[Congressional Record Volume 154, Number 154 (Friday, September 26, 2008)]
[Senate]
[Pages S9676-S9680]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. WYDEN (for himself, Ms. Mikulski, Mr. Whitehouse, and Mr. 
        Cardin):
  S. 3613. A bill to amend title XVIII of the Social Security Act to 
provide certain high cost Medicare beneficiaries suffering from 
multiple chronic conditions with access to Independence at home 
services in lower cost treatment settings, such as their residences, 
under a plan of care developed by an Independence at Home physician or 
Independence at Home nurse practitioner; to the Committee on Finance.
  Mr. WYDEN. Mr. President, together with colleagues in the Senate and 
the House, I am introducing the Independence at Home, IAH, Act. This 
legislation will help Medicare and our Nation improve the efficiency 
and effectiveness of spending on Medicare beneficiaries with multiple 
chronic conditions. It will not only improve care for seniors suffering 
from serious illnesses but also save money.
  Roughly 75 percent of the Nation's health care dollars are spent on 
chronic diseases. Yet spite this enormous investment, today's 
chronically ill only receive just over half, 56 percent, of the 
preventive and maintenance services that they need. Our Nation clearly 
needs to do better.
  Recent Medicare demonstrations have shown that a number of key 
improvements could go a long way to help fix this situation: First, 
primary care physicians and key health professionals must assume more 
responsibility for care coordination; second, we need to target efforts 
at beneficiaries with multiple conditions; third, after-hours care 
needs to be available so people can access medical help when they need 
it and avoid calling 911; and finally, there must be better use of 
health information technology to help manage care.
  The optimal way to address the challenges of caring for persons with 
chronic conditions is to better integrate their care. Medical problems 
are best managed and coordinated by health care professionals who know 
their patients, their problems, their medications, and their other 
health care providers. Using this approach, the IAH provides a better, 
more cost-effective way for Medicare patients with chronic conditions 
to get the care they need.
  We do all these things in the legislation I am introducing along with 
colleagues in the Senate and House: Our bill would put in place a 
demonstration that improves at-home care availability for beneficiaries 
with multiple chronic conditions to help people remain independent in 
their homes. Physicians would get paid better for managing care while 
at the same time they would be responsible for demonstrating at least 5 
percent savings in the cost of their patients' care. The bill also 
includes minimum performance standards for patient health outcomes, and 
would measure patient, caregiver and provider satisfaction.
  The Independence at Home Act establishes a three-year Medicare 
demonstration project that uses a patient-centered health care delivery 
model to ensure that Medicare beneficiaries with multiple chronic 
conditions can remain independent for as long as possible in a 
comfortable environment; advances Medicare reform by creating 
incentives for providers to develop better and lower cost health care 
for the highest cost beneficiaries; incorporates lessons from past 
Medicare demonstration projects; provides for physician and nurse 
practitioner-directed programs that hold providers accountable for 
quality, patient satisfaction, and mandatory annual minimum savings; 
and generates savings by providing better care to Medicare 
beneficiaries with multiple chronic conditions and reducing duplicative 
and unnecessary services, hospitalization, and other health care costs.
  The demonstration program will take place in the thirteen highest-
cost states plus thirteen additional states. Persons eligible for the 
program include Medicare beneficiaries with functional impairments, two 
or more chronic health problems, and recent use of other health 
services. Each IAH patient will receive a comprehensive assessment at 
least annually. The assessment will inform a plan for care that is 
directed by an IAH physician or nurse-practitioner and developed in 
collaboration with the patient. Each patient will also have an IAH plan 
coordinator. Electronic medical records and health information 
technology will be employed to improve patient care. The IAH 
organization will be required to demonstrate savings of at least 5 
percent annually compared with the costs of serving non-participating 
Medicare chronically ill beneficiaries. The IAH organization may keep 
80 percent of savings beyond the required 5 percent savings as an 
incentive to maximize the financial benefits of being an IAH member.
  I would like to thank my cosponsors in the House, Representatives Ed 
Markey, Chris Smith and Rahm Emanuel for their support, along with my 
fellow Senate cosponsors, Senators Barbara Mikulski, Benjamin Cardin 
and Sheldon Whitehouse. I would also like to thank all our staff who 
worked so hard on this legislation, particularly Gregory Hinrichsen in 
my office. Finally, we would like to thank the following groups for 
voicing their support for this legislation: the American Academy of 
Home Care Physicians; the AARP; the American Academy of Nurse 
Practitioners; the National Family Caregivers Association; the Family 
Caregiver Alliance/National Center on Caregiving; the American 
Association of Homes and Services for the Aging; the Maryland-National 
Capital Home Care Association; the Visiting Nurse Associations of 
America, and Intel Corp.
  I urge all of my colleagues to support this important legislation to 
help Medicare patients get better care at lower cost.
  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. 3613

       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 ``Independence at Home Act of 
     2008''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) According to the November 2007 Congressional Budget 
     Office Long Term Outlook for Health Care Spending, unless 
     changes are made to the way health care is delivered, growing 
     demand for resources caused by rising health care costs and 
     to a lesser extent the nation's expanding elderly population 
     will confront Americans with increasingly difficult choices 
     between health care and other priorities. However, 
     opportunities exist to constrain health care costs without 
     adverse health care consequences.
       (2) Medicare beneficiaries with multiple chronic conditions 
     account for a disproportionate share of Medicare spending 
     compared to their representation in the overall Medicare 
     population, and evidence suggests that such patients often 
     receive poorly coordinated care, including conflicting 
     information from health providers and different diagnoses of 
     the same symptoms.

[[Page S9677]]

       (3) People with chronic conditions account for 76 percent 
     of all hospital admissions, 88 percent of all prescriptions 
     filled, and 72 percent of physician visits.
       (4) More than 60 percent of physicians treating patients 
     with chronic conditions believe that their training did not 
     adequately prepare them to coordinate in-home and community 
     services; educate patients with chronic conditions; manage 
     the psychological and social aspects of chronic care; provide 
     effective nutritional guidance; and manage chronic pain.
       (5) Recent studies cited by the Congressional Budget Office 
     found substantial differences among regions of the country in 
     the cost to Medicare of treating beneficiaries with multiple 
     chronic conditions with lower cost regions experiencing 
     better outcomes and lower mortality rates. These studies have 
     suggested that Medicare spending could be reduced by 30 
     percent if more conservative practice styles were adopted, 
     however, the current Medicare fee-for-service program creates 
     incentives to provide fragmented, high cost health care 
     services.
       (6) Studies show that hospital utilization and emergency 
     room visits for patients with multiple chronic conditions can 
     be reduced and significant savings can be achieved through 
     the use of interdisciplinary teams of health care 
     professionals caring for patients in their places of 
     residence.
       (7) The Independence at Home program, designed to fund 
     better health care and improved health care technology 
     through savings it achieves, uses a patient-centered health 
     care delivery model to permit the growing number of Medicare 
     beneficiaries with multiple chronic conditions to remain as 
     independent as possible for as long as possible and to 
     receive care in a setting that is preferred by the 
     beneficiary involved and the family of such beneficiary.
       (8) The Independence at Home program begins Medicare reform 
     by creating incentives for practitioners and providers to 
     develop methods and technologies for providing better and 
     lower cost health care to the highest cost Medicare 
     beneficiaries with the greatest incentives provided in the 
     case of highest cost beneficiaries.
       (9) The Independence at Home program incorporates lessons 
     learned from prior demonstration projects and phase I of the 
     Voluntary Chronic Care Improvement program under section 1807 
     of the Social Security Act, enacted in sections 721 and 722 
     of the Medicare Prescription Drug, Improvement and 
     Modernization Act of 2003 (Public Law 108-173).
       (10) The Independence at Home Act provides for a chronic 
     care coordination demonstration for the highest cost Medicare 
     beneficiaries with multiple chronic conditions that holds 
     providers accountable for quality outcomes, patient 
     satisfaction, and mandatory minimum savings on an annual 
     basis.
       (11) The Independence at Home Act generates savings by 
     providing better, more coordinated care to the highest cost 
     Medicare beneficiaries with multiple chronic conditions, 
     reducing duplicative and unnecessary services, and avoiding 
     unnecessary hospitalizations and emergency room visits.

     SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE AT HOME 
                   CHRONIC CARE COORDINATION DEMONSTRATION PROJECT 
                   UNDER TRADITIONAL MEDICARE FEE-FOR-SERVICE 
                   PROGRAM.

       (a) In General.--Title XVIII of the Social Security Act is 
     amended--
       (1) by amending subsection (c) of section 1807 (42 U.S.C. 
     1395b-8) to read as follows:
       ``(c) Independence at Home Chronic Care Coordination 
     Demonstration Project.--A demonstration project for 
     Independence at Home chronic care coordination programs for 
     high cost Medicare beneficiaries with multiple chronic 
     conditions is set forth in section 1807A.''; and
       (2) by inserting after section 1807 the following new 
     section:


 ``independence at home chronic care coordination demonstration project

       ``Sec. 1807A.  (a) In General.--
       ``(1) Implementation.--The Secretary shall, where possible, 
     enter into agreements with at least two unaffiliated 
     Independence at Home organizations, as described in this 
     section, to provide chronic care coordination services for a 
     period of three years in each of the 13 highest cost States 
     and the District of Columbia and in 13 additional States that 
     are representative of other regions of the United States. 
     Such organizations shall have documented experience in 
     furnishing the types of services covered by this section to 
     eligible beneficiaries in non-institutional settings using 
     qualified teams of health care professionals that are 
     directed by Independence at Home physicians or Independence 
     at Home nurse practitioners and that use health information 
     technology and individualized plans of care.
       ``(2) Eligibility.--Any organization shall be eligible for 
     an Independence at Home agreement in the developmental phase 
     if it is an Independence at Home organization (as defined in 
     subsection (b)(7)) and has the demonstrated capacity to 
     provide the services covered under this section to the number 
     of eligible beneficiaries specified in subsection (e)(3)(C). 
     No organization shall be prohibited from participating 
     because of its small size as long as it meets the eligibility 
     requirements of this section.
       ``(3) Independent evaluation.--The Secretary shall contract 
     for an independent evaluation of the Independence at Home 
     demonstration project under this section with an interim 
     report to be provided after the first year and a final report 
     to be provided after the third year of the project. Such an 
     evaluation shall be conducted by a contractor with knowledge 
     of chronic care coordination programs for the targeted 
     patient population and demonstrated experience in the 
     evaluation of such programs. Each such report shall include 
     an assessment of the following factors and shall identify the 
     characteristics of individual Independence at Home programs 
     that are the most effective:
       ``(A) Quality improvement measures.
       ``(B) Beneficiary, caregiver, and provider satisfaction.
       ``(C) Health outcomes appropriate for patients with 
     multiple chronic conditions.
       ``(D) Cost savings to the program under this title.
       ``(4) Agreements.--The Secretary shall enter into 
     agreements, beginning not later than one year after the date 
     of the enactment of this section, with Independence at Home 
     organizations that meet the participation requirements of 
     this section, including minimum performance standards 
     developed under subsection (e)(3), in order to provide access 
     by eligible beneficiaries to Independence at Home programs 
     under this section.
       ``(5) Regulations.--At least three months before entering 
     into the first agreement under this section, the Secretary 
     shall publish in the Federal Register the specifications for 
     implementing this section.
       ``(6) Periodic progress reports.--Semi-annually during the 
     first year in which this section is implemented and annually 
     thereafter during the period of implementation of this 
     section, the Secretary shall submit to the Committees on Ways 
     and Means and Energy and Commerce of the House of 
     Representatives and the Committee on Finance of the Senate a 
     report that describes the progress of implementation of this 
     section and explaining any variation from the Independence at 
     Home program as described in this section.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Activities of daily living.--The term `activities of 
     daily living' means bathing, dressing, grooming, 
     transferring, feeding, or toileting.
       ``(2) Caregiver.--The term `caregiver' means, with respect 
     to an individual with a qualifying functional impairment, a 
     family member, friend, or neighbor who provides assistance to 
     the individual.
       ``(3) Eligible beneficiary.--
       ``(A) In general.--The term `eligible beneficiary' means, 
     with respect to an Independence at Home program, an 
     individual who--
       ``(i) is entitled to benefits under part A and enrolled 
     under part B, but not enrolled in a plan under part C;
       ``(ii) has a qualifying functional impairment and has been 
     diagnosed with two or more of the chronic conditions 
     described in subparagraph (C); and
       ``(iii) within the 12 months prior to the individual first 
     enrolling with an Independence at Home program under this 
     section, has received benefits under this title for services 
     described in each of clauses (i), (ii) and (iii) of 
     subparagraph (D).
       ``(B) Disqualifications.--Such term does not include an 
     individual--
       ``(i) who is receiving benefits under section 1881;
       ``(ii) who is enrolled in a PACE program under section 
     1894;
       ``(iii) who is enrolled in (and is not disenrolled from) a 
     chronic care improvement program under section 1807;
       ``(iv) who within the previous year has been a resident for 
     more than 90 days in a skilled nursing facility, a nursing 
     facility (as defined in section 1919), or any other facility 
     identified by the Secretary;
       ``(v) who resides in a setting that presents a danger to 
     the safety of in-home health care providers and primary 
     caregivers; or
       ``(vi) whose enrollment in an Independence at Home program 
     the Secretary determines would be inappropriate.
       ``(C) Chronic conditions described.--The chronic conditions 
     described in this subparagraph are the following:
       ``(i) Congestive heart failure.
       ``(ii) Diabetes.
       ``(iii) Chronic obstructive pulmonary disease.
       ``(iv) Ischemic heart disease.
       ``(v) Peripheral arterial disease.
       ``(vi) Stroke.
       ``(vii) Alzheimer's Disease and other dementias designated 
     by the Secretary.
       ``(viii) Pressure ulcers.
       ``(ix) Hypertension.
       ``(x) Neurodegenerative diseases designated by the 
     Secretary which result in high costs under this title, 
     including amyotropic lateral sclerosis (ALS), multiple 
     sclerosis, and Parkinson's disease.
       ``(xi) Any other chronic condition that the Secretary 
     identifies as likely to result in high costs to the program 
     under this title when such condition is present in 
     combination with one or more of the chronic conditions 
     specified in the preceding clauses.
       ``(D) Services described.--The services described in this 
     subparagraph are the following:
       ``(i) Non-elective inpatient hospital services.
       ``(ii) Services in the emergency department of a hospital.
       ``(iii) Any of the following services:

       ``(I) Extended care services.

[[Page S9678]]

       ``(II) Services in an acute rehabilitation facility.
       ``(III) Home health services.

       ``(4) Independence at home assessment.--The term 
     `Independence at Home assessment' means, with respect to an 
     eligible beneficiary, a comprehensive medical history, 
     physical examination, and assessment of the beneficiary's 
     clinical and functional status that--
       ``(A) is conducted by--
       ``(i) an Independence at Home physician or an Independence 
     at Home nurse practitioner;
       ``(ii) a physician assistant, nurse practitioner, or 
     clinical nurse specialist, as defined in section 1861(aa)(5), 
     who is employed by an Independence at Home organization and 
     is working in collaboration with an Independence at Home 
     physician or Independence at Home nurse practitioner; or
       ``(iii) any other health care professional that meets such 
     conditions as the Secretary may specify; and
       ``(B) includes an assessment of--
       ``(i) activities of daily living and other co-morbidities;
       ``(ii) medications and medication adherence;
       ``(iii) affect, cognition, executive function, and presence 
     of mental disorders;
       ``(iv) functional status, including mobility, balance, 
     gait, risk of falling, and sensory function;
       ``(v) social functioning and social integration;
       ``(vi) environmental needs and a safety assessment;
       ``(vii) the ability of the beneficiary's primary caregiver 
     to assist with the beneficiary's care as well as the 
     caregiver's own physical and emotional capacity, education, 
     and training;
       ``(viii) whether the beneficiary is likely to benefit from 
     an Independence at Home program;
       ``(ix) whether the conditions in the beneficiary's home or 
     place of residence would permit the safe provision of 
     services in the home or residence, respectively, under an 
     Independence at Home program; and
       ``(x) other factors determined appropriate by the 
     Secretary.
       ``(5) Independence at home care team.--The term 
     `Independence at Home care team'--
       ``(A) means, with respect to a participant, a team of 
     qualified individuals that provides services to the 
     participant as part of an Independence at Home program; and
       ``(B) includes an Independence at Home physician or an 
     Independence at Home nurse practitioner and an Independence 
     at Home coordinator (who may also be an Independence at Home 
     physician or an Independence at Home nurse practitioner).
       ``(6) Independence at home coordinator.--The term 
     `Independence at Home coordinator' means, with respect to a 
     participant, an individual who--
       ``(A) is employed by an Independence at Home organization 
     and is responsible for coordinating all of the elements of 
     the participant's Independence at Home plan;
       ``(B) is a licensed health professional, such as a 
     physician, registered nurse, nurse practitioner, clinical 
     nurse specialist, physician assistant, or other health care 
     professional as the Secretary determines appropriate, who has 
     at least one year of experience providing and coordinating 
     medical and related services for individuals in their homes; 
     and
       ``(C) serves as the primary point of contact responsible 
     for communications with the participant and for facilitating 
     communications with other health care providers under the 
     plan.
       ``(7) Independence at home organization.--The term 
     `Independence at Home organization' means a provider of 
     services, a physician or physician group practice, a nurse 
     practitioner or nurse practitioner group practice, or other 
     legal entity which receives payment for services furnished 
     under this title (other than only under this section) and 
     which--
       ``(A) has entered into an agreement under subsection (a)(2) 
     to provide an Independence at Home program under this 
     section;
       ``(B)(i) is able to provide all of the elements of the 
     Independence at Home plan in a participant's home or place of 
     residence, or
       ``(ii) if the organization is not able to provide all such 
     elements in such home or residence, has adequate mechanisms 
     for ensuring the provision of such elements by one or more 
     qualified entities;
       ``(C) has Independence at Home physicians, clinical nurse 
     specialists, nurse practitioners, or physician assistants 
     available to respond to patient emergencies 24 hours a day, 
     seven days a week;
       ``(D) accepts all eligible beneficiaries from the 
     organization's service area except to the extent that 
     qualified staff are not available; and
       ``(E) meets other requirements for such an organization 
     under this section.
       ``(8) Independence at home physician.--The term 
     `Independence at Home physician' means a physician who--
       ``(A) is employed by or affiliated with an Independence at 
     Home organization, as required under paragraph (7)(C), or has 
     another contractual relationship with the Independence at 
     Home organization that requires the physician to be 
     responsible for the plans of care for the physician's 
     patients;
       ``(B) is certified--
       ``(i) by the American Board of Family Physicians, the 
     American Board of Internal Medicine, the American Osteopathic 
     Board of Family Physicians, the American Osteopathic Board of 
     Internal Medicine, the American Board of Emergency Medicine, 
     or the American Board of Physical Medicine and 
     Rehabilitation; or
       ``(ii) by a Board recognized by the American Board of 
     Medical Specialties and determined by the Secretary to be 
     appropriate for the Independence at Home program;
       ``(C) has--
       ``(i) a certification in geriatric medicine as provided by 
     American Board of Medical Specialties; or
       ``(ii) passed the clinical competency examination of the 
     American Academy of Home Care Physicians and has substantial 
     experience in the delivery of medical care in the home, 
     including at least two years of experience in the management 
     of Medicare patients and one year of experience in home-based 
     medical care including at least 200 house calls; and
       ``(D) has furnished services during the previous 12 months 
     for which payment is made under this title.
       ``(9) Independence at home nurse practitioner.--The term 
     `Independence at Home nurse practitioner' means a nurse 
     practitioner who--
       ``(A) is employed by or affiliated with an Independence at 
     Home organization, as required under paragraph (7)(C), or has 
     another contractual relationship with the Independence at 
     Home organization that requires the nurse practitioner to be 
     responsible for the plans of care for the nurse 
     practitioner's patients;
       ``(B) practices in accordance with State law regarding 
     scope of practice for nurse practitioners;
       ``(C) is certified--
       ``(i) as a Gerontologic Nurse Practitioner by the American 
     Academy of Nurse Practitioners Certification Program or the 
     American Nurses Credentialing Center; or
       ``(ii) as a family nurse practitioner or adult nurse 
     practitioner by the American Academy of Nurse Practitioners 
     Certification Board or the American Nurses Credentialing 
     Center and holds a certificate of Added Qualification in 
     gerontology, elder care or care of the older adult provided 
     by the American Academy of Nurse Practitioners, the American 
     Nurses Credentialing Center or a national nurse practitioner 
     certification board deemed by the Secretary to be appropriate 
     for an Independence at Home program; and
       ``(D) has furnished services during the previous 12 months 
     for which payment is made under this title.
       ``(10) Independence at home plan.--The term `Independence 
     at Home plan' means a plan established under subsection 
     (d)(2) for a specific participant in an Independence at Home 
     program.
       ``(11) Independence at home program.--The term 
     `Independence at Home program' means a program described in 
     subsection (d) that is operated by an Independence at Home 
     organization.
       ``(12) Participant.--The term `participant' means an 
     eligible beneficiary who has voluntarily enrolled in an 
     Independence at Home program.
       ``(13) Qualified entity.--The term `qualified entity' means 
     a person or organization that is licensed or otherwise 
     legally permitted to provide the specific element (or 
     elements) of an Independence at Home plan that the entity has 
     agreed to provide.
       ``(14) Qualifying functional impairment.--The term 
     `qualifying functional impairment' means an inability to 
     perform, without the assistance of another person, two or 
     more activities of daily living.
       ``(c) Identification and Enrollment of Prospective Program 
     Participants.--
       ``(1) Notice to eligible independence at home 
     beneficiaries.--The Secretary shall develop a model notice to 
     be made available to Medicare beneficiaries (and to their 
     caregivers) who are potentially eligible for an Independence 
     at Home program by participating providers and by 
     Independence at Home programs. Such notice shall include the 
     following information:
       ``(A) A description of the potential advantages to the 
     beneficiary participating in an Independence at Home program.
       ``(B) A description of the eligibility requirements to 
     participate.
       ``(C) Notice that participation is voluntary.
       ``(D) A statement that all other Medicare benefits remain 
     available to beneficiaries who enroll in an Independence at 
     Home program.
       ``(E) Notice that those who enroll in an Independence at 
     Home program may have co-payments for house calls by 
     Independence at Home physicians or by Independence at Home 
     nurse practitioners reduced or eliminated at the discretion 
     of the Independence at Home physician or Independence at Home 
     nurse practitioner involved.
       ``(F) A description of the services that could potentially 
     be provided under an Independence at Home plan.
       ``(G) A description of the method for participating, or 
     withdrawing from participation, in an Independence at Home 
     program or becoming no longer eligible to so participate.
       ``(2) Voluntary participation and choice.--An eligible 
     beneficiary may participate in an Independence at Home 
     program through enrollment in such program on a voluntary 
     basis and may terminate such participation at any time. Such 
     a beneficiary may also receive Independence at Home services 
     from the Independence at Home organization of the 
     beneficiary's choice but may not receive Independence at Home 
     services

[[Page S9679]]

     from more than one Independence at Home organization at a 
     time.
       ``(d) Independence at Home Program Requirements.--
       ``(1) In general.--Each Independence at Home program shall, 
     for each participant enrolled in the program--
       ``(A) designate--
       ``(i) an Independence at Home physician or an Independence 
     at Home nurse practitioner; and
       ``(ii) an Independence at Home coordinator;
       ``(B) have a process to ensure that the participant 
     received an Independence at Home assessment before enrollment 
     in the program;
       ``(C) with the participation of the participant (or the 
     participant's representative or caregiver), an Independence 
     at Home physician or an Independence at Home nurse 
     practitioner, and Independence at Home coordinator, develop 
     an Independence at Home plan for the participant in 
     accordance with paragraph (2);
       ``(D) ensure that the participant receives an Independence 
     at Home assessment at least annually after the original 
     assessment to ensure that the Independence at Home plan for 
     the participant remains current and appropriate;
       ``(E) implement all of the elements of the participant's 
     Independence at Home plan and in instances in which the 
     Independence at Home organization does not provide specific 
     elements of the Independence at Home plan, ensure that 
     qualified entities successfully implement those specific 
     elements;
       ``(F) provide for an electronic medical record and 
     electronic health information technology to coordinate the 
     participant's care and to exchange information with the 
     Medicare program and electronic monitoring and communication 
     technologies and mobile diagnostic and therapeutic 
     technologies as appropriate and accepted by the participant; 
     and
       ``(G) respect the participant's right to health information 
     privacy and obtain permission from the participant (or 
     responsible person) for the use and disclosure of 
     identifiable health information necessary for treatment, 
     payment, or health care operations.
       ``(2) Independence at home plan.--
       ``(A) In general.--An Independence at Home plan for a 
     participant shall be developed with the participant, an 
     Independence at Home physician or an Independence at Home 
     nurse practitioner, an Independence at Home coordinator, and, 
     if appropriate, one or more of the participant's caregivers 
     and shall--
       ``(i) document the chronic conditions, co-morbidities, and 
     other health needs identified in the participant's 
     Independence at Home assessment;
       ``(ii) determine which elements of an Independence at Home 
     plan described in subparagraph (C) are appropriate for the 
     participant; and
       ``(iii) identify the qualified entity responsible for 
     providing each element of such plan.
       ``(B) Communication of individualized independence at home 
     plan to the independence at home coordinator.--If the 
     Independence at Home physician or Independence at Home nurse 
     practitioner responsible for conducting the participant's 
     Independence at Home assessment and developing the 
     Independence at Home plan is not the participant's 
     Independence at Home coordinator, the Independence at Home 
     physician or Independence at Home nurse practitioner is 
     responsible for ensuring that the participant's Independence 
     at Home coordinator has such plan and is familiar with the 
     requirements of the plan and has the appropriate contact 
     information for all of the members of the Independence at 
     Home care team.
       ``(C) Elements of independence at home plan.--An 
     Independence at Home organization shall have the capability 
     to provide, directly or through a qualified entity, and shall 
     offer all of the following elements of an Independence at 
     Home plan to the extent they are appropriate and accepted by 
     a participant:
       ``(i) Self-care education and preventive care consistent 
     with the participant's condition.
       ``(ii) Coordination of all medical treatment furnished to 
     the participant, regardless of whether such treatment is 
     covered and available to the participant under this title.
       ``(iii) Information about, and access to, hospice care.
       ``(iv) Pain and palliative care and end-of-life care.
       ``(v) Education for primary caregivers and family members.
       ``(vi) Caregiver counseling services and information about, 
     and referral to, other caregiver support and health care 
     services in the community.
       ``(vii) Monitoring and management of medications as well as 
     assistance to participants and their caregivers with respect 
     to selection of a prescription drug plan under part D that 
     best meets the needs of the participant's chronic conditions.
       ``(viii) Referral to social services, such as personal 
     care, meals, volunteers, and individual and family therapy.
       ``(ix) Access to phlebotomy and ancillary laboratory and 
     imaging services, including point of care laboratory and 
     imaging diagnostics.
       ``(3) Primary treatment role within an independence at home 
     care team .--An Independence at Home physician or an 
     Independence at Home nurse practitioner may assume the 
     primary treatment role as permitted under State law.
       ``(4) Additional responsibilities.--
       ``(A) Outcomes report.--Each Independence at Home 
     organization offering an Independence at Home program shall 
     monitor and report to the Secretary, in a manner specified by 
     the Secretary, on--
       ``(i) patient outcomes;
       ``(ii) beneficiary, caregiver, and provider satisfaction 
     with respect to coordination of the participant's care; and
       ``(iii) the achievement of mandatory minimum savings 
     described in subsection (e)(6).
       ``(B) Additional requirements.--Each such organization and 
     program shall comply with such additional requirements as the 
     Secretary may specify.
       ``(e) Terms and Conditions.--
       ``(1) In general.--An agreement under this section with an 
     Independence at Home organization shall contain such terms 
     and conditions as the Secretary may specify consistent with 
     this section.
       ``(2) Clinical, quality improvement, and financial 
     requirements.--The Secretary may not enter into an agreement 
     with such an organization under this section for the 
     operation of an Independence at Home program unless--
       ``(A) the program and organization meet the requirements of 
     subsection (d), minimum quality and performance standards 
     developed under paragraph (3), and such clinical, quality 
     improvement, financial, and other requirements as the 
     Secretary deems to be appropriate for participants to be 
     served; and
       ``(B) the organization demonstrates to the satisfaction of 
     the Secretary that the organization is able to assume 
     financial risk for performance under the agreement with 
     respect to payments made to the organization under such 
     agreement through available reserves, reinsurance, or 
     withholding of funding provided under this title, or such 
     other means as the Secretary determines appropriate.
       ``(3) Minimum quality and performance standards.--
       ``(A) In general.--The Secretary shall develop mandatory 
     minimum quality and performance standards for Independence at 
     Home organizations and programs.
       ``(B) Standards to be included.--Such standards shall 
     include measures of--
       ``(i) participant outcomes;
       ``(ii) satisfaction of the beneficiary, caregiver, and 
     provider involved; and
       ``(iii) cost savings consistent with paragraph (6).
       ``(C) Minimum participation standard.--Such standards shall 
     include a requirement that, for any year after the first 
     year, an Independence at Home program had an average number 
     of participants during the previous year of at least 100 
     participants.
       ``(4) Term of agreement and modification.--The agreement 
     under this subsection shall be, subject to paragraphs (3)(C) 
     and (5), for a period of three years, and the terms and 
     conditions may be modified during the contract period only 
     upon the request of the Independence at Home organization.
       ``(5) Termination and non-renewal of agreement.--
       ``(A) In general.--If the Secretary determines that an 
     Independence at Home organization has failed to meet the 
     minimum performance standards under paragraph (3) or other 
     requirements under this section, the Secretary may terminate 
     the agreement of the organization at the end of the contract 
     year.
       ``(B) Required termination where risk to health or safety 
     of a participant.--The Secretary shall terminate an agreement 
     with an Independence at Home organization at any time the 
     Secretary determines that the care being provided by such 
     organization poses a threat to the health and safety of a 
     participant.
       ``(C) Termination by independence at home organizations.--
     Notwithstanding any other provision of this subsection, an 
     Independence at Home organization may terminate an agreement 
     with the Secretary under this section to provide an 
     Independence at Home program at the end of a contract year if 
     the organization provides to the Secretary and to the 
     beneficiaries participating in the program notification of 
     such termination more than 90 days before the end of such 
     year. Paragraphs (6), (8), and (9)(B) shall apply to the 
     organization until the date of termination.
       ``(D) Notice of involuntary termination.--The Secretary 
     shall notify the participants in an Independence at Home 
     program as soon as practicable if a determination is make to 
     terminate an agreement with the Independence at Home 
     organization involuntarily as provided in subparagraphs (A) 
     and (B). Such notice shall inform the beneficiary of any 
     other Independence at Home organizations that might be 
     available to the beneficiary.
       ``(6) Mandatory minimum savings.--
       ``(A) In general.--Under an agreement under this 
     subsection, each Independence at Home organization shall 
     ensure that during any year of the agreement for its 
     Independence at Home program, there is an aggregate savings 
     in the cost to the program under this title for participating 
     beneficiaries, as calculated under subparagraph (B), that is 
     not less than the product of--
       ``(i) 5 percent of the estimated average monthly costs that 
     would have been incurred under parts A, B, and D if those 
     beneficiaries had not participated in the Independence at 
     Home program; and

[[Page S9680]]

       ``(ii) the number of participant-months for that year.
       ``(B) Computation of aggregate savings.--
       ``(i) Model for calculating savings.--The Secretary shall 
     contract with a nongovernmental organization or academic 
     institution to independently develop an analytical model for 
     determining whether an Independence at Home program achieves 
     at least savings required under subparagraph (A) relative to 
     costs that would have been incurred by Medicare in the 
     absence of Independence at Home programs. The analytical 
     model developed by the independent research organization for 
     making these determinations shall utilize state-of-the-art 
     econometric techniques, such as Heckman's selection 
     correction methodologies, to account for sample selection 
     bias, omitted variable bias, or problems with endogeneity.
       ``(ii) Application of the model.--Using the model developed 
     under clause (i), the Secretary shall compare the actual 
     costs to Medicare of beneficiaries participating in an 
     Independence at Home program to the predicted costs to 
     Medicare of such beneficiaries to determine whether an 
     Independence at Home program achieves the savings required 
     under subparagraph (A).
       ``(iii) Revisions of the model.--The Secretary shall 
     require that the model developed under clause (i) for 
     determining savings shall be designed according to 
     instructions that will control, or adjust for, inflation as 
     well as risk factors including, age, race, gender, disability 
     status, socioeconomic status, region of country (such as 
     State, county, metropolitan statistical area, or zip code), 
     and such other factors as the Secretary determines to be 
     appropriate, including adjustment for prior health care 
     utilization. The Secretary may add to, modify, or substitute 
     for such adjustment factors if such changes will improve the 
     sensitivity or specificity of the calculation of costs 
     savings.
       ``(iv) Participant-month.--In making the calculation 
     described in subparagraph (A), each month or part of a month 
     in a program year that a beneficiary participates in an 
     Independence at Home program shall be counted as a 
     `participant-month'.
       ``(C) Notice of savings calculation.--No later than 120 
     days before the beginning of any Independence at Home program 
     year, the Secretary shall publish in the Federal Register a 
     description of the model developed under subparagraph (B)(i) 
     and information for calculating savings required under 
     subparagraph (A), including any revisions, sufficient to 
     permit Independence at Home organizations to determine the 
     savings they will be required to achieve during the program 
     year to meet the savings requirement under such subparagraph. 
     In order to facilitate this notice, the Secretary may 
     designate a single annual date for the beginning of all 
     Independence at Home program years that shall not be later 
     than one year from the date of enactment of this section.
       ``(7) Manner of payment.--Subject to paragraph (8), 
     payments shall be made by the Secretary to an Independence at 
     Home organization at a rate negotiated between the Secretary 
     and the organization under the agreement for--
       ``(A) Independence at Home assessments; and
       ``(B) on a per-participant, per-month basis for the items 
     and services required to be provided or made available under 
     subsection (d).
       ``(8) Ensuring mandatory minimum savings.--The Secretary 
     shall require any Independence at Home organization that 
     fails in any year to achieve the mandatory minimum savings 
     described in paragraph (6) to provide those savings by 
     refunding payments made to the organization under paragraph 
     (7) during such year.
       ``(9) Budget neutral payment condition.--
       ``(A) In general.--Under this section, the Secretary shall 
     ensure that the cumulative, aggregate sum of Medicare program 
     benefit expenditures under parts A, B, and D for participants 
     in Independence at Home programs and funds paid to 
     Independence at Home organizations under this section, shall 
     not exceed the Medicare program benefit expenditures under 
     such parts that the Secretary estimates would have been made 
     for such participants in the absence of such programs.
       ``(B) Treatment of savings.--If an Independence at Home 
     organization achieves aggregate savings in a year in excess 
     of the mandatory minimum savings described in paragraph (6), 
     80 percent of such aggregate savings shall be paid to the 
     organization and the remainder shall be retained by the 
     programs under this title.
       ``(f) Waiver of Coinsurance for House Calls.--A physician 
     or nurse practitioner furnishing services in the home or 
     residence of a participant in an Independence at Home program 
     may waive collection of any coinsurance that might otherwise 
     be payable under section 1833(a) with respect to such 
     services.
       ``(g) Report.--Not later than one year after the end of the 
     Independence at Home demonstration project under this 
     section, the Secretary shall submit to Congress a report on 
     such project. Such report shall include information on--
       ``(1) whether Independence at Home programs under the 
     project met the performance standards for beneficiary, 
     caregiver, and provider satisfaction; and
       ``(2) participant outcomes and cost savings, as well as the 
     characteristics of the programs that were most effective and 
     whether the participant eligibility criteria identified 
     beneficiaries who were in the top ten percent of the highest 
     cost Medicare beneficiaries.''.
       (b) Conforming Amendments.--
       (1) Section 1833(a) of such Act (42 U.S.C. 1395l(a)) is 
     amended, in the matter before paragraph (1), by inserting 
     ``and section 1807A(f)'' after ``section 1876''.
       (2) Section 1128B(b)(3) of such Act (42 U.S.C. 1320a-
     7b(b)(3)) is amended--
       (A) by striking ``and'' at the end of subparagraph (G);
       (B) by striking ``1853(a)(4).'' at the end of the first 
     subparagraph (H) and inserting ``1853(a)(4);'';
       (C) by redesignating the second subparagraph (H) as 
     subparagraph (I) and by striking the period at the end and 
     inserting ``; and''; and
       (D) by adding at the end the following new subparagraph:
       ``(J) a waiver of coinsurance under section 1807A(f).''.
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