[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6413 Introduced in House (IH)]

112th CONGRESS
  2d Session
                                H. R. 6413

 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 HOUSE OF REPRESENTATIVES

                           September 14, 2012

     Mr. Blumenauer (for himself, Mr. Petri, Ms. Schwartz, and Ms. 
 Schakowsky) introduced the following bill; which was referred to the 
 Committee on Energy and Commerce, and in addition to the Committee on 
   Ways and Means, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 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 
2012''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) More than 20 percent of older Americans suffer from 5 
        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 during transitions from 
        one care setting to another contributes to poor continuity of 
        care, inadequate management of complex health care needs, 
        medication errors, and preventable hospital readmissions. These 
        failures create serious patient safety, quality of care, and 
        health outcome concerns.
            (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 5 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) The Medicare Payment Advisory Commission estimates that 
        hospital readmissions cost Medicare approximately $15 billion 
        per year, $12 billion of which is for cases considered 
        preventable.
            (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) There are a number of care models that are designed to 
        enhance coordination during transitions from care settings, 
        including--
                    (A) the Transitional Care Model;
                    (B) the Care Transitions Intervention;
                    (C) the Guided Care Model;
                    (D) Project Boost;
                    (E) Project Re-Engineered Discharge; and
                    (F) the Enhanced Discharge Planning Program.
            (9) These care models and others have demonstrated that 
        effective care transitions lead to improvements in overall 
        health care quality and result in savings to patients and the 
        United States health care system.
            (10) 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. 
        This 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) The Care Transitions Intervention, developed by Eric 
        Coleman, is primarily a transitions self-management model that 
        provides coaching, skills, and tools to help patients and 
        caregivers assert a more active role during transitions. This 
        intervention has demonstrated lower rehospitalization rates and 
        lower hospital costs per patient.
            (12) The National Transitions of Care Coalition has 
        developed the Transition of Care Compendium, providing a 
        centralized resource for providers to access all currently 
        available evidence-based interventions and tools.

SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE SERVICES.

    (a) Coverage.--Section 1861 of the Social Security Act (42 U.S.C. 
1395x) is amended--
            (1) in subsection (s)(2)--
                    (A) by striking ``and'' at the end of subparagraph 
                (EE);
                    (B) by adding ``and'' at the end of subparagraph 
                (FF); and
                    (C) by inserting after subparagraph (FF) the 
                following new subparagraph:
            ``(GG) transitional care services (as defined in subsection 
        (iii)(1));''; and
            (2) by adding at the end the following new subsection:

                      ``Transitional Care Services

    ``(iii)(1) The term `transitional care services' means services 
described in paragraph (2) furnished to a qualified individual 
(described in paragraph (3)) by a transitional care clinician (as 
defined in paragraph (4)) acting as an employee of (or pursuant to a 
contract with) a qualified transitional care entity (as defined in 
paragraph (5)) during the transitional care period (as defined in 
paragraph (6)) for the qualified individual.
    ``(2) The services described in this paragraph are services that 
support a qualified individual during the transitional care period and 
include the following:
            ``(A) A comprehensive assessment of the individual prior to 
        the individual's transition from one care facility to another 
        care facility or home, 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.
            ``(B) Development of a comprehensive, evidenced-based plan 
        of 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.
            ``(C) Development of a comprehensive medications management 
        plan that ensures the safe use of medications and is based on 
        the individual's plan of care. Such management plan shall 
        include the following:
                    ``(i) Identification of individual's medications in 
                use (including prescription and non-prescription 
                medications).
                    ``(ii) Assessment and (if needed) consultation with 
                key medical providers to ensure medications are 
                necessary, appropriate, and free of discrepancies.
                    ``(iii) Assessment of the individual and family 
                caregiver's health literacy regarding the ability to 
                properly follow medication instructions.
                    ``(iv) Individual and family education and 
                counseling about medications.
                    ``(v) 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) Implementation of a plan to facilitate the safe 
        transition of the individual from one level of care, care 
        setting, or provider to another, which transition plan shall 
        include at least the following:
                    ``(i) A process to address the individual's 
                symptoms.
                    ``(ii) An established process for the individual 
                and family caregivers to receive timely access to key 
                health care providers during an episode of care as 
                required by the individual's condition.
                    ``(iii) An established process for communicating 
                with the individual, family caregivers, and other 
                health care providers posttransition from an episode of 
                care.
                    ``(iv) A system that ensures ownership, 
                responsibility, and accountability for the care of the 
                individual at all times, including identifying and 
                documenting any family caregiver (or caregivers) that 
                exist.
                    ``(v) Providing information and resources about 
                condition and care choices to adequately prepare the 
                individual and caregivers for informed decisionmaking.
            ``(E) Providing to the qualified individual, primary 
        caregiver, and appropriate clinicians and the 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 subparagraph (B), progress in achieving such 
        goals, and remaining treatment needs.
            ``(F) Other services that the Secretary determines are 
        appropriate.
The Secretary shall determine and update from time to time 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.
    ``(3)(A) In this subsection, subject to subparagraph (C), the term 
`qualified individual' means an individual who--
            ``(i) has 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
            ``(ii) is identified by the Secretary as being at highest 
        risk for readmission or for a poor transition from such a 
        hospital to a posthospital site of care.
    ``(B) The identification under subparagraph (A)(ii) shall be based 
on achieving a minimum hierarchical condition category score (specified 
by the Secretary) in order to target eligibility benefits under this 
subsection to individuals with multiple chronic conditions and other 
risk factors, such as cognitive impairment, depression, or a history of 
multiple hospitalizations.
    ``(C) After submitting to Congress the evaluation under section 
2(d) of the Medicare Transitional Care Act of 2012 and considering any 
cost savings and quality improvements from the prior implementation of 
transitional care services under this title, 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-risk and lower-risk individuals.
    ``(D) The Secretary shall ensure that qualified individuals 
receiving transitional care services are not receiving duplicative 
services under this title.
    ``(4)(A) The term `transitional care clinician' means, with respect 
to a qualified individual, a nurse, case manager, social worker, 
physician assistant, physician, pharmacist, or other licensed health 
professional who--
            ``(i) 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;
            ``(ii) 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);
            ``(iii) is employed by (or has a contract with) a qualified 
        transitional care entity for the furnishing of transitional 
        care services; and
            ``(iv) meets such participation criteria as the Secretary 
        may specify consistent with this subsection.
    ``(B) In establishing participation criteria under subparagraph 
(A)(iv), the Secretary shall assure that transitional care clinicians 
meet relevant scope of practice and training requirements and have the 
ability to meet the individual needs of qualified individuals.
    ``(5) The term `qualified transitional care entity' means--
            ``(A) a hospital or a critical care hospital;
            ``(B) a home health agency;
            ``(C) a primary care practice;
            ``(D) a federally qualified health center;
            ``(E) a long-term care facility;
            ``(F) a medical home;
            ``(G) an appropriate community-based organization described 
        in section 3026(b)(1)(B) of the Patient Protection and 
        Affordable Care Act (42 U.S.C. 1395b-1 note);
            ``(H) an assisted living center;
            ``(I) an accountable care organization; and
            ``(J) another entity approved by the Secretary for purposes 
        of this subsection.
    ``(6) The term `transitional care period' means, with respect to a 
qualified individual, the period--
            ``(A) 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
            ``(B) 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) Payment and Performance Measures.--Section 1833 of such Act (42 
U.S.C. 1395l) is amended--
            (1) in subsection (a)(1), by striking ``and'' before 
        ``(Z)'' and by inserting before the semicolon at the end the 
        following: ``, and (AA) with respect to transitional care 
        services (as defined in section 1861(iii)(1)), the amounts paid 
        shall be 100 percent of the amount determined under subsection 
        (z)'';
            (2) in the first sentence of subsection (b), by inserting 
        ``or transitional care services (as defined in section 
        1861(iii)(1))'' after ``(as defined in section 1861(hh)(1))''; 
        and
            (3) by adding at the end the following new subsection:
    ``(z) Payment and Performance Measures for Transitional Care 
Services.--
            ``(1) Payment.--
                    ``(A) In general.--The Secretary shall determine 
                the method of payment for transitional care services 
                under this part, 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 paragraph 
                (3). 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.
                    ``(B) HIT incentive payment.--The Secretary may 
                provide for an additional payment with respect to 
                transitional care services to encourage transitional 
                care clinicians and qualified transitional care 
                entities to use health information technology in the 
                provision of such services.
                    ``(C) No payment for required discharge planning 
                services.--Payment shall not be made for transitional 
                care services under this subsection for an entity 
                insofar as such services are otherwise required to be 
                provided through the discharge planning process under 
                section 1861(ee) or under conditions of participation 
                for the entity under section 1866.
            ``(2) Performance measures.--
                    ``(A) Accountability.--
                            ``(i) In general.--The Secretary shall 
                        establish a method whereby qualified 
                        transitional care entities responsible for 
                        furnishing transitional care services are held 
                        accountable for process and outcome based on 
                        performance measures specified by the Secretary 
                        from those that have been endorsed by the 
                        National Quality Forum or similar standard-
                        setting organization or are otherwise used in 
                        other quality programs under this title or 
                        title XIX.
                            ``(ii) Development and endorsement of 
                        performance measure set.--For purposes of 
                        carrying out clause (i), the Secretary shall 
                        enter into an arrangement--
                                    ``(I) with the National Quality 
                                Forum for the evaluation, endorsement, 
                                and recommendation of additional 
                                performance measures for transitional 
                                care services and to identify remaining 
                                gaps in available measures, including 
                                measures to both the sending and 
                                receiving side of the transition; and
                                    ``(II) with the Agency for 
                                Healthcare Research and Quality to 
                                support measure development, to fill 
                                gaps in available measures, to conduct 
                                comparative effectiveness research of 
                                transitional care models and tools, and 
                                to provide for the ongoing maintenance 
                                of the set of performance measures for 
                                transitional care services.
                    ``(B) 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 paragraph (1) for transitional care 
                services shall be linked to performance on such 
                measures.
                    ``(C) Public reporting.--The Secretary shall 
                establish a mechanism to publicly report on a 
                qualifying transitional care entity's performance on 
                such measures, including providing benchmarks to 
                identify high performers and those practices that 
                contribute to lower hospital readmission rates.
                    ``(D) Dissemination of information on best 
                practices.--The Secretary shall disseminate information 
                on best practices used by transitional care clinicians 
                and qualified 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 Program under part B of title 
                XI, and public-private quality alliances, such as the 
                Hospital Quality Alliance.
            ``(3) 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 part or inappropriate 
        limitations on access to needed transitional care services 
        under this part.''.
    (c) Coordination With Hospital Discharge Planning.--Section 
1861(ee)(2) of such Act (42 U.S.C. 1395x(ee)(2)) is amended by adding 
at the end the following:
                    ``(I) In the case of subsection (d) hospitals and 
                critical care hospitals, the hospital must--
                            ``(i) identify, as soon as practicable 
                        after admission, those patients who are 
                        qualified individuals described in paragraph 
                        (3) of section 1861(iii); and
                            ``(ii) provide to such patients and their 
                        primary caregivers a list of transitional care 
                        entities available under such section to 
                        arrange for the provision of transitional care 
                        services, a list of transitional care services 
                        provided under this part, and a notice that the 
                        transitional care service benefit under such 
                        section is provided to qualified individuals 
                        with no deductible or cost sharing.
                Nothing in subparagraph (I) shall be construed as 
                preventing a hospital or critical care 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.''.
    (d) Evaluation; Report.--
            (1) In general.--The Secretary of Health and Human Services 
        shall evaluate the performance of the transitional care benefit 
        under the amendments made by this section by measuring the 
        following, both for individuals receiving transitional care 
        services and for individuals 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 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, 2016, 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 under section 1861(iii)(3)(B) of the Social 
        Security Act, as added by subsection (a).
    (e) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2013.
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