[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 3211 Introduced in Senate (IS)]

<DOC>






114th CONGRESS
  2d Session
                                S. 3211

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 SENATE OF THE UNITED STATES

                             July 14, 2016

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

_______________________________________________________________________

                                 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 
2016''.

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 12 
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 project in accordance with 
        subsection (c);
            ``(2) is selected by the Secretary, in accordance with 
        subsection (d), to participate in the demonstration project; 
        and
            ``(3) is owned by a physician, or is owned by or affiliated 
        with a hospital, that submitted a claim for payment 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 project 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 practitioners (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's agreement period for the 
        demonstration project begins, as determined by the Secretary, 
        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 the 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 measures described in subsection (e) as determined 
                by the Secretary, subject to subsection (e)(1)(B); and
                    ``(B) the experience of care of individuals who are 
                furnished oncology services by the practice for which 
                payment may be made under part B, as measured by a 
                patient experience of care 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's agreement period for the demonstration 
        project begins, as determined by the Secretary;
            ``(8) will, for each year of the demonstration project, 
        meet the performance standards 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 the 
        patient experience of care on which the practice has agreed to 
        report under paragraph (6)(B); 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 15 
        months after the date of the enactment of this section, select 
        oncology practices that submit an application to the Secretary 
        in accordance with subsection (c) to participate in the 
        demonstration project.
            ``(2) Maximum number of practices.--In selecting an 
        oncology practice to participate in the demonstration project 
        under this section, 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--
                    ``(A) increase the total number of practices 
                participating in the demonstration project to a number 
                that is greater than 200 practices (or such number as 
                the Secretary determines appropriate); or
                    ``(B) increase the total number of oncologists who 
                participate in the demonstration project to a number 
                that is greater than 1,500 oncologists (or such number 
                as the Secretary determines appropriate).
            ``(3) Diversity of practices.--
                    ``(A) In general.--Subject to subparagraph (B), in 
                selecting oncology practices to participate in the 
                demonstration project under this section, the Secretary 
                shall, to the extent practicable, include in such 
                selection--
                            ``(i) small-, medium-, and large-sized 
                        practices; and
                            ``(ii) practices located in different 
                        geographic areas.
                    ``(B) Inclusion of small oncology practices.--In 
                selecting oncology practices to participate in the 
                demonstration project under this section, the Secretary 
                shall, to the extent practicable, ensure that at least 
                20 percent of the participating practices are small 
                oncology practices (as determined by the Secretary).
            ``(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 this section 
        that has agreed to participate in a model established under 
        section 1115A for oncology services, such practice may not be 
        assessed a penalty for electing not to participate in such 
        model if the practice makes such election--
                    ``(A) prior to the receipt by the practice of any 
                payment for such model that would not otherwise be paid 
                in the absence of such model; and
                    ``(B) in order to participate in the demonstration 
                project under this section.
    ``(e) Measures.--
            ``(1) Development.--
                    ``(A) In general.--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 as 
                described in paragraph (4)(A)(i).
                    ``(B) Determination of measures reported.--In 
                determining measures to be reported under subsection 
                (c)(6)(A), the Secretary, in consultation with 
                stakeholders, shall ensure that reporting under such 
                subsection is not overly burdensome and that those 
                measures required to be reported are aligned with 
                applicable requirements from other payors.
            ``(2) Measures described.--The measures described in this 
        paragraph, with respect to individuals who are attributed to a 
        participating oncology practice, as determined by the 
        Secretary, are the following:
                    ``(A) Patient care measures.--
                            ``(i) The percentage of such individuals 
                        who receive documented clinical or pathologic 
                        staging prior to initiation of a first course 
                        of cancer treatment.
                            ``(ii) The percentage of such individuals 
                        who undergo advanced imaging and have been 
                        diagnosed with stage I or II breast cancer.
                            ``(iii) The percentage of such individuals 
                        who undergo advanced imaging and have been 
                        diagnosed with stage I or II prostate cancer.
                            ``(iv) The percentage of such individuals 
                        who, prior to receiving cancer treatment, had 
                        their performance status assessed by the 
                        practice.
                            ``(v) The percentage of such individuals 
                        who--
                                    ``(I) undergo treatment with a 
                                chemotherapy regimen provided by the 
                                practice;
                                    ``(II) have at least a 20-percent 
                                risk of developing febrile neutropenia 
                                due to a combination of regimen risk 
                                and patient risk factors; and
                                    ``(III) have 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 who receive 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 are 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 are 
                        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 who receive a survivorship plan not 
                        later than 45 days after the completion of the 
                        administration of such chemotherapy.
                            ``(v) With respect to such individuals who 
                        receive chemotherapy treatment from the 
                        practice, the percentage of such individuals 
                        who receive psychological screening.
                    ``(D) End-of-life care measures.--
                            ``(i) The number of times that such an 
                        individual receives chemotherapy treatment from 
                        the practice within an amount of time specified 
                        by the Secretary, in consultation with 
                        stakeholders, 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 furnished, 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 
                consultation with appropriate stakeholders in a manner 
                determined by the Secretary, modify, replace, remove, 
                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 furnish 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 each 
                        participating oncology practice has, during 
                        such year, used breakthrough or other best-in-
                        class therapies.
                    ``(B) Performance standards.--The Secretary shall, 
                in consultation with the appropriate stakeholders 
                described in paragraph (3)(B) in a manner determined by 
                the Secretary, develop performance standards with 
                respect to--
                            ``(i) each of the measures described in 
                        paragraph (2), including those measures as 
                        modified or added under paragraph (3); and
                            ``(ii) the patient experience of care on 
                        which participating oncology practices agree to 
                        report to the Secretary under subsection 
                        (c)(6)(B).
    ``(f) Payments for Participating Oncology Practices and 
Oncologists.--
            ``(1) Care coordination management fee during first two 
        years of demonstration project.--
                    ``(A) In general.--The Secretary shall, in addition 
                to any other payments made by the Secretary under this 
                title to a participating oncology practice, pay a care 
                coordination management fee to each such practice at 
                each of the times specified in subparagraph (B).
                    ``(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's agreement 
                        period for the demonstration project begins, as 
                        determined by the Secretary.
                            ``(ii) The period that ends 12 months after 
                        the date on which the practice's agreement 
                        period for the demonstration project begins, as 
                        determined by the Secretary.
                            ``(iii) Subject to subsection (c)(7)--
                                    ``(I) the period that ends 18 
                                months after the date on which the 
                                practice's agreement period for the 
                                demonstration project begins, as 
                                determined by the Secretary; and
                                    ``(II) the period that ends 24 
                                months after the date on which the 
                                practice's agreement period for the 
                                demonstration project begins, as 
                                determined by the Secretary.
                    ``(C) Amount of payment.--The Secretary shall, in 
                consultation with oncologists who furnish oncology 
                services for which payment may be made under part B in 
                a manner determined by the Secretary, determine the 
                amount of the care coordination management fee 
                described in subparagraph (A).
            ``(2) Performance incentive payments.--
                    ``(A) In general.--Subject to subparagraphs (C) and 
                (E), the Secretary shall, in addition to any other 
                payments made by the Secretary under this title to a 
                participating oncology practice, pay a performance 
                incentive payment to each such practice for each year 
                of the demonstration project described in subparagraph 
                (B).
                    ``(B) Timing of payments.--The performance 
                incentive payment described in subparagraph (A) shall 
                be paid to a participating oncology practice as soon as 
                practicable following the end of the third, fourth, and 
                fifth years of the demonstration project.
                    ``(C) Source of payments.--Performance incentive 
                payments made to participating oncology practices under 
                subparagraph (A) for each of the years of the 
                demonstration project described in subparagraph (B) 
                shall be paid from the aggregate pool available for 
                making payments for each such year determined under 
                subparagraph (D), as available for each such year.
                    ``(D) Aggregate pool available for making 
                payments.--With respect to each of the years of the 
                demonstration project described in described in 
                subparagraph (B), the aggregate pool available for 
                making performance incentive payments for each such 
                year shall be determined by--
                            ``(i) estimating the amount by which the 
                        aggregate expenditures that would have been 
                        expended for the year under parts A and B for 
                        items and services furnished to individuals 
                        attributed to participating oncology practices 
                        if the demonstration project had not been 
                        implemented exceeds such aggregate expenditures 
                        for such individuals for such year of the 
                        demonstration project;
                            ``(ii) calculating the amount that is half 
                        of the amount estimated 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 
                        calculation made under clause (ii).
                    ``(E) Amount of payments to individual practices 
                that meet performance standards and achieve savings.--
                            ``(i) Payments only to practices that meet 
                        performance standards.--The Secretary may not 
                        make performance incentive payments to a 
                        participating oncology practice under 
                        subparagraph (A) with respect to a year of the 
                        demonstration project described in subparagraph 
                        (B) unless the practice meets or exceeds the 
                        performance standards developed under 
                        subsection (e)(4)(B) for the 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 patient experience of 
                                care 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 
                        consultation with the appropriate stakeholders 
                        described in subsection (e)(3)(B) in a manner 
                        determined by the Secretary, determine the 
                        amount of a performance incentive payment to a 
                        participating oncology practice under 
                        subparagraph (A) for a year of the 
                        demonstration project described in subparagraph 
                        (B). 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) with 
                        respect to the year and the aggregate pool 
                        available for making payments for such year 
                        determined under subparagraph (D), as available 
                        for such year.
            ``(3) Issuance of guidance.--Not later than the date that 
        is 12 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 (D) and 
        (E) of paragraph (2).
    ``(g) Secretary Reports to Participating Oncology Practices.--The 
Secretary shall inform each participating oncology practice, on a 
periodic (such as quarterly) basis, of--
            ``(1) the performance of the practice with respect to the 
        measures on which the practice has agreed to report to the 
        Secretary under subsection (c)(6)(A); and
            ``(2) the estimated amount by which the expenditures that 
        would have been expended under parts A and B for items and 
        services furnished to individuals attributed to the practice if 
        the demonstration project had not been implemented exceeds the 
        actual expenditures for such individuals.
    ``(h) Applications From Entities To Provide Accreditations.--Not 
later than the date that is 18 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) Revisions to Demonstration Project.--The Secretary may make 
appropriate revisions to the demonstration project under this section 
in order for participating oncology practices under such demonstration 
project to meet the definition of an eligible alternative payment 
entity for purposes of section 1833(z).
    ``(j) Waiver Authority.--The Secretary may waive such provisions of 
this title and title XI as the Secretary determines necessary in order 
to implement the demonstration project under this section.
    ``(k) Administration.--Chapter 35 of title 44, United States Code, 
shall not apply to this section.''.
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