[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3780 Introduced in House (IH)]

<DOC>






115th CONGRESS
  1st Session
                                H. R. 3780

 To amend title XVIII of the Social Security Act to provide under the 
      Medicare program for conditions of participation, reporting 
   requirements, and a quality program with respect to air ambulance 
                               services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 14, 2017

 Mr. Hudson (for himself, Mr. Kennedy, Ms. Jenkins of Kansas, and Mr. 
    Kind) 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 provide under the 
      Medicare program for conditions of participation, reporting 
   requirements, and a quality program with respect to air ambulance 
                               services.

    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 ``Air Ambulance Quality and 
Accountability Act''.

SEC. 2. FINDINGS.

    Congress finds as follows:
            (1) Patient access to high quality and essential air 
        ambulance services can mean the difference between life and 
        death and quality of survival for patients.
            (2) Medicare should assure beneficiaries of high quality 
        air ambulance services and patient safety.
            (3) Medicare has no requirements related to quality 
        measurement and reporting, adherence to relevant standards as a 
        condition of participating in Medicare, and robust cost 
        reporting.
            (4) Medicare currently reimburses all suppliers and 
        providers of air ambulance services the same, regardless of 
        clinical capability or investment in aviation safety that 
        exceeds requirements of the Federal Aviation Administration.
            (5) A subset of patients requiring air transport are so 
        critically ill or injured as to require an advanced level of 
        clinical capability to address unstable and life-threatening 
        medical conditions that may develop or deteriorate during 
        transport. The costs of providing care to such patients should 
        be reported to enable the Congress to assess the sufficiency 
        and appropriateness of reimbursement for these most vulnerable 
        patients.
            (6) There remain many geographic areas of the nation with 
        limited access to air ambulance services due to low volume of 
        patients in geographically isolated and very rural areas.
            (7) Medicare and Medicaid payment should be adequate to 
        protect and promote access to air ambulance services that are 
        capable of meeting the clinical needs of the most critically 
        ill and injured patients, allow necessary investments in 
        transport safety, and enable transport to the appropriate 
        medical center to receive them.
            (8) An evaluation of Medicare payment policy is warranted 
        to assess and secure recommendations about payment adequacy for 
        air ambulance providers and suppliers and the realistic costs 
        of providing this life-saving transport services.
            (9) Mandatory cost reporting is necessary for air ambulance 
        services providers receiving Medicare reimbursement to ensure 
        fair and adequate reimbursement and allow appropriate access.
            (10) Such reporting should also capture essential data with 
        regard to access, cost, utilization, quality and variation of 
        such services to enable more specifically narrowly tailoring 
        payments commensurate with higher costs actually incurred such 
        as those treating the most critically ill and injured, 
        investing in higher cost aviation safety and airframes, and 
        serving patients in the most geographically isolated areas.

SEC. 3. STANDARDS FOR AIR AMBULANCE PROVIDERS AND SUPPLIERS.

    (a) Minimum Standards.--Section 1834(l) of the Social Security Act 
(42 U.S.C. 1395m(l)) is amended by adding at the end the following new 
paragraph:
            ``(17) Minimum standards for air ambulance providers and 
        suppliers.--
                    ``(A) In general.--Not later than 2 years after the 
                date of the enactment of this paragraph, the Secretary 
                shall, in consultation with relevant stakeholders, 
                establish minimum standards which air ambulance 
                suppliers and providers would be required to satisfy as 
                a condition of participation under this title.
                    ``(B) Air ambulance minimum standards.--In 
                establishing the minimum standards under subparagraph 
                (A), the Secretary shall include at least minimum 
                standards with respect to the following:
                            ``(i) Scope of practice, training and 
                        clinical capability of medical personnel 
                        relevant to medical condition of patients 
                        transported.
                            ``(ii) Medical equipment (such as patient 
                        monitoring, respiratory and hemodynamic and 
                        other relevant patient support equipment), 
                        devices, technology and formularies.
                            ``(iii) Vehicle attributes to support 
                        needed care, including configuration and 
                        conditions of medical environment, electrical 
                        supply in air ambulance and other related 
                        equipment.
                            ``(iv) Documentation standards, such as 
                        patient care records, timeline of care and 
                        transport, history of present illness and 
                        assessments, and documentation specific to 
                        diagnostic and therapeutic procedures.
                            ``(v) Medical direction and physician 
                        medical oversight, such as credentials of such 
                        physicians.
                            ``(vi) Reporting of always events, such as 
                        care coordination and transition, pain 
                        management, preventing ventilator acquired 
                        pneumonia or invasive line or wound infections.
                            ``(vii) Reporting of never events, such as 
                        loss of oxygen, delivery of a baby during 
                        transport, patient death or disability due to 
                        vehicle failure or crash, transport to 
                        unintended destination, dropping a patient or 
                        allowing a fall during movement of patient, 
                        failure to communicate time of arrival, 
                        hypoglycemia, and medication errors.
                            ``(viii) Patient safety and infection 
                        control.
                            ``(ix) Physician directed clinical quality 
                        management and clinical performance improvement 
                        programs including quality assurance, 
                        utilization review, outcomes, proficiency 
                        measures and patient safety.
                            ``(x) Standards relevant to particular 
                        populations, such as those on balloon pumps or 
                        ECMO.
                    ``(C) Deemed status.--Air ambulance providers and 
                suppliers that are accredited by an accreditation 
                organization approved by the Secretary as having 
                standards that meet or exceed the Secretary's standards 
                for such providers shall be deemed to be in compliance 
                with the minimum requirements required pursuant to this 
                paragraph.''.

SEC. 4. AIR AMBULANCE COST REPORTING PROGRAM.

    Section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), as 
amended by section 3, is further amended by adding at the end the 
following new paragraph:
            ``(18) Air ambulance cost reporting program.--
                    ``(A) In general.--For the first year beginning at 
                least 12 months after the date of the enactment of this 
                paragraph and each subsequent year, an air ambulance 
                provider or supplier of air ambulance services shall 
                submit to the Secretary (in a form and manner and at 
                such time as specified by the Secretary) data described 
                in subparagraph (B) for the reporting period (as 
                specified by the Secretary) for such year.
                    ``(B) Cost data.--For purposes of reporting data 
                under this for air ambulance services furnished with 
                respect to a year, the data described in this 
                subparagraph are cost data specified by the Secretary 
                relating to the following:
                            ``(i) Geographic location factors, 
                        including mileage and number of providers in 
                        the service area.
                            ``(ii) Capital and operational costs, such 
                        as the type of aircraft, including fixed wing 
                        aircraft, rotary wing aircraft--single or twin 
                        engine, instrumented flight or visual flight.
                            ``(iii) Maintenance of aircraft, including 
                        avionics, communications equipment, fuel, and 
                        general repairs.
                            ``(iv) Maintenance of equipment, including 
                        specialty clinical equipment.
                            ``(v) Medical supplies.
                            ``(vi) Employee expenses, including 
                        salaries and insurance (life, health, and 
                        liability).
                            ``(vii) Building expenses, including rent 
                        and maintenance.
                            ``(viii) Any other costs as specified by 
                        the Secretary, in consultation with the 
                        Secretary of Transportation, as needed to be 
                        included under this subparagraph for purposes 
                        of informing the report and evaluation under 
                        section 6 of the Air Ambulance Quality and 
                        Accountability Act or for purposes of enabling 
                        Congress to make appropriate determinations 
                        about payment under this section to air 
                        ambulance providers and suppliers.
                The Secretary, in consultation with providers and 
                suppliers of air ambulance services, shall periodically 
                update, as determined necessary by the Secretary, the 
                cost data specified pursuant to this subparagraph.
                    ``(C) Suspension of payment for failure to 
                report.--
                            ``(i) In general.--With respect to air 
                        ambulance services furnished by a supplier or 
                        provider of air ambulance services during the 
                        second year beginning at least 12 months after 
                        the date of the enactment of this paragraph or 
                        any subsequent year, in the case that the 
                        supplier or provider does not submit data to 
                        the Secretary in accordance with subparagraph 
                        (A) for the reporting period applicable to such 
                        year (which shall be during the previous year), 
                        the Secretary shall suspend payments under the 
                        fee schedule under this subsection for air 
                        ambulance services furnished by such supplier 
                        or provider during such year until such 
                        supplier or provider submits such data in 
                        accordance with such subparagraph.
                            ``(ii) Treatment of new medicare suppliers 
                        and providers of air ambulance services.--In 
                        the case of a supplier or provider of air 
                        ambulance services that first becomes a 
                        Medicare enrolled supplier or provider of air 
                        ambulance services during the reporting period 
                        applicable to a year with respect to which 
                        clause (i) applies (and had not previously 
                        submitted claims under this title such as a 
                        person or entity or under a different billing 
                        number or tax identifier), such supplier or 
                        provider shall not be subject to clause (i) 
                        until the subsequent year and with respect to 
                        data required to be submitted for the reporting 
                        period applicable to such subsequent year.''.

SEC. 5. AIR AMBULANCE QUALITY REPORTING PROGRAM.

    Section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), as 
amended by sections 3 and 4, is further amended by adding at the end 
the following new paragraph:
            ``(19) Air ambulance quality reporting program.--
                    ``(A) Payment based on performance.--
                            ``(i) In general.--The Secretary shall 
                        establish an air ambulance quality reporting 
                        and performance program under which--
                                    ``(I) with respect to air ambulance 
                                services furnished by a supplier or 
                                provider of air ambulance services 
                                during the first consequence year, 
                                second consequence year, or third 
                                consequence year, in the case that the 
                                supplier or provider does not submit a 
                                report, with respect to the performance 
                                period for such year, in accordance 
                                with subparagraph (C), after 
                                determining the percentage increase 
                                under paragraph (3)(B), and after 
                                application of paragraphs (3)(C) and 
                                (18), the Secretary shall reduce such 
                                percentage increase for payments under 
                                the fee schedule under this subsection 
                                during such year by 2 percentage 
                                points; and
                                    ``(II) with respect to air 
                                ambulance services furnished by a 
                                supplier or provider of air ambulance 
                                services during a consequence year 
                                after the third consequence year, the 
                                Secretary applies a percentage point 
                                adjustment to the percentage increase 
                                determined under paragraph (3)(B), 
                                after application of paragraphs (3)(C) 
                                and (18), in a manner that provides for 
                                differential payment to a supplier or 
                                provider of air ambulance services 
                                based upon the quality of care 
                                furnished (as determined under 
                                subparagraph (B)) during a performance 
                                period with respect to such consequence 
                                year (with such percentage point 
                                adjustment ranging from an increase of 
                                5 percentage points for such services 
                                furnished in a consequence year by such 
                                a provider or supplier with the highest 
                                demonstrated performance in the 
                                performance period for such year to a 
                                decrease of 5 percentage points for 
                                such services furnished in the 
                                consequence year by such a provider or 
                                supplier with the lowest demonstrated 
                                performance for the performance period 
                                for such year).
                            ``(ii) Special rule.--The application of 
                        this subparagraph may result in such percentage 
                        increase being less than 0.0 for a year, and 
                        may result in payment rates under the fee 
                        schedule under this subsection for a year being 
                        less than such payment rates for the preceding 
                        year.
                            ``(iii) Noncumulative application.--Any 
                        adjustment under this subparagraph shall apply 
                        only with respect to the year involved and the 
                        Secretary shall not take into account such 
                        adjustment in computing the payment amount 
                        under the fee schedule under this subsection 
                        for a subsequent year.
                            ``(iv) Treatment of new medicare suppliers 
                        and providers of air ambulance services.--In 
                        the case of a supplier or provider of air 
                        ambulance services that first becomes a 
                        Medicare enrolled supplier or provider of air 
                        ambulance services during the performance 
                        period for a consequence year (and had not 
                        previously submitted claims under this title 
                        such as a person or entity or under a different 
                        billing number or tax identifier), the 
                        adjustment under clause (i) shall not apply to 
                        such supplier or provider until the subsequent 
                        consequence year and performance period for 
                        such subsequent consequence year.
                    ``(B) Determining performance.--
                            ``(i) In general.--Under the air ambulance 
                        quality reporting and performance program, the 
                        performance of a provider or supplier of air 
                        ambulance services with respect to a 
                        performance period with respect to a 
                        consequence year after the third consequence 
                        year shall be determined as specified by the 
                        Secretary based on data required under 
                        subparagraph (C) to be submitted (in a form and 
                        manner and at such time as specified by the 
                        Secretary) by the provider or supplier for such 
                        performance period for the consequence year.
                            ``(ii) Treatment of non-reporters.--Under 
                        the air ambulance quality reporting and 
                        performance program, for purposes of 
                        subparagraph (A), any provider or supplier of 
                        air ambulance services who does not submit data 
                        required under subparagraph (C) to submitted 
                        for a performance period with respect to a 
                        consequence year after the third consequence 
                        year, shall be treated as if such provider or 
                        supplier had the lowest demonstrated 
                        performance for the performance period for such 
                        year.
                    ``(C) Reporting.--
                            ``(i) In general.--For purposes of this 
                        paragraph for years beginning with the first 
                        consequence year, an air ambulance provider or 
                        supplier shall submit to the Secretary a 
                        report, with respect to the performance period 
                        for such year, on--
                                    ``(I) the measures described in 
                                subparagraph (D)(i);
                                    ``(II) in the case of a consequence 
                                year before the fourth consequence 
                                year--
                                            ``(aa) at least 2 of the 
                                        measures described in 
                                        subparagraph (D)(ii)(I); and
                                            ``(bb) at least 2 of the 
                                        measures established under 
                                        subparagraph (D)(iii)(I); and
                                    ``(III) in the case of a 
                                consequence year beginning with the 
                                fourth consequence year--
                                            ``(aa) at least 4 of the 
                                        measures described in 
                                        subparagraph (D)(ii)(II); and
                                            ``(bb) at least 4 of the 
                                        measures established under 
                                        subparagraph (D)(iii)(II).
                            ``(ii) Availability of data.--The Secretary 
                        shall establish procedures for making data 
                        submitted under clause (i) available to the 
                        public. Such procedures shall ensure that--
                                    ``(I) data submitted under clause 
                                (i) for the first consequence year 
                                shall not be made public; and
                                    ``(II) an air ambulance provider or 
                                supplier has the opportunity to review 
                                the data that is to be made public with 
                                respect to the air ambulance provider 
                                or supplier prior to such data being 
                                made public.
                    ``(D) Measures.--In establishing the quality 
                program under subparagraph (A), the following shall 
                apply:
                            ``(i) Over-triage.--The Secretary shall 
                        provide for the application of a measure with 
                        respect to over-triage in mode of 
                        transportation.
                            ``(ii) Patient safety measures.--The 
                        Secretary shall, in consultation with providers 
                        and suppliers of air ambulance services, 
                        establish--
                                    ``(I) with respect to a performance 
                                period with respect to a consequence 
                                year before the fourth consequence 
                                year, at least 3 patient safety 
                                measures for providers and suppliers of 
                                air ambulance services; and
                                    ``(II) with respect to a 
                                performance period with respect to a 
                                consequence year beginning with the 
                                fourth consequence year, at least 6 
                                patient safety measures for providers 
                                and suppliers of air ambulance 
                                services.
                            ``(iii) Clinical quality measures.--The 
                        Secretary shall, in consultation with providers 
                        and suppliers of air ambulance services, 
                        establish--
                                    ``(I) with respect to a performance 
                                period with respect to a consequence 
                                year before the fourth consequence 
                                year, at least 3 clinical quality 
                                measures for providers and suppliers of 
                                air ambulance services; and
                                    ``(II) with respect to a 
                                performance period with respect to a 
                                consequence year beginning with the 
                                fourth consequence year, at least 6 
                                clinical quality measures for providers 
                                and suppliers of air ambulance 
                                services.
                            ``(iv) Updates.--The Secretary, in 
                        consultation with providers and suppliers of 
                        air ambulance services, shall periodically 
                        update, as determined necessary by the 
                        Secretary, the measures to be applied pursuant 
                        to this subparagraph.
                    ``(E) Definitions.--For purposes of this paragraph:
                            ``(i) The term `consequence year' means a 
                        year beginning with the 5th year starting at 
                        least 12 months after the date of the enactment 
                        of this paragraph. The terms `first consequence 
                        year', second consequence year, and third 
                        consequence year mean such 5th year starting at 
                        least 12 months after such date of enactment, 
                        the 6th year starting at least 12 months after 
                        such date of enactment, and the 7th year 
                        starting at least 12 months after such date of 
                        enactment, respectively.
                            ``(ii) The term `performance period' means, 
                        with respect to a consequence year, such period 
                        as specified by the Secretary.''.

SEC. 6. MEDPAC STUDY ON ACCESS, QUALITY, COSTS, AND REIMBURSEMENT.

    (a) Evaluation.--Not later than three years after December 31 of 
the first year to which paragraph (18) of section 1834(l) of the Social 
Security Act, as added by section 4, applies, the Medicare Payment 
Advisory Commission shall submit to Congress a report containing an 
evaluation of the costs of air providers and suppliers. Such evaluation 
shall--
            (1) be derived from the cost and other data submitted under 
        such paragraph (18) of such section 1834(l); and
            (2) differentiate as appropriate to recognize variation or 
        higher costs related to--
                    (A) aviation instrument flight control;
                    (B) provision of care to critically ill or injured 
                patients;
                    (C) the provision of services in geographically 
                isolated areas; and
                    (D) the provision of care to uninsured individuals.
    (b) Recommendations.--As part of the report submitted under 
subsection (a), the Medicare Payment Advisory Commission shall provide 
recommendations on whether changes should be made with regard to 
reimbursement of air ambulance providers and suppliers under title 
XVIII of the Social Security Act based upon the data submitted under 
paragraph (18) of section 1834(l) of the Social Security Act, as added 
by section 4, taking into consideration variables affecting payment 
adequacy under such title for and its impact on Medicare beneficiaries, 
including--
            (1) whether payment under such title is sufficient to 
        ensure access to air ambulance services or should be altered, 
        including whether payment should be higher for air ambulance 
        providers and suppliers--
                    (A) with higher levels of clinical capability to 
                serve the most critically ill and injured patients; and
                    (B) that utilize advanced and expense avionics such 
                as Instrument Flight Rules;
            (2) whether uncompensated care borne by air ambulance 
        providers and suppliers impedes access;
            (3) the degree to which there is variation in the 
        utilization of air ambulance services on a per capita and per 
        transport basis, including whether the undersupply or 
        oversupply of helicopters or fixed wing aircraft in a 
        geographic region affects access and the volume and adequacy of 
        payments under such title with regard to such utilization;
            (4) the degree to which membership programs are utilized by 
        air ambulance providers and suppliers to sustain their 
        operations, and if revenue from membership programs is used to 
        reduce their costs or provide capital funding, and whether such 
        programs are beneficial to Medicare beneficiaries;
            (5) the degree of subsidization that occurs from private 
        insurers or hospitals sponsoring air ambulance providers or 
        suppliers to cover inadequate payments under title XVIII or XIX 
        of the Social Security Act and enable reasonable profitability;
            (6) the ratio of charges to Medicare reimbursement and the 
        impact on beneficiary cost sharing of cost, utilization, and 
        variation in air ambulance services;
            (7) appropriate financial or other incentives for the 
        utilization of ground critical care transport where medically 
        appropriate;
            (8) the degree to which a quality reporting and performance 
        program based upon patient safety measures and clinical quality 
        measures should be used in determining a value based payment 
        model for suppliers and providers of air ambulance service; and
            (9) any other information deemed relevant and appropriate 
        by the Medicare Payment Advisory Commission for the purposes of 
        providing such recommendations.
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