[Congressional Record Volume 155, Number 78 (Wednesday, May 20, 2009)]
[Senate]
[Pages S5729-S5732]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DURBIN (for himself and Mr. Burr):
  S. 1114. 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, I rise to introduce legislation with 
Senator Burr to help States improve quality and reduce the costs of 
health care for Medicaid and CHIP enrollees. The Medical Homes Act 
would create a pilot project in Medicaid and the State Children's 
Health Insurance Program to encourage hospitals and health clinics to 
create a medical home for the low-income people they serve.
  Those of us who have a medical home take it 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.
  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 do not 
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.
  Everyone should have access to a medical home, but it requires some 
changes in behavior and expectations 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. And 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 is 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.
  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.
  The bill that Senator Burr and I introduce today 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 2009 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 start-up 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.
  This is a critical time in our country We have a President who wants 
health care reform. We have a Congress ready to act. We have an 
historic level of cooperation among stakeholders. Unlike the last time, 
there is substantial agreement this time among insurers, employers, 
consumers and lawmakers on the need for change and the broad outlines 
of reform. Change will only happen if everyone--doctors, patients, 
insurance companies, everyone--work with each other, not against each 
other. The specifics of the reform package still have to be worked 
out--and that will be difficult. But there is broad agreement that we 
must do a better job of delivering health care, not just treatment for 
illness.
  If patients, provider, payers, and the government continue to 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 2009 and help stabilize 
health care delivery for low-income 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. 1114

       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 2009''.

[[Page S5730]]

     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.
       (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. Presently, CCNC has 
     developed 14 regional networks that include all of the 
     Federally qualified health centers in the State and cover 
     740,000 recipients. 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 doctors' 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 improve patient education.

     SEC. 3. MEDICAID AND CHIP 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 practitioners that--
       (A) provides services in the community in which the 
     practice or health center is located;
       (B) reviews evidence-based practice guidelines;
       (C) selects targeted disease and care processes that 
     address health conditions in 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));
       (D) defines programs to target disease and care processes;
       (E) establishes standards and measures for patient-centered 
     medical homes, taking into account nationally-developed 
     standards and measures; and
       (F) 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 Social 
     Security Act (42 U.S.C. 1320d 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 provide comprehensive and systematic 
     treatment.
       (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;
       (IV) coordinates with a broad range of other specialty, 
     ancillary, and related services; and
       (V) provides health care services and consultations in a 
     culturally and linguistically appropriate manner, as well as 
     at a time and location that is convenient to the patient.

       (iv) Providing ongoing assistance and encouragement in 
     patient self-management.--Whether the practice or health 
     center--

       (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)(E); 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) CHIP.--The term ``CHIP'' 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;

[[Page S5731]]

       (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 at least 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 CHIP.
       (B) Participation in patient-centered medical home.--
     Individuals who are eligible for benefits under Medicaid or 
     CHIP in a State that has been 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 decision-making.
       (b) Establishment.--The Secretary shall establish a 
     demonstration project under Medicaid and CHIP 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 CHIP 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, 2011].
       (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 (in accordance with any 
     applicable Medicaid requirements) 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 
     have access to 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 and 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.

       (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 CHIP 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.--

[[Page S5732]]

       (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 provided medical assistance for primary care case 
     management services and those that did 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 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)).

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