[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1934 Introduced in House (IH)]

114th CONGRESS
  1st Session
                                H. R. 1934

To amend title XVIII of the Social Security Act to establish a national 
Oncology Medical Home Demonstration Project under the Medicare program 
  for the purpose of changing the Medicare payment for cancer care in 
 order to enhance the quality of care and to improve cost efficiency, 
                        and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             April 22, 2015

   Mrs. McMorris Rodgers (for herself and Mr. Israel) 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 establish a national 
Oncology Medical Home Demonstration Project under the Medicare program 
  for the purpose of changing the Medicare payment for cancer care in 
 order to enhance the quality of care and to improve cost efficiency, 
                        and for other purposes.

    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 ``Cancer Care Payment Reform Act of 
2015''.

SEC. 2. ESTABLISHING AN ONCOLOGY MEDICAL HOME DEMONSTRATION PROJECT 
              UNDER THE MEDICARE PROGRAM TO IMPROVE QUALITY OF CARE AND 
              COST EFFICIENCY.

    Title XVIII of the Social Security Act is amended by inserting 
after section 1866E (42 U.S.C. 1395cc-5) the following new section:

``SEC. 1866F. ONCOLOGY MEDICAL HOME DEMONSTRATION PROJECT.

    ``(a) Establishment of Demonstration Project.--Not later than six 
months after the date of the enactment of this section, the Secretary 
shall establish an Oncology Medical Home Demonstration Project (in this 
section referred to as the `demonstration project') to make payments in 
the amounts specified in subsection (f) to each participating oncology 
practice (as defined in subsection (b)).
    ``(b) Definition of Participating Oncology Practice.--For purposes 
of this section, the term `participating oncology practice' means an 
oncology practice that--
            ``(1) submits to the Secretary an application to 
        participate in the demonstration program in accordance with 
        subsection (c);
            ``(2) is selected by the Secretary, in accordance with 
        subsection (d), to participate in the demonstration program; 
        and
            ``(3) is owned by a physician, or is owned by or affiliated 
        with a hospital, that submitted a claim for reimbursement in 
        the prior year for an item or service for which payment may be 
        made under part B.
    ``(c) Application To Participate.--An application by an oncology 
practice to participate in the demonstration program shall include an 
attestation to the Secretary that the practice--
            ``(1) furnishes physicians' services for which payment may 
        be made under part B;
            ``(2) coordinates oncology services furnished to an 
        individual by the practice with services that are related to 
        such oncology services and that are furnished to such 
        individual by medical professionals (including oncology nurses) 
        inside or outside the practice in order to ensure that each 
        such individual receives coordinated care;
            ``(3) meaningfully uses electronic health records;
            ``(4) will, not later than one year after the date on which 
        the practice commences its participation in the demonstration 
        project, be accredited as an Oncology Medical Home by the 
        Commission on Cancer, the National Committee for Quality 
        Assurance, or such other entity as the Secretary determines 
        appropriate;
            ``(5) will repay all amounts paid by the Secretary to the 
        practice under subsection (f)(1)(A) in the case that the 
        practice does not, on a date that is not later than 60 days 
        after the date on which the practice submits an application to 
        the Secretary under subsection (b)(1), submit an application to 
        an entity described in paragraph (4) for accreditation as an 
        Oncology Medical Home in accordance with such paragraph;
            ``(6) will, for each year in which demonstration project is 
        conducted, report to the Secretary, in such form and manner as 
        is specified by the Secretary, on--
                    ``(A) the performance of the practice with respect 
                to not less than ten of the measures described in 
                subsection (e), as selected by the practice; and
                    ``(B) the level of satisfaction of individuals who 
                are provided with oncology services by the practice for 
                which payment may be made under part B, as measured by 
                a patient satisfaction survey based on the Consumer 
                Assessment of Healthcare Providers and Systems survey 
                or by such similar survey as the Secretary determines 
                appropriate;
            ``(7) agrees not to receive the payments described in 
        subclauses (I) and (II) of subsection (f)(1)(B)(iii) in the 
        case that the practice does not report to the Secretary in 
        accordance with paragraph (6) with respect to performance of 
        the practice during the 12-month period beginning on the date 
        on which the practice submits the application described in this 
        subsection to the Secretary;
            ``(8) will, for each year of the demonstration project, 
        meet the minimum performance requirements developed under 
        subsection (e)(4)(B) with respect to each of the measures on 
        which the practice has agreed to report under paragraph (6)(A); 
        and
            ``(9) has the capacity to utilize shared decision-making 
        tools that facilitate the incorporation of the patient needs, 
        preferences, and circumstances of an individual into the 
        medical plan of the individual and that maintain provider 
        flexibility to tailor care of the individual based on the full 
        range of test and treatment options available to the 
        individual.
    ``(d) Selection of Participating Practices.--
            ``(1) In general.--The Secretary shall, not later than six 
        months after the date of the enactment of this section, select 
        oncology practices that submit applications to the Secretary in 
        accordance with subsection (c) to participate in the 
        demonstration program.
            ``(2) Maximum number of practices.--In selecting an 
        oncology practice to participate in the demonstration program 
        under paragraph (1), the Secretary shall ensure that the 
        participation of such practice in the demonstration project 
        does not, on the date on which the practice commences its 
        participation in the demonstration project, increase the total 
        number of oncologists who participate in the demonstration 
        program to a number that is greater than 1,500 oncologists.
            ``(3) Diversity of practices.--In selecting oncology 
        practices to participate in the demonstration project under 
        paragraph (1), the Secretary shall, to the extent practicable, 
        include in such selection--
                    ``(A) small-, medium-, and large-sized practices; 
                and
                    ``(B) practices located in different geographic 
                areas.
            ``(4) No penalty for certain opt-outs by practices.--In the 
        case that the Secretary selects an oncology practice to 
        participate in the demonstration project under paragraph (1) 
        that has agreed to participate in another model, under section 
        1115A or otherwise, for payment under this title for oncology 
        services, such practice may not be assessed a penalty for 
        electing not to participate in such other payment model if such 
        practice makes such election--
                    ``(A) prior to the receipt by the practice of any 
                payment under such model; and
                    ``(B) in order to participate in such demonstration 
                project.
    ``(e) Measures.--
            ``(1) Development.--The Secretary shall use measures 
        described in paragraph (2), and may use measures developed 
        under paragraph (3), to assess the performance of each 
        participating oncology practice, as compared to other 
        participating oncology practices.
            ``(2) Measures described.--The measures described in this 
        paragraph, with respect to individuals who receive treatment 
        for cancer from a participating oncology practice, are the 
        following:
                    ``(A) Patient care measures.--
                            ``(i) The percentage of such individuals 
                        that receives documented clinical or pathologic 
                        staging prior to initiation of a first course 
                        of cancer treatment.
                            ``(ii) The percentage of such individuals 
                        that is undergoing advanced imaging and has 
                        been diagnosed with stage I or II breast 
                        cancer.
                            ``(iii) The percentage of such individuals 
                        that is undergoing advanced imaging and has 
                        been diagnosed with stage I or II prostate 
                        cancer.
                            ``(iv) The percentage of such individuals 
                        that, prior to receiving cancer treatment, had 
                        its performance status assessed by the 
                        practice.
                            ``(v) The percentage of such individuals 
                        that--
                                    ``(I) is undergoing treatment with 
                                a chemotherapy regimen provided by the 
                                practice;
                                    ``(II) has at least a 20-percent 
                                risk of developing febrile neutropenia 
                                due to a combination of regimen risk 
                                and patient risk factors; and
                                    ``(III) has received from the 
                                practice either GCSF or white cell 
                                growth factor.
                            ``(vi) With respect to such individuals who 
                        receive chemotherapy treatment from the 
                        practice, the percentage of such individuals so 
                        treated that receives a treatment plan prior to 
                        the administration of such chemotherapy.
                            ``(vii) With respect to chemotherapy 
                        treatments administered to such individuals by 
                        the practice, the percentage of such treatments 
                        that adhere to guidelines published by the 
                        National Comprehensive Cancer Network or such 
                        other entity as the Secretary determines 
                        appropriate.
                            ``(viii) With respect to antiemetic drugs 
                        dispensed by the practice to individuals as 
                        part of moderately or highly emetogenic 
                        chemotherapy regimens for such individuals, the 
                        extent to which such drugs are administered in 
                        accordance with evidence-based guidelines or 
                        pathways that are compliant with guidelines 
                        published by the National Comprehensive Cancer 
                        Network or such other entity as the Secretary 
                        determines appropriate.
                    ``(B) Resource utilization measures.--
                            ``(i) With respect to emergency room visits 
                        in a year by such individuals who are receiving 
                        active chemotherapy treatment administered by 
                        the practice as of the date of such visits, the 
                        percentage of such visits that is associated 
                        with qualified cancer diagnoses of the 
                        individuals.
                            ``(ii) With respect to hospital admissions 
                        in a year by such individuals who are receiving 
                        active chemotherapy treatment administered by 
                        the practice as of the date of such visits, the 
                        percentage of such admissions that is 
                        associated with qualified cancer diagnoses of 
                        the individuals.
                    ``(C) Survivorship measures.--
                            ``(i) Survival rates for such individuals 
                        who have been diagnosed with stage I through IV 
                        breast cancer.
                            ``(ii) Survival rates for such individuals 
                        who have been diagnosed with stage I through IV 
                        colorectal cancer.
                            ``(iii) Survival rates for such individuals 
                        who have been diagnosed with stage I through IV 
                        lung cancer.
                            ``(iv) With respect to such individuals who 
                        receive chemotherapy treatment from the 
                        practice, the percentage of such individuals so 
                        treated that receives a survivorship plan not 
                        later than 45 days after the completion of the 
                        administration of such chemotherapy to such 
                        individuals.
                            ``(v) With respect to such individuals who 
                        receive chemotherapy treatment from the 
                        practice, the percentage of such individuals 
                        that receives psychological screening.
                    ``(D) End-of-life care measures.--
                            ``(i) The number of times that such an 
                        individual receives chemotherapy treatment from 
                        the practice not later than 30 days prior to 
                        the death of the individual.
                            ``(ii) With respect to such individuals who 
                        have a stage IV disease and have received 
                        treatment for such disease from the practice, 
                        the percentage of such individuals so treated 
                        who have had a documented end-of-life care 
                        conversation with a physician in the practice 
                        or another health care provider who is a member 
                        of the cancer care team of the practice.
                            ``(iii) With respect to such an individual 
                        who is referred to hospice care by a physician 
                        in the practice or a health care provider who 
                        is a member of the cancer care team of the 
                        practice, regardless of the setting in which 
                        such care is provided, the average number of 
                        days that the individual receives hospice care 
                        prior to the death of the individual.
                            ``(iv) With respect to such individuals who 
                        die while receiving care from the practice, the 
                        percentage of such deceased individuals whose 
                        death occurred in an acute care setting.
            ``(3) Modification or addition of measures.--
                    ``(A) In general.--The Secretary may, in 
                conjunction with appropriate stakeholders, modify or 
                add to the measures described in paragraph (2).
                    ``(B) Appropriate stakeholders described.--For 
                purposes of subparagraph (A), the term `appropriate 
                stakeholders' includes oncology societies, oncologists 
                who provide oncology services to one or more 
                individuals for which payment may be made under part B, 
                allied health professionals, health insurance issuers 
                that have implemented alternative payment models for 
                oncologists, patients and organizations that represent 
                patients, and biopharmaceutical and other medical 
                technology manufacturers.
            ``(4) Assessment.--
                    ``(A) In general.--The Secretary shall, for each 
                year in which the demonstration project is conducted, 
                assess--
                            ``(i) the performance of each participating 
                        oncology practice for such year with respect to 
                        the measures on which the practice has agreed 
                        to report to the Secretary under subsection 
                        (c)(6)(A), as compared to the performance of 
                        other participating oncology practices with 
                        respect to such measures; and
                            ``(ii) the extent to which the practice 
                        has, during such year, used breakthrough or 
                        other best-in-class therapies.
                    ``(B) Minimum performance requirements.--The 
                Secretary shall, in conjunction with the appropriate 
                stakeholders described in paragraph (3)(B), develop 
                minimum performance requirements with respect to--
                            ``(i) each of the measures developed under 
                        this subsection; and
                            ``(ii) the level of satisfaction on which 
                        practices agree to report to the Secretary 
                        under subsection (c)(6)(B).
    ``(f) Payments for Participating Oncologists.--
            ``(1) Care coordination management fee.--
                    ``(A) In general.--Subject to subparagraphs (D) and 
                (E), the Secretary shall, in addition to any other 
                payments made by the Secretary under this title to a 
                participating oncology practice, make payment of a care 
                coordination management fee to each such practice.
                    ``(B) Timing of payments.--The care coordination 
                management fee described in subparagraph (A) shall be 
                paid to a participating oncology practice at the end of 
                each of the following periods:
                            ``(i) The period that ends 6 months after 
                        the date on which the practice submits the 
                        application described in subsection (c) to the 
                        Secretary under subsection (b)(1).
                            ``(ii) The period that ends 12 months after 
                        the date on which the practice submits such 
                        application to the Secretary.
                            ``(iii) Subject to subsection (c)(7)--
                                    ``(I) the period that ends 18 
                                months after the date on which the 
                                practice submits such application to 
                                the Secretary; and
                                    ``(II) the period that ends 24 
                                months after the date on which the 
                                practice submits such application to 
                                the Secretary.
                    ``(C) Amount of payment.--The amount of the care 
                coordination management fee described in subparagraph 
                (A) shall be determined by the Secretary in conjunction 
                with oncologists who provide oncology services for 
                which payment may be made under part B.
            ``(2) Payment in subsequent years.--
                    ``(A) In general.--Subject to subparagraphs (C) and 
                (D), the Secretary shall make payments of an ongoing 
                management fee to each participating oncology practice.
                    ``(B) Timing of payments.--The ongoing management 
                fee described in subparagraph (A) shall be paid to a 
                participating oncology practice at the end of the 
                third, fourth, and fifth years of the demonstration 
                project.
                    ``(C) Aggregate amount of payments.--With respect 
                to each of the dates of payment described in 
                subparagraph (B), the aggregate amount of payments to 
                participating oncology practices on such date shall be 
                determined by--
                            ``(i) determining the amount by which the 
                        aggregate expenditures that would have been 
                        expended for the previous year under this title 
                        if the demonstration project had not been 
                        implemented exceeds the aggregate expenditures 
                        under this title for such previous year;
                            ``(ii) calculating the amount that is half 
                        of the amount determined under clause (i); and
                            ``(iii) subtracting from the amount 
                        calculated under clause (ii) the total amount 
                        of payments made under paragraph (1) that have 
                        not, in a prior application of this clause, 
                        previously been so subtracted from a payment 
                        determination made under this subparagraph.
                    ``(D) Amount of payments to individual practices.--
                            ``(i) Minimum performance requirements.--
                        The Secretary may not make payments to a 
                        practice under subparagraph (A) at the end of a 
                        year of the demonstration project described in 
                        subparagraph (B) unless the practice meets or 
                        exceeds the minimum performance requirements 
                        developed under subsection (e)(4)(B) for such 
                        year with respect to--
                                    ``(I) the measures on which the 
                                practice has agreed to report to the 
                                Secretary under subsection (c)(6)(A); 
                                and
                                    ``(II) the level of satisfaction on 
                                which the practice has agreed to report 
                                to the Secretary under subsection 
                                (c)(6)(B).
                            ``(ii) Consideration of performance 
                        assessment.--The Secretary shall, in 
                        conjunction with the appropriate stakeholders 
                        described in subsection (e)(3)(B), determine 
                        the amount of a payment to an individual 
                        oncology practice under subparagraph (A) for a 
                        year. In making a determination under the 
                        preceding sentence, the Secretary shall take 
                        into account the performance assessment of the 
                        practice under subsection (e)(4)(A) for the 
                        previous year, as compared to the performance 
                        assessment of other participating oncology 
                        practices under such subsection for such 
                        previous year.
            ``(3) Issuance of guidance.--Not later than the date that 
        is six months after the date of the enactment of this section, 
        the Secretary shall issue guidance detailing the methodology 
        that the Secretary will use to implement subparagraphs (C) and 
        (D) of paragraph (2).
    ``(g) Secretary Reports to Participating Oncology Practices.--The 
Secretary shall inform each participating oncology practice, on a 
quarterly basis, of--
            ``(1) the performance of the practice during the prior 
        quarter with respect to the measures on which the practice has 
        agreed to report to the Secretary under subsection (c)(6)(A); 
        and
            ``(2) the amount by which the expenditures that would have 
        been expended for the prior quarter under this title by a 
        typical oncology practice if the demonstration project had not 
        been implemented exceeds the actual expenditures by the 
        participating oncology practice under this title for such 
        quarter.
    ``(h) Applications From Entities To Provide Accreditations.--Not 
later than the date that is six months after the date of the enactment 
of this section, the Secretary shall establish a process for the 
acceptance and consideration of applications from entities for purposes 
of determining which entities may provide accreditation to practices 
under subsection (c)(4) in addition to the entities described in such 
subsection.
    ``(i) GAO Report.--Not later than June 1, 2019, the Comptroller 
General of the United States shall submit a report to Congress 
evaluating the success of the demonstration project that includes an 
assessment of the impact of the project upon the quality and cost-
efficiency of oncology services furnished to individuals under this 
title, including an assessment of the satisfaction of such individuals 
with respect to such services that were furnished under such project. 
Such report shall include recommendations regarding the possible 
expansion of the demonstration project, as well as any possible reforms 
that are based on the demonstration project that can be made to the 
program under this title with respect to payment for cancer care.''.
                                 <all>