[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 2157 Introduced in Senate (IS)]

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116th CONGRESS
  1st Session
                                S. 2157

   To amend title XI of the Social Security Act to expand the use of 
              global payments to hospitals in rural areas.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             July 18, 2019

   Mr. Casey introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
   To amend title XI of the Social Security Act to expand the use of 
              global payments to hospitals in rural areas.

    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 ``Rural Hospital Sustainability Act''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Approximately 10,000,000 individuals age 65 and older 
        live in rural America today. In fact, 1 out of every 4 older 
        adults lives in a small town or other rural area.
            (2) Residents of rural areas are more likely to be poorer, 
        sicker, and have lower incomes compared to their urban 
        counterparts.
            (3) According to the Office of Rural Health Policy, from 
        2005 to 2009, people living in rural areas had an average life 
        expectancy of 76.8 years, a full two years less than their 
        urban counterparts who had an average life expectancy of 78.8 
        years.
            (4) Many rural hospitals are located in areas where a 
        majority of the population is age 65 and older and has Medicare 
        coverage.
            (5) Certain State-based demonstrations to improve payment 
        models for rural hospitals show promise in improving 
        healthcare, reducing costs, and integrating services for 
        patients.
            (6) Experts and organizations suggest that transitioning 
        rural hospitals to global payment systems would benefit 
        patients, providers, and rural communities.

SEC. 3. EXPANDING THE USE OF GLOBAL PAYMENTS TO HOSPITALS IN RURAL 
              AREAS.

    Section 1115A(b)(2) of the Social Security Act (42 U.S.C. 
1315a(b)(2)) is amended--
            (1) in subparagraph (B), by adding at the end the following 
        new clause:
                            ``(xxviii) National testing of a model for 
                        global payments to hospitals in rural areas as 
                        described in subparagraph (D).''; and
            (2) by adding at the end the following new subparagraph:
                    ``(D) National testing of model for global payments 
                to hospitals in rural areas.--In the case where the 
                Secretary selects the model described in clause (ii) of 
                this subparagraph for testing pursuant to clause 
                (xxviii) of subparagraph (B), the following shall 
                apply:
                            ``(i) National testing.--
                                    ``(I) In general.--Subject to 
                                subclause (II), the Secretary shall 
                                allow each State to develop and submit 
                                to the Secretary an application to 
                                begin testing such model in accordance 
                                with this clause within 1 year of the 
                                date on which the model is selected for 
                                such testing.
                                    ``(II) State designation of 
                                entities.--A State may designate an 
                                entity or organization for purposes of 
                                developing and submitting an 
                                application under subclause (I) with 
                                respect to the State, which may include 
                                the implementation of such model in the 
                                State. In the case where a State makes 
                                such a designation, with respect to any 
                                activities covered by the designation, 
                                the entity or organization so 
                                designated shall be subject to any 
                                requirements applicable to the 
                                implementing State under this 
                                subparagraph in the same manner as such 
                                requirements are applicable to the 
                                implementing State.
                                    ``(III) No effect on ongoing models 
                                or demonstration projects.--Nothing in 
                                this subparagraph shall effect the 
                                testing of any model under this 
                                subsection or any demonstration project 
                                under this Act that is implemented 
                                prior to the date of the enactment of 
                                this subparagraph.
                            ``(ii) Model described.--The model 
                        described in this clause seeks to increase 
                        rural Americans' access to quality care in 
                        order to improve health, while also reducing 
                        the growth of hospital expenditures across 
                        payers, including Medicare, and increasing the 
                        financial viability of rural hospitals to 
                        ensure continued access to care. Under this 
                        model, participating rural hospitals would--
                                    ``(I) be paid based on all-payer 
                                global budget, a fixed amount that is 
                                set in advance for inpatient and 
                                outpatient hospital-based services and 
                                paid monthly by Medicare fee-for-
                                service, State Medicaid plans, and all 
                                other participating payers;
                                    ``(II) deliberately redesign the 
                                delivery of care to improve quality of 
                                care and meet the needs of their local 
                                communities;
                                    ``(III) receive an upfront, fixed 
                                payment for infrastructure redesign, in 
                                an amount to be recovered over a period 
                                of time as set forth by the Secretary;
                                    ``(IV) receive annual global budget 
                                payment adjustments based on an amount 
                                determined in conjunction with the 
                                Secretary; and
                                    ``(V) partner with non-hospital 
                                providers such as physicians, 
                                behavioral health providers, schools, 
                                and community based organizations to 
                                create a comprehensive care delivery 
                                system.
                            ``(iii) Definitions.--In this subparagraph:
                                    ``(I) Implementing state.--The term 
                                `implementing State' means a State 
                                whose application to begin testing such 
                                model is approved by the Secretary 
                                under clause (i).
                                    ``(II) Rural hospital.--The term 
                                `rural hospital' means the following:
                                            ``(aa) A critical access 
                                        hospital (as defined in section 
                                        1861(mm)(1)).
                                            ``(bb) A sole community 
                                        hospital (as defined in section 
                                        1886(d)(5)(D)(iii)).
                                            ``(cc) A medicare-
                                        dependent, small rural hospital 
                                        (as defined in section 
                                        1886(d)(5)(G)(iv)).
                                            ``(dd) Any other hospital 
                                        that is located in a rural area 
                                        (as defined in section 
                                        1886(d)(2)(D)) or is treated as 
                                        being located in a rural area 
                                        pursuant to section 
                                        1886(d)(8)(E).
                            ``(iv) Requirements for participating 
                        hospitals.--
                                    ``(I) In general.--In order to 
                                participate in the model in an 
                                implementing State, a rural hospital 
                                must--
                                            ``(aa) subject to subclause 
                                        (II), conduct a community 
                                        health needs assessment survey 
                                        to determine the condition and 
                                        health needs in their 
                                        community, including those 
                                        needs with respect to mental or 
                                        behavioral health; and
                                            ``(bb) following such 
                                        assessment survey, submit and, 
                                        subject to clause (vi), receive 
                                        approval of a Rural Hospital 
                                        Transformation Plan (as 
                                        described in clause (v)) from 
                                        the implementing State and the 
                                        Secretary.
                                    ``(II) Exception.--A rural hospital 
                                meets the requirement described in 
                                subclause (I)(aa) if the rural hospital 
                                has conducted a community health needs 
                                assessment survey during the preceding 
                                year for any purpose.
                            ``(v) Rural hospital transformation plan 
                        described.--A Rural Hospital Transformation 
                        Plan described in this clause, with respect to 
                        a rural hospital, shall include the following 
                        information:
                                    ``(I) Results of the community 
                                health needs assessment survey under 
                                clause (iv)(I)(aa) and an explanation 
                                of how the Transformation Plan suits 
                                the needs of the community.
                                    ``(II) The population of 
                                individuals who will be served by the 
                                rural hospital under the model.
                                    ``(III) The types of services that 
                                will be included in the global payment 
                                under the model.
                                    ``(IV) How the rural hospital 
                                intends to improve quality and health 
                                outcomes under the model, including 
                                which population health outcomes the 
                                hospital will assess on an annual 
                                basis.
                                    ``(V) How the rural hospital will 
                                achieve patient engagement and 
                                involvement in the model.
                                    ``(VI) How the rural hospital will 
                                identify, partner with, and pay other 
                                entities participating in the model.
                                    ``(VII) How private payers will be 
                                included in the model.
                                    ``(VIII) Plans to account for any 
                                market share changes under the model.
                                    ``(IX) How access to preventive 
                                care will be increased under the model.
                                    ``(X) How the rural hospital will 
                                sustain the changes made under the 
                                model.
                                    ``(XI) How savings under the model 
                                will accrue to the Medicare program 
                                under title XVIII.
                                    ``(XII) Any other information 
                                required by the implementing State or 
                                the Secretary.
                            ``(vi) Opportunity for public comment.--In 
                        order for the Secretary or an implementing 
                        State to approve a Rural Hospital 
                        Transformation Plan under clause (iv), the 
                        Secretary in consultation with the implementing 
                        State, shall--
                                    ``(I) provide the public with a 
                                meaningful opportunity, as determined 
                                by the Secretary, to provide comments 
                                on the plan; and
                                    ``(II) make a summary of comments 
                                provided available to the public on the 
                                Internet website of the Centers for 
                                Medicare & Medicaid Services.
                            ``(vii) Technical assistance.--The 
                        Secretary shall designate an entity to provide 
                        technical assistance to participating rural 
                        hospitals as they redesign the care they 
                        deliver under the model.
                            ``(viii) Accounting for uncertainty.--In 
                        order for implementing States and participating 
                        rural hospitals to receive unanticipated 
                        additional resources needed to implement the 
                        model, the Secretary shall establish procedures 
                        for implementing States and participating rural 
                        hospitals to submit to the Secretary a request 
                        for additional resources, should variations in 
                        services outside of normally planned volume 
                        occur or should new technologies be developed, 
                        or in such other circumstances as the Secretary 
                        determines appropriate.
                            ``(ix) Monitoring outcomes.--The Secretary, 
                        in conjunction with implementing States and 
                        participating rural hospitals, shall develop a 
                        plan to--
                                    ``(I) identify, using a 
                                participating rural hospital's approved 
                                Rural Hospital Transformation Plan 
                                described in clause (v), the relevant 
                                local population of patients 
                                attributable to the hospital, the data 
                                points the hospital may need to guide 
                                care redesign for that population, and 
                                how the hospital may use such data;
                                    ``(II) annually monitor outcomes 
                                under the model, which may include 
                                financial, quality, access, and 
                                utilization outcomes;
                                    ``(III) annually monitor the 
                                specific population health outcomes 
                                listed in the approved Rural Hospital 
                                Transformation Plan of each 
                                participating rural hospital pursuant 
                                to clause (v)(IV); and
                                    ``(IV) any other outcomes as 
                                determined by the Secretary.
                            ``(x) Risk mitigation.--As part of the 
                        model, the Secretary, in conjunction with 
                        implementing States and participating rural 
                        hospitals, shall develop appropriate mechanisms 
                        to mitigate risks, including the use of 
                        reinsurance.
                            ``(xi) Reporting requirements.--
                                    ``(I) Report to secretary.--An 
                                implementing State, as a condition of 
                                implementing the model, shall partner 
                                with an independent entity to report to 
                                the Secretary on the ability of a 
                                participating rural hospital to carry 
                                out the Rural Hospital Transformation 
                                Plan described in clause (v).
                                    ``(II) Report to congress.--Not 
                                less frequently than every 5 years (for 
                                the duration of the implementation of 
                                the model under this subparagraph), the 
                                Secretary shall submit to Congress a 
                                report on the implementation of the 
                                model under this subparagraph. The 
                                report shall include best practices for 
                                future implementation efforts and any 
                                other information the Secretary 
                                determines appropriate, including the 
                                information reported under subclause 
                                (I), together with recommendations for 
                                such legislation and administrative 
                                action as the Secretary determines 
                                appropriate.
                            ``(xii) Funding.--The Secretary shall 
                        allocate funds made available under subsection 
                        (f)(1) to design, implement, evaluate, and 
                        report on the model described in clause (ii) in 
                        accordance with this subparagraph.''.
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