[Congressional Record Volume 155, Number 79 (Thursday, May 21, 2009)]
[Senate]
[Pages S5829-S5834]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. WYDEN (for himself, Mr. Burr, Mr. Whitehouse, and Mr. 
        Cardin):
  S. 1131. 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 coordinated, primary care 
medical services in lower cost treatment settings, such as their 
residences, under a plan of care developed by a team of qualified and 
experienced health care professionals; to the Committee on Finance.
  Mr. WYDEN. Mr. President, I am reintroducing the Independence at Home 
Act together with colleagues in the Senate and the House. Mr. Burr, Mr. 
Whitehouse, Mr. Cardin and I are proud to join forces with our House 
colleagues, Mr. Markey, and his cosponsor, Mr. Smith, to move forward 
with this important legislation to provide a coordinated team-based 
approach to primary care for chronically ill Medicare beneficiaries in 
their own homes. Returning to basics like paying doctors for home 
visits to vulnerable patients, and following them through the course of 
their illness while saving taxpayers money, is the kind of legislation 
I am proud to introduce.
  The Independence at Home, or IAH, Act comes at the perfect time. The 
American people and the federal government need to save money on health 
care, while having more choices and getting better results. This 
delivery model has a proven track record of doing just this. Similar 
``house calls'' programs, currently operating across the country, are 
reducing costs, improving care quality, and helping people remain 
independent as long as possible. This delivery model is also providing 
much needed relief to caregivers who are often juggling a full-time job 
while caring for their very ill family member. This is medical care 
Americans want and deserve.
  It is not too often that health policy has good outcome results 
before the pilot program phase begins, but that is exactly the case 
with the IAH Act. Similar home health delivery models, such as the 
Veterans Administration's Home-Based Primary Care, Boston, 
Massachusetts' Urban Medical's House Calls Program, and Portland, 
Oregon's Housecall Providers have been so successful in improving 
quality and reducing costs, that our bill guarantees 5 percent savings 
to Medicare.
  These successful home health programs have demonstrated that the 
optimal way to address the challenges of caring for persons with 
chronic conditions is to better integrate their care and to work with 
their caregivers. 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 Independence at Home Act provides a better, more cost-
effective way for Medicare patients with chronic conditions to get the 
care they need. It further advances Medicare reform by creating 
incentives for providers to develop better and lower cost health care 
for the highest cost beneficiaries.
  This bipartisan, bicameral bill would create a pilot program to 
improve in-home care availability for beneficiaries with multiple 
chronic conditions. This is a win-win for all involved. It will help 
people remain in their homes for longer periods of time, it will 
improve the quality of care, and physicians will receive a bundled 
payment for coordinating this care with a team of healthcare providers.
  More specifically, the Independence at Home Act establishes a two-
phase three-year Medicare pilot 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. By incorporating lessons from 
past Medicare demonstration projects and from current home health

[[Page S5830]]

models, this bill provides for programs that hold providers accountable 
for quality, mandatory annual minimum savings, and patient 
satisfaction. Savings are generated by providing better care to 
Medicare beneficiaries with multiple chronic conditions and reducing 
duplicative and unnecessary services, hospitalization, and other health 
care costs.
  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, nurse-
practitioner, or physician's assistant. The plan is developed by an IAH 
plan coordinator in collaboration with the patient and caregiver. 
Medication management is provided by pharmacists due to their expertise 
in pharmacology, and electronic medical records and health information 
technology will be employed to improve patient care and reduce costs.
  The two-phase pilot program will take place in the thirteen highest-
cost states plus thirteen additional states. After review of Phase I 
and the evaluation report, the Secretary may elect to expand the 
program nationwide so it could then become an ongoing benefit for 
Medicare beneficiaries.
  A shared-savings agreement incentive program allows this innovative 
delivery model to attract and maintain providers. 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 organization. Any 
savings beyond 25 percent would be split, with 50 percent directed to 
the IAH organization and 50 percent to Medicare. In Phase II, the 
Secretary may modify the payment incentive structure to increase 
savings to the Medicare Trust Fund only if it will not impede access to 
IAH services to eligible beneficiaries.
  I would like to thank my fellow Senate cosponsors, Richard Burr, 
Sheldon Whitehouse, and Benjamin Cardin, and my cosponsor in the House, 
Representative Ed Markey, and his cosponsor, Chris Smith, for their 
support. I also thank Rahm Emanuel for his support of IAH in the last 
Congress. I would also like to thank all our staff who worked so hard 
on this legislation, particularly Gregory Hinrichsen in my office. 
Finally, I would like to thank the following groups for voicing their 
support for this legislation: The American Academy of Home Care 
Physicians; The American Academy of Neurology; The AARP; The 
Alzheimer's Association; The Alzheimer's Foundation of America; The 
American Academy of Nurse Practitioners; The American College of Nurse 
Practitioners; American Academy of Physician Assistants; The American 
Society of Consultant Pharmacists; The National Family Caregivers 
Association; The Family Caregiver Alliance/National Center on 
Caregiving; The American Association of Homes and Services for the 
Aging; The Housecalls Doctors of Texas; The Maryland-National Capital 
Home Care Association; The Visiting Nurse Associations of America; 
Housecall Providers, Inc. of Portland, OR; Intel Corp.; The National 
Council on Aging; U.S. PIRG; Massachusetts Neurologic Society; Naples 
Health Care Associates; Urban Medical House Calls of Boston, MA; MD2U 
Doctors Who Make Housecalls (Louisville, KY); Wyeth Pharmaceuticals.
  I urge all of my colleagues to support this important legislation to 
help Medicare patients get better care at lower cost.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows;

                                S. 1131

       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 
     2009''.

     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.
       (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) 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.
       (5) The Independence at Home Act creates a chronic care 
     coordination pilot project to bring primary care medical 
     services to the highest cost Medicare beneficiaries with 
     multiple chronic conditions in their home or place of 
     residence so that they may be as independent as possible for 
     as long as possible in a comfortable setting.
       (6) The Independence at Home Act generates savings by 
     providing better, more coordinated care across all treatment 
     settings to the highest cost Medicare beneficiaries with 
     multiple chronic conditions, reducing duplicative and 
     unnecessary services, and avoiding unnecessary 
     hospitalizations, nursing home admissions, and emergency room 
     visits.
       (7) The Independence at Home Act holds providers 
     accountable for improving beneficiary outcomes, ensuring 
     patient and caregiver satisfaction, and achieving cost 
     savings to Medicare on an annual basis.
       (8) The Independence at Home Act creates 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 Act contains the central 
     elements of proven home-based primary care delivery models 
     that have been utilized for years by the Department of 
     Veterans Affairs and ``house calls'' programs across the 
     country to deliver coordinated care for chronic conditions in 
     the comfort of a patient's home or place of residence.

     SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE AT HOME 
                   CHRONIC CARE COORDINATION PILOT 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 Pilot 
     Project.--A pilot 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 pilot project

       ``Sec. 1807A.  (a) Implementation.--
       ``(1) In general.--The Secretary shall provide for the 
     phased in development, implementation, and evaluation of 
     Independence at Home programs described in this section to 
     meet the following objectives:
       ``(A) To improve patient outcomes, compared to comparable 
     beneficiaries who do not participate in such a program, 
     through reduced hospitalizations, nursing home admissions, or 
     emergency room visits, increased symptom self-management, and 
     similar results.
       ``(B) To improve satisfaction of patients and caregivers, 
     as demonstrated through a quantitative pre-test and post-test 
     survey developed by the Secretary that measures patient and 
     caregiver satisfaction of care coordination, educational 
     information, timeliness of response, and similar care 
     features.
       ``(C) To achieve a minimum of 5 percent cost savings in the 
     care of beneficiaries under this title suffering from 
     multiple high cost chronic diseases.
       ``(2) Initial implementation (phase i).--
       ``(A) In general.--In carrying out this section and to the 
     extent possible, the Secretary shall enter into agreements 
     with at least two unaffiliated Independence at Home 
     organizations in each of the 13 highest cost States (based on 
     average per capita expenditures per State under this title), 
     in the District of Columbia, and in 13 additional States that 
     are representative of other regions of the United States and 
     include medically underserved rural and urban areas, to 
     provide chronic care coordination services for a period of 
     three years or until those agreements are terminated by the 
     Secretary. Such agreements under this paragraph shall 
     continue in effect until the Secretary makes the 
     determination described in paragraph (3) or until those 
     agreements are supplanted by new agreements under such 
     paragraph. The phase of implementation under this paragraph 
     is

[[Page S5831]]

     referred to in this section as the `initial implementation' 
     phase or `phase I'.
       ``(B) Preference.--In selecting Independence at Home 
     organizations under this paragraph, the Secretary shall give 
     a preference, to the extent practicable, to organizations 
     that--
       ``(i) have documented experience in furnishing the types of 
     services covered by this section to eligible beneficiaries in 
     the home or place of residence using qualified teams of 
     health care professionals that are directed by individuals 
     who have the qualifications of Independence at Home 
     physicians, or in cases when such direction is provided by an 
     Independence at Home physician to a physician assistant who 
     has at least one year of experience providing gerontological 
     medical and related services for chronically ill individuals 
     in their homes, or other similar qualification as determined 
     by the Secretary to be appropriate for the Independence at 
     Home program, by the physician assistant acting under the 
     supervision of an Independence at Home physician and as 
     permitted under State law, or Independence at Home nurse 
     practitioners;
       ``(ii) have the capacity to provide services covered by 
     this section to at least 150 eligible beneficiaries; and
       ``(iii) use electronic medical records, health information 
     technology, and individualized plans of care.
       ``(3) Expanded implementation phase (phase ii).--
       ``(A) In general.--For periods beginning after the end of 
     the 3-year initial implementation period under paragraph (2), 
     subject to subparagraph (B), the Secretary shall renew 
     agreements described in paragraph (2) with Independence at 
     Home organization that have met all 3 objectives specified in 
     paragraph (1) and enter into agreements described in 
     paragraph (2) with any other organization that is located in 
     any State or the District of Columbia, that was not an 
     Independence at Home organization during the initial 
     implementation period, and that meets the qualifications of 
     an Independence at Home organization under this section. The 
     Secretary may terminate and not renew such an agreement with 
     an organization that has not met such objectives during the 
     initial implementation period. The phase of implementation 
     under this paragraph is referred to in this section as the 
     `expanded implementation' phase or `phase II'.
       ``(B) Contingency.--The expanded implementation under 
     subparagraph (A) shall not occur if the Secretary finds, not 
     later than 60 days after the date of issuance of the 
     independent evaluation under paragraph (5), that continuation 
     of the Independence at Home project is not in the best 
     interest of beneficiaries under this title or in the best 
     interest of Federal health care programs.
       ``(4) Eligibility.--No organization shall be prohibited 
     from participating under this section during expanded 
     implementation phase under paragraph (3) (and, to the extent 
     practicable, during initial implementation phase under 
     paragraph (2)) because of its small size as long as it meets 
     the eligibility requirements of this section.
       ``(5) Independent evaluations.--
       ``(A) In general.--The Secretary shall contract for an 
     independent evaluation of the initial implementation phase 
     under paragraph (2) with an interim report to Congress to be 
     provided on such evaluation as soon as practicable after the 
     first year of such phase and a final report to be provided to 
     Congress as soon as practicable following the conclusion of 
     the initial implementation phase, but not later than 6 months 
     following the end of such phase. Such an evaluation shall be 
     conducted by individuals with knowledge of chronic care 
     coordination programs for the targeted patient population and 
     demonstrated experience in the evaluation of such programs.
       ``(B) Information to be included.--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 in producing 
     improvements in--
       ``(i) beneficiary, caregiver, and provider satisfaction;
       ``(ii) health outcomes appropriate for patients with 
     multiple chronic diseases; and
       ``(iii) cost savings to the program under this title, such 
     as in reducing--

       ``(I) hospital and skilled nursing facility admission rates 
     and lengths of stay;
       ``(II) hospital readmission rates; and
       ``(III) emergency department visits

       ``(C) Breakdown by condition.--Each such report shall 
     include data on performance of Independence at Home 
     organizations in responding to the needs of eligible 
     beneficiaries with specific chronic conditions and 
     combinations of conditions, as well as the overall eligible 
     beneficiary population.
       ``(6) Agreements.--
       ``(A) In general.--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.
       ``(B) Authority.--If the Secretary deems it necessary to 
     serve the best interest of the beneficiaries under this title 
     or the best interest of Federal health care programs, the 
     Secretary may--
       ``(i) require screening of all potential Independence at 
     Home organizations, including owners, (such as through 
     fingerprinting, licensure checks, site-visits, and other 
     database checks) before entering into an agreement;
       ``(ii) require a provisional period during which a new 
     Independence at Home organization would be subject to 
     enhanced oversight (such as prepayment review, unannounced 
     site visits, and payment caps); and
       ``(iii) require applicants to disclose previous affiliation 
     with entities that have uncollected Medicare or Medicaid 
     debt, and authorize the denial of enrollment if the Secretary 
     determines that these affiliations pose undue risk to the 
     program.
       ``(7) 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. Such specifications shall describe 
     the implementation process from initial to final 
     implementation phases, including how the Secretary will 
     identify and notify potential enrollees and how and when 
     beneficiaries may enroll and disenroll from Independence at 
     Home programs and change the programs in which they are 
     enrolled.
       ``(8) 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.
       ``(9) Annual best practices conference.--During the initial 
     implementation phase and to the extent practicable at 
     intervals thereafter, the Secretary shall provide for an 
     annual Independence at Home teleconference for Independence 
     at Home organizations to share best practices and review 
     treatment interventions and protocols that were successful in 
     meeting all 3 objectives specified in paragraph (1).
       ``(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 part A for the following 
     services:

       ``(I) Non-elective inpatient hospital services.
       ``(II) Services in the emergency department of a hospital.
       ``(III) Any one of the following:

       ``(aa) Skilled nursing or sub-acute rehabilitation services 
     in a Medicare-certified nursing facility.
       ``(bb) Comprehensive acute rehabilitation facility or 
     Comprehensive outpatient rehabilitation facility services.
       ``(cc) Skilled nursing or rehabilitation services through a 
     Medicare-certified home health agency.
       ``(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 a 12-month period 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.

[[Page S5832]]

       ``(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.
       ``(4) Independence at home assessment.--The term 
     `Independence at Home assessment' means a determination of 
     eligibility of an individual for an Independence at Home 
     program as an eligible beneficiary (as defined in paragraph 
     (3)), a comprehensive medical history, physical examination, 
     and assessment of the beneficiary's clinical and functional 
     status that--
       ``(A) is conducted in person by an individual--
       ``(i) who--

       ``(I) is an Independence at Home physician or an 
     Independence at Home nurse practitioner; or
       ``(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 supervised by an Independence at Home physician or 
     Independence at Home nurse practitioner; and

       ``(ii) does not have an ownership interest in the 
     Independence at Home organization unless the Secretary 
     determines that it is impracticable to preclude such 
     individual's involvement; 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, in the professional judgment of the 
     individual conducting the assessment, 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;
       ``(x) whether the beneficiary has a designated primary care 
     physician whom the beneficiary has seen in an office-based 
     setting within the previous 12 months; and
       ``(xi) 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 services 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 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) provides all of the services 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 
     services in such home or residence, has adequate mechanisms 
     for ensuring the provision of such services 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, as determined under the 
     agreement with the Secretary under this section, 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 make in-home 
     visits and 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 
     make in-home visits and 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 service (or 
     services) provided under 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.
       ``(15) Qualified individual.--The term `qualified 
     individual' means a individual that is licensed or otherwise 
     legally permitted to provide the specific service (or 
     services) under an Independence at Home plan that the 
     individual has agreed to provide.
       ``(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.

[[Page S5833]]

       ``(E) Notice that those who enroll in an Independence at 
     Home program will be responsible for copayments for house 
     calls made by Independence at Home physicians, physician 
     assistants, or by Independence at Home nurse practitioners, 
     except that such copayments may be reduced or eliminated at 
     the discretion of the Independence at Home physician, 
     physician assistant, or Independence at Home nurse 
     practitioner involved in accordance with subsection (f).
       ``(F) A description of the services that could be provided.
       ``(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 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, a physician assistant under the 
     supervision of an Independence at Home physician and as 
     permitted under State law, or an Independence at Home nurse 
     practitioner, and the 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 every 6 months after the original 
     assessment to ensure that the Independence at Home plan for 
     the participant remains current and appropriate;
       ``(E) implement all of the services under the participant's 
     Independence at Home plan and in instances in which the 
     Independence at Home organization does not provide specific 
     services within the Independence at Home plan, ensure that 
     qualified entities successfully provide those specific 
     services; and
       ``(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.
       ``(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, a physician assistant under 
     the supervision of an Independence at Home physician and as 
     permitted under State law, an Independence at Home nurse 
     practitioner, or 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 services under an Independence at 
     Home plan described in subparagraph (C) are appropriate for 
     the participant; and
       ``(iii) identify the qualified entity responsible for 
     providing each service under such plan.
       ``(B) Communication of individualized independence at home 
     plan to the independence at home coordinator.--If the 
     individual 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) Services provided under an independence at home 
     plan.--An Independence at Home organization shall coordinate 
     and make available through referral to a qualified entity the 
     services described in the following clauses (i) through (iii) 
     to the extent they are needed and covered by under this title 
     and shall provide the care coordination services described in 
     the following clause (iv) to the extent they are appropriate 
     and accepted by a participant:
       ``(i) Primary care services, such as physician visits, 
     diagnosis, treatment, and preventive services.
       ``(ii) Home health services, such as skilled nursing care 
     and physical and occupational therapy.
       ``(iii) Phlebotomy and ancillary laboratory and imaging 
     services, including point of care laboratory and imaging 
     diagnostics.
       ``(iv) Care coordination services, consisting of--

       ``(I) Monitoring and management of medications by a 
     pharmacist who is certified in geriatric pharmacy by the 
     Commission for Certification in Geriatric Pharmacy or 
     possesses other comparable certification demonstrating 
     knowledge and expertise in geriatric pharmacotherapy, 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.
       ``(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) Self-care education and preventive care consistent 
     with the participant's condition.
       ``(IV) Education for primary caregivers and family members.
       ``(V) Caregiver counseling services and information about, 
     and referral to, other caregiver support and health care 
     services in the community.
       ``(VI) Referral to social services, such as personal care, 
     meals, volunteers, and individual and family therapy.
       ``(VII) Information about, and access to, hospice care.
       ``(VIII) Pain and palliative care and end-of-life care, 
     including information about developing advanced directives 
     and physicians orders for life sustaining treatment.

       ``(3) Primary treatment role within an independence at home 
     care team.--An Independence at Home physician, a physician 
     assistant under the supervision of an Independence at Home 
     physician and as permitted under State law, 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 provide the Secretary with listings of 
     individuals employed by the organization, including contract 
     employees, and individuals with an ownership interest in the 
     organization and 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, program integrity, 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) improvement in participant outcomes;
       ``(ii) improvement in 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 
     and except as the Secretary may provide for a program serving 
     a rural area, 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 by the 
     Secretary as necessary to serve the best interest of the 
     beneficiaries under this title or the best interest of 
     Federal health care programs or upon the request of the 
     Independence at Home organization.
       ``(5) Termination and non-renewal of agreement.--

[[Page S5834]]

       ``(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, or if the Secretary deems it 
     necessary to serve the best interest of the beneficiaries 
     under this title or the best interest of Federal health care 
     programs, 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 made 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) Required.--
       ``(i) 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 5 percent of the product described in clause 
     (ii) for such participating beneficiaries and year.
       ``(ii) Product described.--The product described in this 
     clause for participating beneficiaries in an Independence at 
     Home program for a year is the product of--

       ``(I) the estimated average monthly costs that would have 
     been incurred under parts A and B (and, to the extent cost 
     information is available, part D) if those beneficiaries had 
     not participated in the Independence at Home program; and
       ``(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 30 days 
     before the beginning of the first year of the pilot project 
     under this section and 120 days before the beginning of any 
     Independence at Home program year after the first such 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 subparagraph (A). 
     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)(2)(C)(iv).
       ``(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.--
       ``(i) Initial implementation phase.--If an Independence at 
     Home organization achieves aggregate savings in a year in the 
     initial implementation phase in excess of the mandatory 
     minimum savings described in paragraph (6)(A)(ii), 80 percent 
     of such aggregate savings shall be paid to the organization 
     and the remainder shall be retained by the programs under 
     this title during the initial implementation phase.
       ``(ii) Expanded implementation phase.--If an Independence 
     at Home organization achieves aggregate savings in a year in 
     the expanded implementation phase in excess of 5 percent of 
     the product described in paragraph (6)(A)(ii)--

       ``(I) insofar as such savings do not exceed 25 percent of 
     such product, 80 percent of such aggregate savings shall be 
     paid to the organization and the remainder shall be retained 
     by the programs under this title; and.
       ``(II) insofar as such savings exceed 25 percent of such 
     product, in the Secretary's discretion, 50 percent of such 
     excess 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, 
     physician assistant, or nurse practitioner furnishing 
     services related to the Independence at Home program 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 but only if the conditions described in section 
     1128A(i)(6)(A) are met.
       ``(g) Report.--Not later than three months after the date 
     of receipt of the independent evaluation provided under 
     subsection (a)(5) and each year thereafter during which this 
     section is being implemented, the Secretary shall submit to 
     the Committees of jurisdiction in Congress a report that 
     shall include--
       ``(1) whether the Independence at Home programs under this 
     section are meeting the minimum quality and performance 
     standards in (e)(3);
       ``(2) a comparative evaluation of Independence at Home 
     organizations in order to identify which programs, and 
     characteristics of those programs, were the most effective in 
     producing the best participant outcomes, patient and 
     caregiver satisfaction, and cost savings; and
       ``(3) an evaluation of whether the participant eligibility 
     criteria identified beneficiaries who were in the top ten 
     percent of the highest cost Medicare beneficiaries.''.
       (b) Conforming Amendment.--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''.
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