[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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