approved application (as described in
section 3(b)(1)) that has entered into an agreement with the
Secretary to conduct a REDUCE demonstration program.
(5) REDUCE demonstration program.--The term ``REDUCE
demonstration program'' means a program described in section 3
that is conducted pursuant to an agreement between the
Secretary and a participating State.
(6) Safety net hospital.--The term ``safety net hospital''
means a hospital with a low-income utilization rate greater
than 25 percent (as defined under section 1923(b)(3) of the
Social Security Act (42 U.S.C. 1396r-4(b)(3)));
(7) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(8) State.--The term ``State'' has the meaning given that
term for purposes of Medicaid.
(9) Targeted medicaid beneficiary.--
(A) In general.--The term ``targeted Medicaid
beneficiary'' means an individual who has--
(i) attained age 19 and is eligible for
medical assistance under a State plan or waiver
under Medicaid;
(ii) been diagnosed with 2 or more chronic
conditions;
(iii) been identified by a participating
State as a frequent user of health services;
and
(iv) been identified by a participating
State as likely to benefit from participation
in the REDUCE demonstration program (pursuant
to the needs-based criteria described in
section 3(c)(3)).
(B) Voluntary participation.--A targeted Medicaid
beneficiary may participate in the REDUCE demonstration
program on a voluntary basis and may terminate
participation at any time.
SEC. 3. REDUCE DEMONSTRATION PROGRAM.
(a) In General.--The Secretary shall establish the REDUCE
demonstration program under which the Secretary shall enter into
agreements with States to provide for the development, implementation,
and evaluation of innovative approaches to coordinated care management
and increased access to community support services for targeted
Medicaid beneficiaries in order to reduce hospital admissions and the
use of emergency health care services.
(b) Application and Agreements.--
(1) Application.--A State seeking to participate in the
REDUCE demonstration program shall submit to the Secretary, in
such form and manner as the Secretary shall require, an
application that, in addition to such other information as the
Secretary may require, contains--
(A) a description of the proposed demonstration
program, including the information specified in
paragraphs (2) through (4) of subsection (c); and
(B) a plan for ensuring continuity of services for
targeted Medicaid beneficiaries who are participating
in the program on such date that the demonstration
program ceases to be conducted in the State.
(2) Agreement.--
(A) In general.--Not later than 12 months after the
date of enactment of this Act, the Secretary shall
enter into agreements with not more than 10 States to
conduct the REDUCE demonstration program in accordance
with the requirements of this section.
(B) Duration.--An agreement entered into by the
Secretary and a State to conduct a REDUCE demonstration
program shall be for a period of 5 years.
(c) Demonstration Program Requirements.--
(1) Individualized care plans.--
(A) In general.--A REDUCE demonstration program
shall be designed to improve the health outcomes for
targeted Medicaid beneficiaries participating in the
program, reduce hospital admissions and frequent usage
of emergency care services, and reduce associated costs
under Medicaid by--
(i) identifying health care providers that
provide integration of primary care and
behavioral health services through co-location
of such services or use of multi-disciplinary
integrated treatment teams that work
collaboratively to provide comprehensive and
evidence-based treatment, rehabilitation, and
support services for targeted Medicaid
beneficiaries;
(ii) providing targeted Medicaid
beneficiaries with an individualized care plan
(developed in consultation with the beneficiary
and the beneficiary's support staff, medical
care providers, and family) that provides for
flexible services that are based on an
examination of the beneficiary's individual
care needs (as determined through application
of needs-based criteria under paragraph (3));
and
(iii) providing access to a care management
team that--
(I) includes, at a minimum--
(aa) a physician, physician
assistant, or nurse
practitioner;
(bb) a social worker; and
(cc) a community health
worker (as licensed or defined
by the participating State);
and
(II) provides health care services,
coordination of primary and specialty
care, and assistance with social
services in a home or shelter setting.
(B) Physician, physician assistant, or nurse
practitioner.--For purposes of the care management team
described under subparagraph (A)(iii), such team shall
include a physician or, if a physician is not
available, a physician assistant or nurse practitioner
who may provide such health care services as are within
their authorized scope of practice (as determined by
the participating State).
(C) Best practices.--Delivery of health care
services provided pursuant to an individualized care
plan (as described in subparagraph (A)(ii)) shall be
determined based upon best practices and research
regarding--
(i) effective strategies for improving
health outcomes (including behavioral health
outcomes) and quality of life; and
(ii) cost-effective methods for delivery of
health care services.
(2) State plan and projections.--
(A) In general.--A participating State shall
provide the Secretary with a proposal for the
development and implementation of the REDUCE
demonstration program that includes--
(i) a projection of the number of targeted
Medicaid beneficiaries that the State expects
to participate in the REDUCE demonstration
program; and
(ii) identification of targeted Medicaid
beneficiaries through individual assessment and
analysis of data from Medicaid claims, hospital
records, or other informational sources to
identify beneficiaries that have--
(I) engaged in frequent use of
emergency, inpatient, or crisis
services; or
(II) exhibited identified risk
factors that indicate the probability
of frequent use of emergency,
inpatient, or crisis services;
(iii) a strategy for outreach to targeted
Medicaid beneficiaries to provide
individualized health care services in order to
reduce hospital admissions and prevent frequent
use of emergency, inpatient, or crisis
services; and
(iv) criteria for selection of health care
providers (including behavioral health care
providers) that have demonstrated their
experience and capacity to effectively engage
and serve individuals that--
(I) have been diagnosed with 2 or
more chronic conditions; or
(II) exhibit other risk factors
identified by the State.
(B) Gainsharing.--Subject to approval by the
Secretary, a participating State may develop and
establish a gainsharing arrangement among health care
providers participating in the REDUCE demonstration
program to allow such providers to retain a share of
any savings generated through the demonstration program
in order to encourage improved outcomes and increased
efficiency.
(C) Limitation.--A participating State may, on a
statewide or regional basis, provide for a limit on the
total number of targeted Medicaid beneficiaries that
may be eligible for services under the REDUCE
demonstration program and may establish a waiting list
for such services.
(D) Priority considerations.--
(i) In general.--In reviewing criteria
established by a participating State for
selection of health care providers (as
described in subparagraph (A)(iv)), the
Secretary shall give priority to a State that
includes in such selection--
(I) safety net providers, including
public hospitals, federally qualified
health centers (as described under
section 1905(l)(2)(B) of the Social
Security Act (42 U.S.C.
1396d(i)(2)(B))), and community mental
health centers (as described under
section 1861(ff)(3)(B) of such Act (42
U.S.C. 1395x(ff)(3)(B)));
(II) health provider coalitions
that--
(aa) have a geographic,
community-based focus;
(bb) are based out of--
(AA) a federally
qualified health
center;
(BB) an university
or academic medical
center;
(CC) a hospital
(including a safety net
hospital);
(DD) a private
entity whose purpose is
to improve access to
community health care
services for high-risk
individuals and those
requiring primary care
services; or
(EE) a similar
organization; and
(cc) have agreements with
not less than 2 hospitals, a
housing agency, a mental health
provider, and not less than 2
primary care physicians within
the local community; and
(III) programs that have
demonstrated a capacity to share,
combine, and analyze health data for
frequent users of health services
through data sharing agreements with
multiple local health institutions.
(ii) Reimbursement.--The Secretary shall
not waive any requirements under title XIX of
the Social Security Act relating to services
provided by, or reimbursement provided to,
federally qualified health centers for purposes
of the REDUCE demonstration program. To the
extent that participation by a federally
qualified health center or safety net hospital
in the REDUCE demonstration program requires
the center or hospital to provide services that
are not covered under the State plan, the
participating State shall be required to fully
reimburse the center or hospital for the cost
of such services.
(3) Needs-based criteria.--A participating State shall
establish needs-based criteria for determining the eligibility
of individuals for participation in the REDUCE demonstration
program. The criteria shall provide for consideration of an
individual's medical history, including--
(A) the number and severity of chronic conditions;
(B) functional impairments;
(C) care and support needs;
(D) any recent patterns of excessive utilization of
emergency or inpatient care in a hospital or similar
facility; and
(E) other factors which the State determines are
associated with increased hospital admissions or
frequent utilization of emergency, inpatient, or crisis
services (including housing status and other social
determinants of health status).
(4) Covered services.--
(A) In general.--A participating State shall
provide the Secretary with a comprehensive list of
services that shall be available to targeted Medicaid
beneficiaries under the REDUCE demonstration program.
Such services shall be established and targeted to
reduce frequent utilization of health services by
targeted Medicaid beneficiaries.
(B) Additional services.--Upon request by the State
and subject to approval by the Secretary, a
participating State may provide additional services
under the demonstration program that are not covered
under the State plan upon a showing that such services
will reduce avoidable utilization of health services by
targeted Medicaid beneficiaries.
(d) Waiver.--Except as provided in subsection (c)(2)(D)(ii), the
Secretary may waive such requirements of titles XI, XVIII, and XIX of
the Social Security Act as the Secretary determines necessary for a
participating State to conduct the REDUCE demonstration program.
SEC. 4. EVALUATION AND REPORT.
(a) Evaluation.--
(1) In general.--Subject to paragraph (2), the Secretary
shall, by grant, contract, or interagency agreement, provide
for an evaluation of the REDUCE demonstration programs
conducted by participating States under this Act, including an
assessment of whether the demonstration programs--
(A) reduce avoidable hospitalizations or other
institutional admissions (including at intermediate
care facilities for the mentally retarded or nursing
facilities);
(B) reduce the use of ambulances, hospital
emergency health services, detoxification treatments,
or emergency mental health services;
(C) reduce expenditures under the Medicaid program;
and
(D) improve the overall health status and
satisfaction of the targeted Medicaid beneficiaries
participating in the program (including improvements in
housing status and other social determinants of health
status).
(2) Evaluation requirements.--The evaluation shall be
conducted by an entity that has demonstrated experience with
care improvement programs. Such evaluation shall be conducted
on an ongoing basis throughout the duration of the
demonstration program.
(b) Report.--Not later than 12 months after completion of all
REDUCE demonstration programs conducted by participating States under
this Act, the Secretary shall prepare and submit a final report on the
results of the evaluation to Congress that contains recommendations for
such legislative and administrative actions as the Secretary determines
appropriate to develop additional programs to provide coordinated care
for individuals with complex medical and behavioral health conditions
and reduce avoidable hospital readmissions and the use of emergency
health care services.
SEC. 5. FUNDING.
(a) Manner of Payment.--The Secretary shall pay each participating
State a quarterly payment for expenditures for providing a covered
service (as specified in section 3(c)(4)) to targeted Medicaid
beneficiaries that participate in the REDUCE demonstration program
conducted by the State. Such payments shall be made in the same manner
as other quarterly payments are made to the State under section 1903(a)
of the Social Security Act (42 U.S.C. 1396b(a)).
(b) Matching Rate.--Subject to subsection (c), the Secretary shall
pay a participating State for State expenditures described in
subsection (a)--
(1) for fiscal years 2011 or 2012, 100 percent of the
amount of such expenditures for the fiscal year; and
(2) for fiscal years 2013, 2014, or 2015, 75 percent of the
amount of such expenditures for the fiscal year.
(c) Limitation on Funds.--The total amount of payments under this
Act shall not exceed $150,000,000 for the period of fiscal years 2011
through 2015.
(d) Appropriation.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the Secretary
to carry out this Act, $150,000,000 for the period of fiscal
years 2011 through 2015, of which $15,000,000 shall be used for
the evaluation required under section 4.
(2) Budget authority.--This Act constitutes budget
authority in advance of appropriations Acts and represents the
obligation of the Secretary to provide for the payment of
amounts provided under this Act.
<all>