[Congressional Record Volume 153, Number 178 (Friday, November 16, 2007)]
[Senate]
[Pages S14621-S14624]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
By Mr. DURBIN (for himself and Mr. Burr):
S. 2376. A bill to establish a demonstration project to provide for
patient-centered medical homes to improve the effectiveness and
efficiency in providing medical assistance under the Medicaid program
and child health assistance under the State Children's Health Insurance
Program; to the Committee on Finance.
Mr. DURBIN. Mr. President, we are all aware of the current healthcare
crisis in our nation. Health care spending continues to rise at an
unsustainable rate, constituting 16 percent of the Federal budget.
Health care costs have increased 78 percent since 2001, more than 4
times the pace of prices and wages.
One reason for the rise in costs and spending is the increase in
chronic disease. Heart disease, cancer, and diabetes are the leading
causes of death and disability in the U.S. They also account for 70
percent of all deaths in the U.S., or 1.7 million people each year.
These diseases also make life harder for the 1 of 10 Americans who are
living with them. The irony, of course, is that chronic diseases are
both preventable and manageable.
The quality of our healthcare has not changed substantially despite
the fact that we live in the wealthiest country in the world with the
best researchers and medical doctors at our fingertips. At a time when
both health care costs and chronic illnesses are on the rise, we need a
better way to provide care.
Changing the delivery of care is a controversial topic, but it is a
topic that has gained more traction in recent months. Last week, the
New York Times published an article titled, ``A Model for Health Care
That Pays for Quality.'' The article described a new model for
healthcare, and I quote here, ``to identify the best primary care
doctors and to steer patients their way. Those doctors, in turn, would
be paid for more services than are currently reimbursed under typical
health plan payments for office visits. The idea is to encourage
doctors to meet with patients for more than a few minutes during an
office visit and to also compensate them, or nurse coordinators, for
communicating with patients by phone and e-mail outside office hours.''
This is an approach to delivering care that national physician groups
and patient advocacy organizations call the medical home.
A medical home is something that those of us who have it take for
granted. We see the same doctor, in the same setting, for extended
periods of time. Our medical history is in one place, and even if we
are seeing specialists or different doctors in the same practice, there
is continuity in decisions about our health care. This is a medical
home.
But many people do not have this luxury. Think about people who move
from place to place, whose home lives are less than stable, who don't
have health insurance, whose medical care is sporadic. For these
members of our community, each visit to a clinic or an emergency room
means starting over again.
So, everyone should have access to a medical home. A medical home is
not only a place, but an approach to providing comprehensive primary
care that respects, and responds to, individual patient preferences and
needs and helps patients develop relationships with their providers.
It sounds easy, but it requires some changes and creative thinking
and, perhaps most importantly, it requires a commitment by local
providers to work together. The medical home model makes sense for
improving health care for everyone. It is a model of care that makes
sense for stretching our limited Federal health care dollars.
States like Illinois and North Carolina are already seeing progress
with implementing the medical home model. Illinois Health Connect is a
new program at the Illinois Department of Healthcare and Family
Services that uses the medical home model to deliver primary and
preventive care for children and adults covered through the All Kids
program. This emphasis on coordinated and ongoing care is leading to
better health outcomes, and it's saving money.
Community Care of North Carolina launched a medical home model in
1998, through nine physician-led networks. North Carolina started by
creating medical homes for 250,000 Medicaid enrollees. Today, it is a
State-wide program that has saved the state at least $60 million in
Medicaid costs in 2003 and $120 million in 2004.
[[Page S14622]]
Cost savings is not the only benefit. Several studies show that the
medical home approach improves quality of care. Early analyses are
finding that having regular access to a particular physician through
the medical home is associated with earlier and more accurate
diagnoses, fewer emergency room visits, fewer hospitalizations, lower
costs, better care, and increased patient satisfaction. Many studies
conclude that having both health insurance and a medical home leads to
improved overall health for the entire population, which brings down
the cost of care and reduces health care disparities.
Today, I am proud to be joined by my colleague Senator Richard Burr
of North Carolina to introduce the Medical Homes Act of 2007. This bill
would make it easier for other states to implement a medical home
model, much like Illinois and North Carolina have. Congress passed a
medical home demonstration project for Medicare last year. The Medical
Homes Act of 2007 would do this for Medicaid and SCHIP beneficiaries by
making Federal funding available for a demonstration project in 8
States to provide care through patient-centered medical homes.
The approach we propose requires a per-member, per-month care
management fee to help pay for participating doctors and provides
initial start-up funding for participating States. The startup funds
are used for the purchase of health information technology, primary
care case managers, and other uses appropriate for the delivery of
patient-centered care.
If patients, provider, payers, and the government work together to
create a system that values the patient more than payments and the
health outcome of the patient more than the number of patients seen, we
can really change the way primary care is provided. I urge my
colleagues to support the Medical Homes Act of 2007 and help stabilize
healthcare delivery for low-income and elderly Americans.
Mr. President, I ask unanimous consent that the text of the bill be
printed in the Record.
There being no objection, the text of the bill was ordered to be
printed in the Record, as follows:
S. 2376
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 ``Medical Homes Act of 2007''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Medical homes provide patient-centered care, leading to
better health outcomes and greater patient satisfaction. A
growing body of research supports the need to involve
patients and their families in their own health care
decisions, to better inform them of their treatment options,
and to improve their access to information.
(2) Medical homes help patients better manage chronic
diseases and maintain basic preventive care, resulting in
better health outcomes than those who lack medical homes. An
investigation of the Chronic Care Model discovered that the
medical home reduced the risk of cardiovascular disease in
diabetes patients, helped congestive heart failure patients
become more knowledgeable and stay on recommended therapy,
and increased the likelihood that asthma and diabetes
patients would receive appropriate therapy.
(3) Medical homes also reduce disparities in access to
care. A survey conducted by the Commonwealth Fund found that
74 percent of adults with a medical home have reliable access
to the care they need, compared with only 52 percent of
adults with a regular provider that is not a medical home and
38 percent of adults without any regular source of care or
provider.
(4) Medical homes reduce racial and ethnic differences in
access to medical care. Three-fourths of Caucasians, African
Americans, and Hispanics with medical homes report getting
care when they need it in a medical home.
(5) Medical homes reduce duplicative health services and
inappropriate emergency room use. In 1998, North Carolina
launched the Community Care of North Carolina (CCNC) program,
which employs the medical home concept. Today CCNC includes
14 networks, that include all Federally qualified health
centers in the State, covering 740,000 recipients across the
entire State. An analysis conducted by Mercer Human Resources
Consulting Group found that CCNC resulted in $244,000,000 in
savings to the Medicaid program in 2004, with similar results
in 2005 and 2006.
(6) Health information technology is a crucial foundation
for medical homes. While many doctor's offices use electronic
health records for billing or other administrative functions,
few practices utilize health information technology
systematically to measure and improve the quality of care
they provide. For example, electronic health records can
generate reports to ensure that all patients with chronic
conditions receive recommended tests and are on target to
meet their treatment goals. Computerized ordering systems,
particularly with decision-support tools, can prevent medical
and medication errors, while e-mail and interactive Internet
websites can facilitate communication between patients and
providers and patient education.
SEC. 3. MEDICAID AND SCHIP DEMONSTRATION PROJECT TO SUPPORT
PATIENT-CENTERED PRIMARY CARE.
(a) Definitions.--In this section:
(1) Care management model.--The term ``care management
model'' means a model that--
(A) uses health information technology and other
innovations such as the chronic care model, to improve the
management and coordination of care provided to patients;
(B) is centered on the relationship between a patient and
their personal primary care provider;
(C) seeks guidance from--
(i) a steering committee; and
(ii) a medical management committee; and
(D) has established, where practicable, effective referral
relationships between the primary care provider and the major
medical specialties and ancillary services in the region.
(2) Health center.--The term ``health center'' has the
meaning given that term in section 330(a) of the Public
Health Service Act (42 U.S.C. 254b(a)).
(3) Medicaid.--The term ``Medicaid'' means the program for
medical assistance established under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.).
(4) Medical management committee.--The term ``medical
management committee'' means a group of local practitioners
that--
(A) reviews evidence-based practice guidelines;
(B) selects targeted diseases and care processes that
address health conditions of the community (as identified in
the National or State health assessment or as outlined in
``Healthy People 2010'', or any subsequent similar report (as
determined by the Secretary));
(C) defines programs to target diseases and care processes;
(D) establishes standards and measures for patient-centered
medical homes, taking into account nationally-developed
standards and measures; and
(E) makes the determination described in subparagraph
(A)(iii) of paragraph (5), taking into account the
considerations under subparagraph (B) of such paragraph.
(5) Patient-centered medical home.--
(A) In general.--The term ``patient-centered medical home''
means a physician-directed practice or a health center that--
(i) incorporates the attributes of the care management
model described in paragraph (1);
(ii) voluntarily participates in an independent evaluation
process whereby primary care providers submit information to
the medical management committee of the relevant network;
(iii) the medical management committee determines has the
capability to achieve improvements in the management and
coordination of care for targeted beneficiaries (as defined
by Statewide quality improvement standards and outcomes); and
(iv) meets the requirements imposed on a covered entity for
purposes of applying part C of title XI of the Public Health
Service Act (42 U.S.C. 300b-1 et seq.) and all regulatory
provisions promulgated thereunder, including regulations
(relating to privacy) adopted pursuant to the authority of
the Secretary under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2
note).
(B) Considerations.--In making the determination under
subparagraph (A)(iii), the medical management committee shall
consider the following:
(i) Access and communication with patients.--Whether the
practice or health center applies both standards for access
to care for and standards for communication with targeted
beneficiaries who receive care through the practice or health
center.
(ii) Managing patient information and using information
management to support patient care.--Whether the practice or
health center has readily accessible, clinically useful
information on such beneficiaries that enables the practice
or health center to comprehensively and systematically treat
such beneficiaries.
(iii) Managing and coordinating care according to
individual needs.--Whether the practice or health center--
(I) maintains continuous relationships with such
beneficiaries by implementing evidence-based guidelines and
applying such guidelines to the identified needs of
individual beneficiaries over time and with the intensity
needed by such beneficiaries;
(II) assists in the early identification of health care
needs;
(III) provides ongoing primary care; and
(IV) coordinates with a broad range of other specialty,
ancillary, and related services.
(iv) Providing ongoing assistance and encouragement in
patient self-management.--Whether the practice or health
center--
[[Page S14623]]
(I) collaborates with targeted beneficiaries who receive
care through the practice or health center to pursue their
goals for optimal achievable health;
(II) assesses patient-specific barriers; and
(III) conducts activities to support patient self-
management.
(v) Resources to manage care.--Whether the practice or
health center has in place the resources and processes
necessary to achieve improvements in the management and
coordination of care for targeted beneficiaries who receive
care through the practice or health center.
(vi) Monitoring performance.--Whether the practice or
health center--
(I) monitors its clinical process and performance
(including process and outcome measures) in meeting the
applicable standards under paragraph (4)(D); and
(II) provides information in a form and manner specified by
the steering committee and medical management committee with
respect to such process and performance.
(6) Personal primary care provider.--The term ``personal
primary care provider'' means--
(A) a physician, nurse practitioner, or other qualified
health care provider (as determined by the Secretary), who--
(i) practices in a patient-centered medical home; and
(ii) has been trained to provide first contact, continuous,
and comprehensive care for the whole person, not limited to a
specific disease condition or organ system, including care
for all types of health conditions (such as acute care,
chronic care, and preventive services); or
(B) a health center that--
(i) is a patient-centered medical home; and
(ii) has providers on staff that have received the training
described in subparagraph (A)(ii).
(7) Primary care case management services; primary care
case manager.--The terms ``primary care case management
services'' and ``primary care case manager'' have the meaning
given those terms in section 1905(t) of the Social Security
Act (42 U.S.C. 1396d(t)).
(8) Project.--The term ``project'' means the demonstration
project established under this section.
(9) SCHIP.--The term ``SCHIP'' means the State Children's
Health Insurance Program established under title XXI of the
Social Security Act (42 U.S.C. 1396aa et seq.).
(10) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(11) Steering committee.--The term ``steering committee''
means a local management group comprised of collaborating
local health care practitioners or a local not-for-profit
network of health care practitioners--
(A) that implements State-level initiatives;
(B) that develops local improvement initiatives;
(C) whose mission is to--
(i) investigate questions related to community-based
practice; and
(ii) improve the quality of primary care; and
(D) whose membership--
(i) represents the health care delivery system of the
community it serves; and
(ii) includes physicians (with an emphasis on primary care
physicians) and 1 representative from each part of the
collaborative or network (such as a representative from a
health center, a representative from the health department, a
representative from social services, and a representative
from each public and private hospital in the collaborative or
the network).
(12) Targeted beneficiary.--
(A) In general.--The term ``targeted beneficiary'' means an
individual who is eligible for benefits under a State plan
under Medicaid or a State child health plan under SCHIP.
(B) Participation in patient-centered medical home.--
Individuals who are eligible for benefits under Medicaid or
SCHIP in a State selected to participate in the project shall
receive care through a patient-centered medical home when
available.
(C) Ensuring choice.--In the case of such an individual who
receives care through a patient-centered medical home, the
individual shall receive guidance from their personal primary
care provider on appropriate referrals to other health care
professionals in the context of shared decisionmaking.
(b) Establishment.--The Secretary shall establish a
demonstration project under Medicaid and SCHIP for the
implementation of a patient-centered medical home program
that meets the requirements of subsection (d) to improve the
effectiveness and efficiency in providing medical assistance
under Medicaid and child health assistance under SCHIP to an
estimated 500,000 to 1,000,000 targeted beneficiaries.
(c) Project Design.--
(1) Duration.--The project shall be conducted for a 3-year
period, beginning not later than October 1, 2009.
(2) Sites.--
(A) In general.--The project shall be conducted in 8
States--
(i) four of which already provide medical assistance under
Medicaid for primary care case management services as of the
date of enactment of this Act; and
(ii) four of which do not provide such medical assistance.
(B) Application.--A State seeking to participate in the
project shall submit an application to the Secretary at such
time, in such manner, and containing such information as the
Secretary may require.
(C) Selection.--In selecting States to participate in the
project, the Secretary shall ensure that urban, rural, and
underserved areas are served by the project.
(3) Grants and payments.--
(A) Development grants.--
(i) First year development grants.--The Secretary shall
award development grants to States participating in the
project during the first year the project is conducted.
Grants awarded under this clause shall be used by a
participating State to--
(I) assist with the development of steering committees,
medical management committees, and local networks of health
care providers; and
(II) facilitate coordination with local communities to be
better prepared and positioned to understand and meet the
needs of the communities served by patient-centered medical
homes.
(ii) Second year funding.--The Secretary shall award
additional grant funds to States that received a development
grant under clause (i) during the second year the project is
conducted if the Secretary determines such funds are
necessary to ensure continued participation in the project by
the State. Grant funds awarded under this clause shall be
used by a participating State to assist in making the
payments described in paragraph (B). To the extent a State
uses such grant funds for such purpose, no matching payment
may be made to the State for the payments made with such
funds under section 1903(a) or 2105(a) of the Social Security
Act (42 U.S.C. 1396b(a); 1397ee(a)).
(B) Additional payments to personal primary care providers
and steering committees.--
(i) Payments to personal primary care providers.--
(I) In general.--Subject to subsection (d)(6)(B), a State
participating in the project shall pay a personal primary
care provider not less than $2.50 per month per targeted
beneficiary assigned to the personal primary care provider,
regardless of whether the provider saw the targeted
beneficiary that month.
(II) Federal matching payment.--Subject to subparagraph
(A)(ii), amounts paid to a personal primary care provider
under subclause (I) shall be considered medical assistance or
child health assistance for purposes of section 1903(a) or
2105(a), respectively, of the Social Security Act (42 U.S.C.
1396b(a); 1397ee(a)).
(III) Patient population.--In determining the amount of
payment to a personal primary care provider per month with
respect to targeted beneficiaries under this clause, a State
participating in the project shall take into account the care
needs of such targeted beneficiaries.
(ii) Payments to steering committees.--
(I) In general.--Subject to subsection (d)(6)(B), a State
participating in the project shall pay a steering committee
not less than $2.50 per targeted beneficiary per month.
(II) Federal matching payment.--Subject to subparagraph
(A)(ii), amounts paid to a steering committee under subclause
(I) shall be considered medical assistance or child health
assistance for purposes of section 1903(a) or 2105(a),
respectively, of the Social Security Act (42 U.S.C. 1396b(a);
1397ee(a)).
(III) Use of funds.--Amounts paid to a steering committee
under subclause (I) shall be used to purchase health
information technology, pay primary care case managers,
support network initiatives, and for such other uses as the
steering committee determines appropriate.
(4) Technical assistance.--The Secretary shall make
available technical assistance to States, physician
practices, and health centers participating in the project
during the duration of the project.
(5) Best practices information.--The Secretary shall
collect and make available to States participating in the
project information on best practices for patient-centered
medical homes.
(d) Patient-Centered Medical Home Program.--
(1) In general.--For purposes of this section, a patient-
centered medical home program meets the requirements of this
subsection if, under such program, targeted beneficiaries
designate a personal primary care provider in a patient-
centered medical home as their source of first contact,
comprehensive, and coordinated care for the whole person.
(2) Elements.--
(A) Mandatory elements.--
(i) In general.--Such program shall include the following
elements:
(I) A steering committee.
(II) A medical management committee.
(III) A network of physician practices and health centers
that have volunteered to participate as patient-centered
medical homes to provide high-quality care, focusing on
preventive care, at the appropriate time and place in a cost-
effective manner.
(IV) Hospitals and local public health departments that
will work in cooperation with the network of patient-centered
medical homes to coordinate and provide health care.
(V) Primary care case managers to assist with care
coordination.
(VI) Health information technology to facilitate the
provision and coordination of health care by network
participants.
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(ii) Multiple locations in the state.--In the case where a
State operates a patient-centered medical home program in 2
or more areas in the State, the program in each of those
areas shall include the elements described in clause (i).
(B) Optional elements.--Such program may include a non-
profit organization that--
(i) includes a steering committee and a medical management
committee; and
(ii) manages the payments to steering committees described
in subsection (c)(3)(B)(ii).
(3) Goals.--Such program shall be designed--
(A) to increase--
(i) cost efficiencies of health care delivery;
(ii) access to appropriate health care services, especially
wellness and prevention care, at times convenient for
patients;
(iii) patient satisfaction;
(iv) communication among primary care providers, hospitals,
and other health care providers;
(v) school attendance; and
(vi) the quality of health care services (as determined by
the relevant steering committee and medical management
committee, taking into account nationally-developed standards
and measures); and
(B) to decrease--
(i) inappropriate emergency room utilization, which can be
accomplished through initiatives, such as expanded hours of
care throughout the program network;
(ii) avoidable hospitalizations; and
(iii) duplication of health care services provided.
(4) Payment.--Under the program, payment shall be provided
to personal primary care providers and steering committees
(in accordance with subsection (c)(3)(B)).
(5) Notification.--The State shall notify individuals
enrolled in Medicaid or SCHIP about--
(A) the patient-centered medical home program;
(B) the providers participating in such program; and
(C) the benefits of such program.
(6) Treatment of states with a managed care contract.--
(A) In general.--In the case where a State contracts with a
private entity to manage parts of the State Medicaid program,
the State shall--
(i) ensure that the private entity follows the care
management model; and
(ii) establish a medical management committee and a
steering committee in the community.
(B) Adjustment of payment amounts.--The State may adjust
the amount of payments made under (c)(3)(B), taking into
consideration the management role carried out by the private
entity described in subparagraph (A) and the cost
effectiveness provided by such entity in certain areas, such
as health information technology.
(e) Evaluation and Project Report.--
(1) In general.--
(A) Evaluation.--The Secretary, in consultation with
appropriate health care professional associations, shall
evaluate the project in order to determine the effectiveness
of patient-centered medical homes in terms of quality
improvement, patient and provider satisfaction, and the
improvement of health outcomes.
(B) Project report.--Not later than 12 months after
completion of the project, the Secretary shall submit to
Congress a report on the project containing the results of
the evaluation conducted under subparagraph (A). Such report
shall include--
(i) an assessment of the differences, if any, between the
quality of the care provided through the patient-centered
medical home program conducted under the project in the
States that provide medical assistance for primary care case
management services and those that do not;
(ii) an assessment of quality improvements and clinical
outcomes as a result of such program;
(iii) estimates of cost savings resulting from such
program; and
(iv) recommendations for such legislation and
administrative action as the Secretary determines to be
appropriate.
(2) Sense of the senate.--It is the sense of the Senate
that, during the next authorization of SCHIP, titles XIX and
XXI of the Social Security Act (42 U.S.C. 1396 et seq.;
1397aa et seq.) should be amended, based on the results of
the evaluation and report under paragraph (1), to establish a
patient-centered medical home program under such titles on a
permanent basis.
(f) Waiver.--
(1) In general.--Subject to paragraph (2), the Secretary
shall waive compliance with such requirements of titles XI,
XIX, and XXI of the Social Security Act (42 U.S.C. 1301 et
seq.; 1396 et seq.; 1397aa et seq.) to the extent and for the
period the Secretary finds necessary to conduct the project.
(2) Limitation.--In no case shall the Secretary waive
compliance with the requirements of subsections (a)(10)(A),
(a)(15), and (bb) of section 1902 of the Social Security Act
(42 U.S.C. 1396a) under paragraph (1), to the extent that
such requirements require the provision of, and reimbursement
for services described in section 1905(a)(2)(C) of such Act
(42 U.S.C. 1396d(a)(2)(C)).
______