[Congressional Record Volume 155, Number 92 (Thursday, June 18, 2009)]
[Senate]
[Pages S6812-S6814]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. SHAHEEN (for herself, Ms. Collins, and Mrs. Lincoln):
  S. 1295. A bill to amend title XVIII of the Social Security Act to 
cover transitional care services to improve the quality and cost 
effectiveness of care under the Medicare program; to the Committee on 
Finance.
  Mrs. SHAHEEN. Mr. President, I rise today to introduce the Medicare 
Transitional Care Act of 2009. Time and again, we have heard that our 
health care system is not working. Costs are too high, outcomes too 
poor and access too limited. I agree with so many of my colleagues that 
we need to work together to ensure that all Americans have access to 
quality and affordable health care.
  Everyone deserves stable health care coverage that they can count on, 
regardless of the job they hold or the curveballs life may throw. All 
Americans should be able to count on insurance premiums and deductibles 
that will not continue to rise and eat away more and more of our 
paychecks. Finally, all Americans deserve stable care that lets you 
keep your doctor, and your health care plan, that you trust and with 
whom you have built a relationship.
  Let me be clear: health care costs are too high. Every day in New 
Hampshire and across our country, families are struggling with the 
crushing cost of health care that threatens their financial stability, 
leaving them exposed to higher premiums and deductibles, and putting 
them at risk for a possible loss of health insurance coverage and even 
bankruptcy. In 2007 our Nation spent $2.2 trillion--or 16.2 percent of 
the GDP on health care. This is twice the average of other developed 
nations. As a Nation, our health outcomes are no better. We still lag 
behind other countries when it comes to efficiency, access, patient 
safety and adoption of information technology.
  It is essential that we cut our Nation's health care costs and 
improve the quality of care our patients receive.
  I rise today to offer a solution that can help address this crisis. I 
rise to introduce the Medicare Transitional Care Act of 2009--
legislation that will reduce costly hospital readmissions, improve 
Medicare patients' care and cut Medicare costs. I thank Representative 
Blumenauer and Representative Boustany for their leadership on this 
issue in the House and I am pleased to be joined by colleagues, Senator 
Collins, and Senator Lincoln, in introducing this legislation.
  This bill is about reducing costs and offering better support and 
coordination of care to Medicare patients. It will help keep seniors 
who are discharged from the hospital from going back. Simply put, it 
will improve the health care we offer our seniors while saving money.
  According to a report from the New England Journal of Medicine, 
almost one third of Medicare beneficiaries discharged from the hospital 
were re-hospitalized within 90 days. One half of the individuals re-
hospitalized had not visited a physician since their discharge, 
indicating a lack of follow-up care. The study also estimated that in 
2004 Medicare spent $17.4 billion on unplanned re-hospitalizations. 
This problem is costly for our government and troublesome for our 
seniors. But the good news is that this problem is avoidable.
  Research shows that the transition from the hospital to the patient's 
next place of care--be it home, or a nursing facility or rehabilitation 
center--can be complicated and risky. This is especially true for older 
individuals with multiple chronic illnesses. These patients talk about 
the difficulty remembering instructions, confusion over correct use of 
medications, and general uncertainty about their own conditions.

  For example, take Michael, a 71-year-old patient who lives with his 
73-year-old wife, and has diabetes. Michael had a knee replacement that 
required two surgical revisions. He uses a walker and has been 
hospitalized four times. He says ``they would discharge me and the same 
day I'd be back in the ER. The wound would burst apart.'' Under this 
legislation, a transitional care clinician could be there to help make 
sure that Michael and his wife do not need to go back to the hospital.
  Let me also tell you about Bill. Over time, Bill has endured a heart 
attack that required open heart surgery, angioplasty with stent 
placement, stroke, kidney disease, HIV and depression. He has been 
hospitalized three times, underwent rehabilitation therapy in an 
inpatient facility once and lives alone. He says ``there was no help at 
home [after surgery]. My mother

[[Page S6813]]

came and took care of household stuff. I was flat on my back for two 
weeks. The hospital called to make sure I was okay--`Hey how are you 
doing?'--but what could they do?'' Bill also notes the difficulty he 
had with discharge instructions: ``By the time I'm home,'' he says, ``I 
don't remember what the doctor said. Sometimes they write it down, but 
I have comprehension problems.''
  Stories like Bill's and Michael's demonstrate that patients need 
support and assistance to manage their health needs along with their 
caregivers. This legislation provides that opportunity.
  Under the Medicare Transitional Care Act, a transitional care 
clinician would help ensure that appropriate follow-up care is provided 
to patients during the vulnerable time after discharge from a 
hospital--and help ensure that they are not re-hospitalized 
unnecessarily.
  The benefit would be phased-in and provided first for the most at-
risk individuals. It will be tailored to their needs. It may be as 
simple as making sure each patient understands how and when to take 
their medication; or helping to make sure they schedule and are able to 
get to follow-up appointments with the doctors, or it may be helping 
patients and caregivers coordinate support services, such as medical 
equipment, meal delivery, transportation or assistance with other daily 
activities.
  I am pleased that the legislation has the strong support of the AARP.
  Proper transitional care is important not only to reduce hospital 
readmissions, but also to improve patient outcomes and satisfaction. 
Experts estimate that this legislation could save as much as $5,000 per 
Medicare beneficiary.
  I look forward to working with my colleagues in the Senate to pass 
comprehensive health care reform to fix our broken system. I urge them 
to join me in supporting a transitional care benefit that will support 
patients during the very vulnerable time after discharge from the 
hospital. The evidence is clear. We can implement a transitional care 
option that will save money by reducing hospital re-admisssions while 
improving the quality of care we deliver to patients in New Hampshire 
and all across this country.
  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. 1295

       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 ``Medicare Transitional Care 
     Act of 2009''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) More than 20 percent of older Americans suffer from 
     five or more chronic conditions and these older adults 
     typically require health care services from numerous 
     providers across several care settings each year.
       (2) Insufficient communication among older adults, family 
     caregivers, and health care providers contributes to poor 
     continuity of care, inadequate management of complex health 
     care needs, and preventable hospital admissions.
       (3) Research suggests that family caregivers often lack the 
     knowledge, skills, and resources to effectively address the 
     complex needs of older adults coping with multiple coexisting 
     conditions.
       (4) In 2005, health care services for Medicare 
     beneficiaries with five or more chronic conditions accounted 
     for 75 percent of total Medicare spending. The vast majority 
     of these costs were due to high rates of hospital admission 
     and readmission.
       (5) According to Medicare claims data from 2003-2004, 
     almost one fifth (19.6 percent) of the 11,855,702 Medicare 
     beneficiaries who had been discharged from a hospital were 
     rehospitalized within 30 days, and 34.0 percent were 
     rehospitalized within 90 days.
       (6) A New England Journal of Medicine study estimates that 
     the cost to Medicare of unplanned rehospitalizations in 2004 
     was $17.4 billion.
       (7) The MetLife Caregiving Cost Study demonstrates that 
     American businesses lose an estimated $34 billion each year 
     due to employees' need to care for loved ones.
       (8) The Transitional Care Model, developed by the 
     University of Pennsylvania, is a care management strategy 
     that identifies patients' health goals, coordinates care 
     throughout acute episodes of illness, develops a streamlined 
     plan of care to prevent future hospitalizations, and prepares 
     the beneficiary and family caregivers to implement this care 
     plan.
       (9) The major goal of the Transitional Care Model is to 
     interrupt cycles of avoidable hospitalizations and promote 
     longer-term positive health outcomes.
       (10) The Transitional Care Model has shown through multiple 
     randomized clinical trials to produce significant health 
     outcome improvements, reductions in health care costs among 
     at-risk and chronically ill older adults, and increased 
     patient satisfaction.
       (11) Preliminary results from a clinical trial of the 
     Guided Care Model (based on a Medical Home which includes 
     transitional care) demonstrated reductions in hospital days, 
     skilled nursing facility days, and home health episodes, as 
     well as preliminary findings of net savings.
       (12) A clinical trial of the Care Transitions Intervention 
     demonstrated lower re-hospitalization rates and lower 
     hospital costs per patient.

     SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE.

       Title XVIII of the Social Security Act is amended by adding 
     at the end the following new section:


   ``coverage of transitional care services for qualified individuals

       ``Sec. 1899.  (a) Coverage Under Part B.--
       ``(1) In general.--In the case of a qualified individual 
     (as defined in subsection (b)), the Secretary shall provide 
     under part B for benefits for transitional care services (as 
     defined in subsection (c)) furnished by a transitional care 
     clinician (as defined in subsection (d)) acting as an 
     employee of (or pursuant to a contract with) a qualified 
     transitional care entity (as defined in paragraph (3)(A)) in 
     accordance with this section during the transitional care 
     period (as defined in paragraph (3)(B)) for the qualified 
     individual.
       ``(2) Initial implementation.--The Secretary shall first 
     implement this section for services furnished on or after 
     January 1, 2010.
       ``(3) General definitions.--In this section:
       ``(A) Qualified transitional care entity.--The term 
     `qualified transitional care entity' means--
       ``(i) a hospital or a critical care hospital;
       ``(ii) a home health agency;
       ``(iii) a primary care practice;
       ``(iv) a Federally qualified health center; or
       ``(v) another entity approved by the Secretary for purposes 
     of this section.
       ``(B) Transitional care period.--The term `transitional 
     care period' means, with respect to a qualified individual, 
     the period--
       ``(i) beginning on the date the individual is admitted to a 
     subsection (d) hospital (as defined for purposes of section 
     1886) for inpatient hospital services, or is admitted to a 
     critical care hospital for inpatient critical access hospital 
     services, for which payment may be made under this title; and
       ``(ii) ending on the last day of the 90-day period 
     beginning on the date of the individual's discharge from such 
     hospital or critical care hospital.
       ``(b) Qualified Individuals.--
       ``(1) Limiting first phase of implementation to high-risk 
     individuals.--Except as provided in this subsection, 
     qualified individuals are limited to individuals who--
       ``(A) have been admitted to a subsection (d) hospital (as 
     defined for purposes of section 1886) for inpatient hospital 
     services or to a critical care hospital for inpatient 
     critical access hospital services; and
       ``(B) are identified by the Secretary as being at highest 
     risk for readmission or for a poor transition from such a 
     hospital to a post-hospital site of care.

     The identification under subparagraph (B) shall be based on 
     achieving a minimum hierarchical condition category score 
     (specified by the Secretary) in order to target eligibility 
     for benefits under this section to individuals with multiple 
     chronic conditions and other risk factors, such as cognitive 
     impairment, depression, or a history of multiple 
     hospitalizations.
       ``(2) Second phase of implementation.--After submitting to 
     Congress the evaluation under subsection (i)(2) and 
     considering any cost-savings and quality improvements from 
     the prior implementation of this section, the Secretary may 
     expand eligibility of qualified individuals to include 
     moderate-risk and lower-risk individuals, as determined in 
     accordance with eligibility criteria specified by the 
     Secretary. In expanding eligibility, the Secretary may modify 
     or scale transitional care services to meet the specific 
     needs of moderate- and lower-risk individuals.
       ``(3) Avoiding duplication of services.--The Secretary 
     shall ensure that qualified individuals receiving 
     transitional care services are not receiving duplicative 
     services under this title.
       ``(c) Transitional Care Services Defined.--In this section, 
     the term `transitional care services' means services that 
     support a qualified individual during the transitional care 
     period and includes the following:
       ``(1) A comprehensive assessment prior to discharge 
     including an assessment of the individual's physical and 
     mental condition, cognitive and functional capacities, 
     medication regimen and adherence, social and environmental 
     needs, and primary caregiver needs and resources.
       ``(2) Development of a comprehensive, evidenced-based plan 
     of transitional care for the individual developed with the 
     individual and the individual's primary caregiver and other 
     health team members, identifying potential health risks, 
     treatment goals, current therapies, and future services for 
     both the individual and any primary caregiver.
       ``(3) A visit at the care setting within 24 hours after 
     discharge from the hospital or critical access hospital.

[[Page S6814]]

       ``(4) Home visits to implement the plan of care.
       ``(5) Implementation of the plan of care, including--
       ``(A) addressing symptoms;
       ``(B) teaching and promoting self-management skills for the 
     individual and any primary caregiver;
       ``(C) teaching and counseling the individual and the 
     individual's primary caregiver (as appropriate) to assure 
     adherence to medications and other therapies and avoid 
     adverse events;
       ``(D) promoting individual access to primary care and 
     community-based services;
       ``(E) coordinating services provided by other health team 
     members and community caregivers; and
       ``(F) facilitating transitions to palliative or hospice 
     care, where appropriate.
       ``(6) Accompanying the individual to follow-up physician 
     visits, as appropriate.
       ``(7) Providing information and resources about conditions 
     and care.
       ``(8) Educating and assisting the individual and the 
     individual's primary caregiver to arrange and coordinate 
     clinician visits and health care services.
       ``(9) Informing providers of services and suppliers of 
     those items and services that have been ordered for and 
     received by the individual from other providers.
       ``(10) Working with providers of services and suppliers to 
     assure appropriate referrals to specialists, tests, and other 
     services.
       ``(11) Educating and assisting the individual and the 
     individual's primary caregiver with arranging and 
     coordinating community resources and support services (such 
     as medical equipment, meals, homemaker services, assistance 
     with daily activities, shopping, and transportation).
       ``(12) Providing to the qualified individual, primary 
     caregiver, and appropriate clinicians and qualified 
     transitional care entity providing ongoing care at the 
     conclusion of the transitional care period a written summary 
     that includes the goals established in the plan of care 
     described in paragraph (2), progress in achieving such goals, 
     and remaining treatment needs.
       ``(13) Other services that the Secretary determines are 
     appropriate.

     The Secretary shall determine and update the services to be 
     included in transitional care services as appropriate, based 
     on the evidence of their effectiveness in reducing hospital 
     readmissions and improving health outcomes.
       ``(d) Transitional Care Clinicians.--
       ``(1) In general.--In this section, the term `transitional 
     care clinician' means, with respect to a qualified 
     individual, a nurse or other health professional who--
       ``(A) has received specialized training in the clinical 
     care of people with multiple chronic conditions (including 
     medication management) and communication and coordination 
     with multiple providers of services, suppliers, patients, and 
     their primary caregivers;
       ``(B) is supported by an interdisciplinary team in a manner 
     that assures continuity of care throughout a transitional 
     care period and across care settings (including the 
     residences of qualified individuals);
       ``(C) is employed by (or has a contract with) with a 
     qualified transitional care entity for the furnishing of 
     transitional care services; and
       ``(D) meets such participation criteria as the Secretary 
     may specify consistent with this subsection.
       ``(2) Participation criteria.--In establishing 
     participation criteria under paragraph (1)(C), the Secretary 
     shall assure that transitional care clinicians meet relevant 
     experience and training requirements and have the ability to 
     meet the individual needs of qualified individuals.
       ``(3) Encouragement of hit.--The Secretary may provide for 
     an additional payment to encourage transitional care 
     clinicians and qualified transitional care entities to use 
     health information technology in the provision of 
     transitional care services.
       ``(e) Payment.--
       ``(1) In general.--The Secretary shall determine the method 
     of payment for transitional care services under this section, 
     including appropriate risk adjustment that reflects the 
     differences in resources needed to provide transitional care 
     services to individuals with differing characteristics and 
     circumstances and, when applicable, the performance measures 
     under subsection (f). The payment amount shall be sufficient 
     to ensure the provision of necessary transitional care 
     services throughout the transitional care period. The payment 
     shall be structured in a manner to explicitly recognize 
     transitional care as an episode of services that crosses 
     multiple care settings, providers of services, and suppliers. 
     The payment with respect to transitional care services 
     furnished by a transitional care clinician shall be made, 
     notwithstanding any other provision of this title, to the 
     qualified transitional care entity which employs, or has a 
     contract with, the clinician for the furnishing of such 
     services.
       ``(2) No cost-sharing.--Notwithstanding section 1833, there 
     shall be no deductible or cost-sharing applicable to payment 
     under this section for transitional care services.
       ``(f) Performance Measures.--
       ``(1) Accountability.--
       ``(A) In general.--The Secretary shall establish a method 
     whereby qualified transitional care entities responsible for 
     furnishing transitional care services would be held 
     accountable for process and outcome performance measures 
     specified by the Secretary from those that have been endorsed 
     by the National Quality Forum.
       ``(B) Development and endorsement of performance measure 
     set.--For purposes of carrying out subparagraph (A), the 
     Secretary shall enter into an arrangement--
       ``(i) with the National Quality Forum for the evaluation, 
     endorsement, and recommendation of an appropriate set of 
     performance measures for transitional care services and for 
     the identification of gaps in available measures; and
       ``(ii) with the Agency for Healthcare Research and Quality 
     to support measure development, to fill gaps in available 
     measures, and to provide for the ongoing maintenance of the 
     set of performance measures for transitional care services.
       ``(2) Pay for performance.--As soon as practicable after 
     reliable process and outcome performance measures have been 
     endorsed and specified under subparagraph (A), the Secretary 
     shall provide that the payment amounts under subsection (e) 
     for transitional care services shall be linked to performance 
     on such measures.
       ``(3) Public reporting.--The Secretary shall establish a 
     mechanism to publicly report on a qualifying entity's 
     transitional care performance on such measures, including 
     providing benchmarks to identify high performers and those 
     practices that contribute to lower hospital readmission 
     rates.
       ``(4) Dissemination of information on best practices.--The 
     Secretary shall disseminate information on best practices 
     used by transitional care clinicians and qualifying 
     transitional care entities in furnishing transitional care 
     services for purposes of application in other settings, such 
     as in conditions of participation under this title, under the 
     Quality Improvement Organization (QIO) Program under part B 
     of title XI, and public-private quality alliances, such as 
     the Hospital Quality Alliance.
       ``(g) Notification of Eligibility and Coordination With 
     Hospital Discharge Planning.--In establishing standards for 
     discharge planning under section 1861(ee)(1), the Secretary 
     shall require each subsection (d) hospital and each critical 
     care hospital--
       ``(1) to identify, as soon as practicable after admission, 
     those patients who are qualified individuals under this 
     section; and
       ``(2) to provide to such patients and their primary 
     caregivers a list of qualified transitional care entities 
     available to arrange for the provision of transitional care 
     services, a list of transitional services provided under this 
     section, and a notice that the transitional care service 
     benefit is provided to qualified individuals with no 
     deductible or cost-sharing.

     Nothing in this section shall be construed as preventing such 
     a hospital from entering into an agreement with a qualified 
     transitional care entity or a transitional care clinician for 
     the furnishing of transitional care services to the 
     hospital's patients.
       ``(h) Prevention of Inappropriate Steering.--The Secretary 
     shall promulgate such regulations as the Secretary deems 
     necessary to address any protections needed, beyond those 
     otherwise provided under law and regulations, to prevent 
     inappropriate steering of qualified individuals to providers 
     of services, suppliers, qualified transitional care entities, 
     or transitional care clinicians, under this section or 
     inappropriate limitations on access to needed transitional 
     care services under this section.
       ``(i) Evaluation of Benefit.--
       ``(1) In general.--The Secretary shall evaluate the 
     performance of the transitional care benefit under this 
     section by measuring the following (for those receiving 
     transitional care services and those not receiving such 
     services):
       ``(A) Admission rates to health care facilities.
       ``(B) Hospital readmission rates.
       ``(C) Cost of transitional care and all other health care 
     services.
       ``(D) Quality of transitional care experiences.
       ``(E) Measures of quality and efficiency.
       ``(F) Beneficiary, primary caregiver, and provider 
     experience.
       ``(G) Health outcomes.
       ``(H) Reductions in expenditures under this title over 
     time.
       ``(2) Report.--The Secretary shall submit a report to 
     Congress no later than April 1, 2013, on the performance 
     measures achieved by the transitional care benefit in the 
     first 2 years of implementation. After submitting such 
     report, the Secretary may expand the benefit to moderate-risk 
     and lower-risk individuals in accordance with subsection 
     (b)(2).''.
                                 ______