[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 3096 Introduced in Senate (IS)]

<DOC>






114th CONGRESS
  2d Session
                                S. 3096

To establish a pilot program promoting an alternative payment model for 
     person-centered care for Medicare beneficiaries with advanced 
                               illnesses.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 23, 2016

 Mr. Whitehouse (for himself and Ms. Warren) introduced the following 
  bill; which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To establish a pilot program promoting an alternative payment model for 
     person-centered care for Medicare beneficiaries with advanced 
                               illnesses.

    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 ``Removing Barriers to Person-Centered 
Care Act of 2016''.

SEC. 2. IDENTIFICATION AND DEVELOPMENT OF ADVANCE CARE QUALITY 
              MEASURES.

    (a) In General.--The Secretary of Health and Human Services 
(referred to in this Act as ``the Secretary''), in consultation with 
the Administrator of the Centers for Medicare & Medicaid Services, the 
Director of the Agency for Healthcare Research and Quality Services, 
and the entity with a contract under section 1890(a) of the Social 
Security Act (42 U.S.C. 1395aaa(a)), shall identify and develop a 
recommended set of not more than 20 advance care quality measures for 
Medicare beneficiaries that may be tested in, and allow for the 
assessment of, the pilot program established under subparagraph (D) of 
section 1115A(b)(2) of the Social Security Act (42 U.S.C. 1315a(b)(2)), 
as added by section 3. Such set of quality measures shall include 
outcome, structural, and process measures in the following categories:
            (1) Patient and family experience of care.
            (2) Access to needed services (medical and supportive), 
        such as timely referral to hospice.
            (3) Completion of care planning documentation, such as 
        health care proxies, advance directives, and portable treatment 
        orders.
            (4) Consistency of care with documented care preferences.
            (5) Screening for physical symptoms, such as dyspnea, 
        nausea, and constipation.
            (6) Utilization of health care and support services.
    (b) Process for Identifying and Developing Quality Measures.--In 
identifying and developing the quality measures described in subsection 
(a), the Secretary shall take the following actions:
            (1) Identify existing measures.--Identify existing quality 
        measures that are in use under public and privately sponsored 
        health care arrangements.
            (2) Development of measures.--Enter into grants, contracts, 
        or intergovernmental agreements with eligible entities for the 
        purposes of developing quality measures (which may include 
        improving existing quality measures) that, to the extent 
        practicable, allow for the use of health information 
        technologies in collecting data relating to such quality 
        measures.
    (c) Publication and Report.--Not later than January 1, 2018, the 
Secretary shall--
            (1) publish an initial core set of quality measures; and
            (2) submit a report to Congress that--
                    (A) evaluates the set of quality measures published 
                under paragraph (1); and
                    (B) includes a strategy for designating a core set 
                of quality measures on advance illness care that may be 
                used across public and private payers and eliminating 
                redundant measures that are not part of the core set.
    (d) Funding.--There are authorized to be appropriated such sums as 
may be necessary for fiscal year 2017 to carry out this section.

SEC. 3. PILOT PROGRAM FOR MEDICARE BENEFICIARIES WITH ADVANCED 
              ILLNESSES.

    (a) In General.--Section 1115A of the Social Security Act (42 
U.S.C. 1315a) is amended--
            (1) in the last sentence of subparagraph (A) of subsection 
        (b)(2), by inserting ``, and shall include the model described 
        in subsection (h)'' before the period at the end; and
            (2) by adding at the end the following new subsection:
    ``(h) Pilot Program To Promote Person-Centered Care for Medicare 
Beneficiaries With Advanced Illnesses.--
            ``(1) In general.--The model described in this subsection 
        is a pilot program under which the Secretary shall enter into 
        demonstration project agreements with advance care 
        collaboratives to provide services and supplies under parts A 
        and B of title XVIII in a manner that promotes accountability 
        for target Medicare beneficiaries, coordinates the provision of 
        items and services under parts A and B of such title, and 
        encourages investment in infrastructure and redesigned care 
        processes for coordinated, person- and family-centered, and 
        high-quality service delivery.
            ``(2) Eligibility.--An advance care collaborative shall be 
        eligible to enter into a demonstration project agreement under 
        this subsection if the collaborative--
                    ``(A) submits a timely application under paragraph 
                (3); and
                    ``(B) meets such other requirements and satisfies 
                such conditions as the Secretary shall determine.
            ``(3) Application.--
                    ``(A) In general.--Not later than October 1, 2018, 
                each advance care collaborative that wishes to enter 
                into a demonstration project agreement with the 
                Secretary shall submit to the Secretary an application 
                that includes--
                            ``(i) information about each provider of 
                        services, physician, and practitioner in the 
                        collaborative;
                            ``(ii) a description of, and an 
                        implementation plan for, the demonstration 
                        project that the collaborative intends to carry 
                        out under paragraph (6), including intended 
                        uses of grant amounts under paragraph (5), and 
                        a strategy for the continued participation of 
                        community-based social services organizations, 
                        including faith-based organizations, in the 
                        care of the target Medicare beneficiary 
                        population;
                            ``(iii) a description of how the 
                        collaborative intends to use the waivers and 
                        expanded services described in paragraphs (7) 
                        and (8) to conduct the demonstration project;
                            ``(iv) with respect to the collection and 
                        reporting of data relating to the results of 
                        the demonstration project--
                                    ``(I) subject to the availability 
                                of such measures, a description of how 
                                the collaborative will collect and 
                                report on data pertaining to the 
                                recommended set of quality measures 
                                established by the Secretary under 
                                section 2 of the Removing Barriers to 
                                Person-Centered Care Act of 2016; and
                                    ``(II) a description of additional 
                                quality measures the collaborative 
                                proposes to use to measure any 
                                characteristics of its demonstration 
                                project that are not captured in the 
                                quality measures described in subclause 
                                (I), and how the collaborative will 
                                collect and report on data pertaining 
                                to such measures; and
                            ``(v) a description of how the 
                        collaborative will identify its target Medicare 
                        beneficiary population for the demonstration 
                        project.
                    ``(B) Priority.--In selecting advance care 
                collaboratives to participate in the pilot program, the 
                Secretary may give priority to collaboratives that are 
                located in States that use, or are in the process of 
                developing, a uniform, portable medical order for life-
                sustaining treatment.
                    ``(C) Geographic diversity.--In selecting advance 
                care collaboratives to participate in the pilot 
                program, the Secretary shall make efforts to select 
                collaboratives from geographically diverse areas.
            ``(4) Demonstration project agreement.--
                    ``(A) In general.--Not later than January 1, 2019, 
                the Secretary shall enter into agreements with up to 20 
                advance care collaboratives to participate in the pilot 
                program.
                    ``(B) Required terms.--As part of any agreement 
                between the Secretary and an advance care collaborative 
                under this paragraph:
                            ``(i) Pre-implementation grant.--The 
                        advance care collaborative shall receive a 
                        grant described in paragraph (5).
                            ``(ii) Demonstration project.--The advance 
                        care collaborative shall conduct a 
                        demonstration project described in paragraph 
                        (6).
                    ``(C) Termination.--The Secretary may terminate an 
                agreement with an advance care collaborative if the 
                collaborative's expenditures under the demonstration 
                project for services and supplies under parts A and B 
                of title XVIII substantially exceed the benchmark 
                established for the collaborative by the Secretary 
                under paragraph (6)(B)(ii).
            ``(5) Grants for pre-implementation activities.--
                    ``(A) In general.--Beginning in fiscal year 2019, 
                from the amount made available under subsection 
                (f)(2)(B), the Secretary shall award grants to advance 
                care collaboratives that have entered into 
                demonstration project agreements with the Secretary to 
                facilitate the implementation of demonstration 
                projects.
                    ``(B) Use of grant amounts.--A grant awarded under 
                this paragraph may be used by an advance care 
                collaborative for the following purposes:
                            ``(i) To conduct a needs assessment in 
                        collaboration with community-based social 
                        service organizations, such as faith-based 
                        organizations, beneficiary groups, and 
                        providers of long-term services and supports to 
                        identify gaps in services and supports for the 
                        target Medicare beneficiary population 
                        identified by the collaborative.
                            ``(ii) To modify, upgrade, or purchase 
                        health information technology to facilitate the 
                        exchange of information between members of the 
                        collaborative, including technologies that 
                        support data aggregation and analytics, 
                        increase interoperability across medical and 
                        supportive services, or improve accessibility 
                        of beneficiary care plans.
                            ``(iii) To conduct education and training 
                        for health care professionals, beneficiaries 
                        and family caregivers, or community-based 
                        social service organizations, including faith-
                        based organizations, in methods for learning, 
                        documenting, and communicating treatment 
                        preferences and goals, on best practices for 
                        pain and symptom management, and to improve 
                        understanding of palliative care and hospice 
                        services, among other topics.
                            ``(iv) To hire staff to conduct care 
                        management and coordination activities.
                            ``(v) To conduct other activities 
                        determined appropriate by the Secretary.
            ``(6) Demonstration project.--
                    ``(A) In general.--Not later than January 1, 2020, 
                each advance care collaborative that has a 
                demonstration project agreement with the Secretary 
                shall begin to conduct a demonstration project to 
                provide coordinated, person- and family-centered, and 
                high-quality service delivery to target Medicare 
                beneficiaries by utilizing the waivers and expanded 
                services described in paragraphs (7) and (8).
                    ``(B) Shared savings payments.--
                            ``(i) In general.--Beginning in fiscal year 
                        2021, in addition to reimbursement that would 
                        otherwise be due under title XVIII for services 
                        provided by the advance care collaborative in 
                        conducting the demonstration project, a 
                        collaborative shall be eligible for shared 
                        savings payments if the Secretary determines 
                        that expenditures under the demonstration 
                        project for services and supplies under parts A 
                        and B of title XVIII are below the expenditures 
                        benchmark established by the Secretary for the 
                        collaborative under clause (ii).
                            ``(ii) Benchmark.--The Secretary shall 
                        establish an appropriate expenditures benchmark 
                        for each advance care collaborative conducting 
                        a demonstration project under this subsection.
                    ``(C) Duration.--Subject to paragraph (4)(C), any 
                demonstration project under this paragraph shall be 
                conducted for not less than 3 years.
            ``(7) Waiver of certain requirements.--As part of a 
        demonstration project under the pilot program, the Secretary 
        shall waive the following requirements with respect to coverage 
        of, and payment for, services under title XVIII provided to a 
        target Medicare beneficiary by an advance care collaborative 
        under such demonstration project:
                    ``(A) Coverage of curative care during election 
                period.--The requirement described in section 
                1812(d)(2)(A) that an individual electing to receive 
                hospice care shall be deemed to have waived all rights 
                to have payment made under title XVIII with respect to 
                services described in clause (ii)(I) of such section.
                    ``(B) Alternative certification for home care.--
                With respect to home health services furnished to an 
                individual by a Medicare-certified home health agency, 
                the requirements described in section 1814(a)(2) and 
                subparagraph (C) of such section that--
                            ``(i) a physician make the certification 
                        (and recertification, where such services are 
                        provided over a period of time) described in 
                        such subparagraph (C);
                            ``(ii) a plan for furnishing such services 
                        to such individual is periodically reviewed by 
                        a physician; and
                            ``(iii) the physician (or another 
                        practitioner who is collaborating with or 
                        supervised by the physician) has a face-to-face 
                        encounter with the individual,
                provided that such certification and recertification, 
                and review of such plan, is conducted by a nurse 
                practitioner (as defined in section 1861(aa)(5)) who is 
                authorized to conduct such certification, 
                recertification, and review under State law.
                    ``(C) Alternative certification for hospice care.--
                The requirements described in subparagraphs (A) and (B) 
                of section 1814(a)(7) that an individual's attending 
                physician and the medical director (or physician member 
                of the interdisciplinary group described in section 
                1861(gg)) of the Medicare-certified hospice program 
                providing (or arranging for) the individual's hospice 
                care certify that the individual is terminally ill and 
                periodically review the written plan for hospice care, 
                provided that such certification and review is 
                conducted by a nurse practitioner (as defined in 
                section 1861(aa)(5)) who is authorized to conduct such 
                certification and review under State law.
                    ``(D) Coverage of skilled nursing services without 
                inpatient stay.--With respect to extended care services 
                furnished to an individual by a Medicare-certified 
                skilled nursing facility, the requirement described in 
                section 1861(i) that an individual must have been an 
                inpatient in a hospital for not less than 3 consecutive 
                days before his discharge and transfer to the skilled 
                nursing facility before such extended care services may 
                be deemed post-hospital extended care services.
                    ``(E) Coverage of home health care without 
                homebound status requirement.--With respect to home 
                health services furnished to an individual by a 
                Medicare-certified home health agency (as defined in 
                section 1861(o)), the requirement described in section 
                1814(a)(2)(C) that the individual is or was confined to 
                his or her home.
            ``(8) Availability of expanded services.--As part of a 
        demonstration project under the pilot program, an advance care 
        collaborative may receive payment for the furnishing the 
        following services to target Medicare beneficiaries in the same 
        manner, and subject to the same limitations, that a hospice 
        program is paid for hospice care under section 1814(i):
                    ``(A) Inpatient alternative to routine hospice 
                care.--
                            ``(i) In general.--Notwithstanding 
                        regulations in effect prior to the enactment of 
                        this subparagraph, if an assessment meeting 
                        such requirements as the Secretary determines 
                        appropriate has been made that the home of an 
                        individual who is certified for hospice care 
                        and has elected to receive hospice care is 
                        unsafe or otherwise unsuitable for the 
                        provision of such care, such individual may 
                        receive such care in an inpatient setting, 
                        including a Medicare-certified hospice that 
                        meets the conditions of participation specified 
                        in section 418.110 of title 42, Code of Federal 
                        Regulations (as in effect on the date of 
                        enactment of this subparagraph), or a skilled 
                        nursing facility that meets the standards 
                        specified in subsections (b) and (e) of such 
                        section, for the duration of the election 
                        period. The assessment described in the 
                        preceding sentence may be conducted by the 
                        individual's attending physician, a nurse 
                        practitioner, or the medical director (or 
                        physician member of the interdisciplinary group 
                        described in section 1861(gg)) of the hospice 
                        program providing (or arranging for) the 
                        individual's hospice care.
                            ``(ii) Application of limitation on 
                        inpatient care days.--For purposes of any 
                        limitation on the number of total inpatient 
                        care days for which a hospice may receive 
                        payment, hospice care that is provided in an 
                        inpatient setting under this subclause (but 
                        would otherwise be provided in an outpatient 
                        setting) shall not count towards such 
                        limitation.
                    ``(B) Home-based alternative to inpatient respite 
                care.--
                            ``(i) In general.--Notwithstanding section 
                        1861(dd)(1)(G), an individual who is certified 
                        for hospice care and has elected to receive 
                        hospice care may receive short-term, home-based 
                        respite care as an alternative to inpatient 
                        respite care.
                            ``(ii) Limitations.--The home-based respite 
                        care described in clause (i) is subject to the 
                        same limitations that apply to inpatient 
                        respite care under section 1861(dd)(1)(G), 
                        including the limitation that respite care may 
                        be provided only on an intermittent, non-
                        routine, and occasional basis and may not be 
                        provided consecutively over longer than 5 days.
            ``(9) Participation by beneficiaries, providers, and 
        suppliers voluntary.--Participation in a demonstration project 
        conducted under the pilot program with respect to target 
        Medicare beneficiaries, providers of services, physicians, and 
        practitioners shall be voluntary.
            ``(10) Definitions.--In this subparagraph:
                    ``(A) Advance care collaborative.--The term 
                `advance care collaborative' means an affiliated group 
                of providers of services, physicians, or practitioners 
                that--
                            ``(i) has a mechanism for shared governance 
                        between participating providers of services, 
                        physicians, and practitioners; and
                            ``(ii) has a formal legal structure that 
                        would allow for the receipt and distribution of 
                        shared savings payments under paragraph (6)(B) 
                        to the providers of services, physicians, and 
                        practitioners that belong to the group.
                    ``(B) Demonstration project agreement.--The term 
                `demonstration project agreement' means an agreement 
                between the Secretary and an advance care collaborative 
                under paragraph (4).
                    ``(C) Pilot program.--The term `pilot program' 
                means the pilot program described in this subsection.
                    ``(D) Physician.--The term `physician' has the 
                meaning given such term in section 1861(r)(1).
                    ``(E) Practitioner.--The term `practitioner' has 
                the meaning given such term in section 1842(b)(18)(C).
                    ``(F) Provider of services.--The term `provider of 
                services' has the meaning given such term in section 
                1861(u).
                    ``(G) Supplier.--The term `supplier' has the 
                meaning given such term in 1861(d).
                    ``(H) Target medicare beneficiary.--The term 
                `target Medicare beneficiary' means an individual who--
                            ``(i) is enrolled for benefits under parts 
                        A and B of title XVIII, but who is not enrolled 
                        in a Medicare Advantage plan under part C of 
                        such title, an eligible organization under 
                        section 1876, or a PACE program under section 
                        1894; and
                            ``(ii) demonstrates two or more of the 
                        following characteristics:
                                    ``(I) Has one or more advanced 
                                chronic conditions, such as late-stage 
                                cancer, congestive heart failure, 
                                chronic kidney disease, chronic 
                                obstructive pulmonary disease, 
                                geriatric frailty, Alzheimer's disease, 
                                or another form of progressive 
                                dementia.
                                    ``(II) Has evidence of recent and 
                                progressive cognitive impairment or 
                                functional limitations (such as an 
                                inability to perform one or more 
                                activities of daily living).
                                    ``(III) Has, during the previous 12 
                                months, experienced an increase in 
                                health care utilization, such as two or 
                                more nonelective hospital admissions.
                                    ``(IV) Other characteristics 
                                identified by the Secretary.''.
    (b) Availability of Funds for Pre-Implementation Grants.--Section 
1115A(f)(2) of the Social Security Act (42 U.S.C. 1315a(f)(2)) is 
amended--
            (1) by striking ``Out of amounts appropriated'' and 
        inserting ``(A) Out of amounts appropriated''; and
            (2) by adding at the end the following new subparagraph:
                    ``(B) Out of the amount appropriated under 
                subparagraph (B) of paragraph (1), $10,000,000 shall be 
                made available for fiscal year 2019 for the purpose of 
                awarding grants under subsection (h)(6), and shall 
                remain available for such purpose until expended.''.
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