[Congressional Record Volume 160, Number 9 (Wednesday, January 15, 2014)]
[Senate]
[Pages S373-S379]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
STATEMENT ON INTRODUCED BILLS AND JOINT RESOLUTIONS
______
By Mr. WYDEN (for himself and Mr. Isakson):
S. 1932. A bill to amend title XVIII of the Social Security Act to
establish a Medicare Better Care Program to provide integrated care for
Medicare beneficiaries with chronic conditions, and for other purposes;
to the Committee on Finance.
Mr. WYDEN. Mr. President, I rise today to show my strong support for
the Medicare Program with the introduction of the Better Care, Lower
Cost Act with my colleague, Senator Isakson.
The Medicare Program, treasured by millions of Americans today, is
now dominated by cancer, diabetes, heart disease, and other chronic
conditions. It is time for reform that offers seniors with chronic
health challenges better quality, more affordable health care.
Fortunately, there are several pioneering health care leaders already
paving the way to reform. The bipartisan legislation we are offering is
designed to remove the government's shackles on innovation so that the
types of successful approaches discussed by health care leaders here
this morning become the norm rather than the exception.
The good news is that when the Senate Finance Committee recently
approved legislation to fix Medicare's broken system of reimbursing
doctors, the bill locked in specific incentives to move away from fee-
for-service medicine. As part of its markup, the Senate Finance
Committee added the foundation for improving chronic care for seniors:
reforms that guarantee many more seniors access to individual care
plans tailored to their unique needs.
The Better Care, Lower Cost Act builds on that progress and
introduces a bold new concept in Medicare: the idea that chronic care
should come first. Here are a few things the legislation does to
promote this idea:
First, the legislation creates the Better Care Program, allowing
health practices to create better care practices and health plans to
become better health plans that care for patients with teams led by
nurses, doctors, and physician assistants that must adhere to the
highest quality standards. These innovators will receive one payment
for their collective efforts to meet the chronic health needs of the
seniors enrolled. This will give providers the flexibility to deliver
the right care at the right time in the right place.
Second, because most seniors lack access to coordinated, chronic care
services today, the legislation sets aside the limiting Federal
mandates--like the ``attribution rule''--that prevent these teams from
actively reaching out to the seniors who would benefit most from
specialized chronic care. Our legislation also changes Federal law so
that participating practices and plans are able to reward seniors who
participate in the Better Care Program by lowering their out-of-pocket
costs when they work with their health care team.
Third, this bill recognizes that seniors with chronic conditions live
all over the country and sets out a plan for bringing providers and
plans to every nook and cranny of America. And for those seniors and
providers in rural or underserved areas, the legislation uses
telemedicine and other technologies as resources to help to closely
monitor and manage chronic conditions.
[[Page S374]]
Finally, a word about the private sector. This bill recognizes the
advances that have been made that prove that better care can be
provided at lower cost. There should not be as many barriers when
arriving at the gates of Medicare. In fact, in my hometown of Portland,
OR, when seniors talk about their Medicare, they are really talking
about plans like Kaiser and Providence that are fully integrated.
Seniors should have those care choices no matter where they live.
In Washington, there is talk a lot about ``Medicare delivery system
reform'' without mentioning why it is necessary or how it will actually
help the people Medicare serves. The legislation Senator Isakson and I
are introducing today is about giving seniors with chronic illnesses
the focus and attention they need and deserve.
Every day Americans hear new statistics about the impact chronic
illness has on families, productivity, and the economy as a whole. But
I can't recall a legislative effort where all those involved have
remained singularly focused on solutions to this big problem.
To be clear, this legislation is not driven by a simple desire to cut
costs. Anyone can save money by cutting benefits, but this legislation
would actually improve the care that seniors receive. I urge my
colleagues to join us in this effort by cosponsoring this important
legislation.
There being no objection, the text of the bill was ordered to be
printed in the Record, as follows:
S. 1932
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Better
Care, Lower Cost Act''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Medicare Better Care Program.
Sec. 4. Chronic special needs plans.
Sec. 5. Improvements to welcome to Medicare visit and annual wellness
visits.
Sec. 6. Chronic care innovation centers.
Sec. 7. Curricula requirements for direct and indirect graduate medical
education payments.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) The field of medicine is ever-evolving and we need a
highly skilled, team-oriented workforce that can meet the
health care needs of today as well as the health care
challenges of tomorrow.
(2) The Medicare program should recognize the growing uses
and benefits of health technology in delivering quality and
cost-efficient care by encouraging the use of telemedicine
and remote patient monitoring.
SEC. 3. MEDICARE BETTER CARE PROGRAM.
(a) In General.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended by adding at the end the
following new section:
``medicare better care program
``Sec. 1899B. (a) Establishment.--
``(1) In general.--Not later than January 1, 2017, the
Secretary shall establish an integrated chronic care delivery
program (in this section referred to as the `program') that
promotes accountability and better care management for
chronically ill patient populations and coordinates items and
services under parts A, B, and D, while encouraging
investment in infrastructure and redesigned care processes
that result in high quality and efficient service delivery
for the most vulnerable and costly populations. The program
shall--
``(A) focus on long-term cost containment and better
overall health of the Medicare population by implementing
through qualified BCPs (as described in paragraph (2)(A))
strategies that prevent, delay, or minimize the progression
of illness or disability associated with chronic conditions;
and
``(B) include the program elements described in paragraph
(2).
``(2) Program elements.--The following program elements are
described in this paragraph:
``(A) A health plan or group of providers of services and
suppliers, or a health plan working with such a group, that
the Secretary certifies in accordance with subsection (e) as
meeting criteria developed by the Secretary to recognize the
challenges of managing a chronically ill population,
including patient satisfaction and engagement, quality
measurement developed specifically for a chronically ill
population, and effective use of resources and providers, may
manage and coordinate care for BCP eligible individuals
through an integrated care network, or Better Care Program
(referred to in this section as a `qualified BCP'). A group
of providers of services and suppliers described in the
preceding sentence may also be participating in another
alternative payment model (as defined in subsection (k)).
``(B) Payments to a qualified BCP shall be made in
accordance with subsection (g).
``(C) Implementation of the program shall focus on
physical, behavioral, and psychosocial needs of BCP eligible
individuals.
``(D) Quality and cost containment are considered
interdependent goals of the program.
``(E) The calculation of long-term cost savings is
dependent on qualified BCPs delivering the full continuum of
covered primary, post-acute care, and social services using
capitated financing.
``(3) Targeted participation.--
``(A) In general.--In certifying qualified BCPs throughout
the country, the Secretary shall give priority to areas--
``(i) that do not have a concentration of accountable care
organizations under section 1899; and
``(ii) with a high burden of chronic conditions.
``(B) Initial requirement.--In the first 5 years of the
program, at least 50 percent of all new qualified BCPs
certified nationwide by the Secretary shall be from counties
or regions, as determined by the Secretary, where the
prevalence of the most costly chronic conditions is at or
greater than 125 percent of the national average.
``(C) Restricting the number of participating bcps.--
``(i) In general.--The Secretary shall take into account
geography, urban and rural designations, and the population
case mix that will be served, when selecting BCPs for
participation.
``(ii) Limitation during the first four program years.--
During the first four years of the program, the total number
of qualified BCPs certified by the Secretary shall not exceed
250.
``(iii) No limitation during fifth and subsequent program
years.--During the fifth year and any subsequent year of the
program, the Secretary may certify any BCP that meets the
requirements to be certified as a qualified BCP.
``(4) Alignment with approved state plan waivers.--In
certifying qualified BCPs, the Secretary shall ensure
alignment with other approved waivers of State plans under
title XIX.
``(b) Definition of BCP Eligible Individuals.--
``(1) Definition.--For purposes of this section, the term
`BCP eligible individual' means an individual who--
``(A) is entitled to benefits under part A and enrolled
under parts B and D, including an individual who is enrolled
in a Medicare Advantage plan under part C, an eligible
organization under section 1876, or a PACE program under
section 1894; and
``(B) is medically complex given the prevalence of chronic
disease that actively and persistently affects their health
status, and absent appropriate care interventions, causes
them to be at enhanced risk for hospitalization, limitations
on activities of daily living, or other significant health
outcomes.
``(2) Dual eligible individuals.--An individual who is
dually eligible for Medicare and Medicaid shall not be
excluded from enrolling in a qualified BCP. Dually eligible
beneficiaries enrolled in a qualified BCP will see the full
scope of their benefits under this title and title XIX (other
than long-term care) managed by the qualified BCP.
``(c) Notification and Enrollment.--
``(1) Notification.--Not later than October 1 of each year,
the Secretary shall use all available tools, including the
notice mailed annually under section 1804(a) and State health
insurance assistance programs, to notify BCP eligible
individuals of qualified BCPs in their area for the upcoming
plan year. Such information shall also be easily accessible
on the Internet website of the Centers for Medicare &
Medicaid Services.
``(2) Enrollment.--The Secretary shall establish procedures
under which BCP eligible individuals may voluntarily enroll
in a qualified BCP at the following times:
``(A) During the annual, coordinated election period under
section 1851(e)(3)(B).
``(B) During or following (for a length of time determined
by the Secretary)--
``(i) an initial preventive physical examination (as
defined in section 1861(ww)); or
``(ii) any subsequent visit where a chronic condition is
identified or a previous condition is identified as having
escalated to the level of a chronic condition.
``(d) Patient Assessment.--
``(1) Standardized functional and health risk assessment.--
``(A) Minimum guidelines.--Not later than January 1, 2016,
the Secretary shall publish minimum guidelines for qualified
BCPs to furnish to enrollees a health information technology-
compatible, standardized, and multidimensional risk
assessment that--
``(i) assesses and quantifies the medical, psychosocial,
and functional status of an enrollee; and
``(ii) includes a mechanism to determine the level of
patient activation and ability to engage in self-care of an
enrollee.
``(B) Updating.--Not less frequently than once every 3
years, the Secretary shall, through rulemaking, update such
minimum guidelines to reflect new clinical standards and
practices, as appropriate.
``(2) Individual patient-centered chronic care plan.--
``(A) Model plan.--Not later than January 1, 2016, the
Secretary shall publish minimum guidelines for qualified BCPs
to develop individual patient-centered chronic care plans for
enrollees. Such a plan shall--
[[Page S375]]
``(i) allow health professionals to incorporate the
medical, psychosocial, and functional components identified
in the risk assessment described in paragraph (1)(A)(i);
``(ii) provide a framework that can be easily integrated
into electronic health records, allowing clinicians to make
timely, accurate, evidence-based decisions at the point of
care; and
``(iii) allow for the provider to describe how services
will be provided to the enrollee.
``(B) Use of technology for patient self care.--
``(i) In general.--Whenever appropriate, the individual
patient-centered chronic care plan of an enrollee shall
include the use of technologies that enhance communication
between patients, providers, and communities of care, such as
telehealth, remote patient monitoring, Smartphone
applications, and other such enabling technologies, that
promote patient engagement and self care while maintaining
patient safety.
``(ii) Coordination and development of streamlined
pathway.--The Secretary shall work with the Office of the
National Coordinator for Health Information Technology and
the Department of Health and Human Services Chief Technology
Officer to develop a streamlined pathway for the use of
mobile applications and communications devices that
effectively enhance the experience of the patient while
maintaining patient safety and cost-effectiveness. Such
pathway shall not duplicate existing efforts.
``(e) Qualified BCP Providers.--
``(1) Criteria.--
``(A) In general.--Any health plan, provider of services,
or group of providers of services and suppliers, who agrees
to meet the requirements described in paragraph (2) and is
specified in subparagraph (C) may form a multidisciplinary
team of health professionals to be certified as a qualified
BCP. Those providers may also choose to partner with a
qualified insurer to become a qualified BCP.
``(B) No preemption of state licensure laws.--Nothing in
this section shall preempt State licensure laws.
``(C) Groups of providers and suppliers specified.--
``(i) In general.--As determined appropriate by the
Secretary, the following health plans, providers of services,
or groups of providers of services and suppliers, that meet
the criteria described in clause (ii) may be certified as
qualified BCPs under the program:
``(I) Health professionals acting as part of a
multidisciplinary team.
``(II) Networks of individual practices of health
professionals that may include community health centers,
Federally qualified health centers, rural health clinics, and
partnerships or affiliations with hospitals.
``(III) Health plans that meet appropriate network adequacy
standards, as determined by the Secretary, and that include
providers with experience and interest in managing a
population with chronic conditions.
``(IV) Independent health professionals partnering with an
independent risk manager.
``(V) Such other groups of providers of services or
suppliers as the Secretary determines appropriate.
``(ii) Criteria described.--The following criteria are
described in this clause:
``(I) Demonstrated capacity to manage the full continuum of
care (other than long-term care) for the specialized
population of BCP eligible individuals.
``(II) Having a high rate of Medicare customer
satisfaction, when applicable, or partnering with providers
of services or suppliers with such a demonstrated high
satisfaction rate.
``(2) Requirements.--A qualified BCP shall meet the
following requirements:
``(A) The qualified BCP shall be accountable for the
quality, cost, and overall care of enrolled BCP eligible
individuals and agree to be at financial risk for that
enrolled population. A qualified BCP shall be established
with the objective of serving BCP eligible individuals.
``(B) The qualified BCP shall be responsible for the full
continuum of care (other than long-term care) for enrollees.
This continuum shall include medical care, skilled nursing
and home health services, behavioral health care, and social
services. The qualified BCP may not actively restrict an
enrollee's access to providers based on a practitioner's
license or medical specialty based on cost alone.
``(C) The qualified BCP shall primarily consist of a care
team tasked with responding to, treating, and actively
supporting the needs of BCP eligible individuals. The care
team shall also develop a care plan for each eligible BCP
enrollee and use it as a tool to execute effective care
management and transitions.
``(D) The qualified BCP shall include physicians, nurse
practitioners, registered nurses, social workers,
pharmacists, and behavioral health providers who commit to
caring for BCP eligible individuals.
``(E) The qualified BCP shall enter into an agreement with
the Secretary to participate in the program under this
section for not less than a 3-year period.
``(F) The qualified BCP shall include adequate numbers of
primary care and other relevant professionals that can
effectively care for the number of BCP eligible individuals
enrolled in the qualified BCP.
``(G) The qualified BCP shall provide the Secretary with
such information regarding qualified BCP professionals
participating in the qualified BCP necessary to support the
enrollment of BCP eligible individuals in a qualified BCP,
including evidence relating to high patient satisfaction when
available, the implementation of quality reporting and other
reporting requirements, and evidence to support a
determination of capitated payments in accordance with
subsection (g).
``(H) The qualified BCP shall have in place a structure
that includes clinical and administrative systems, including
health information technology, that supports the integration
of services and providers across sites of care.
``(I) The qualified BCP may develop a collaborative
partnership that supports the mission of the BCP with each of
the following:
``(i) A regional or national Chronic Care Innovation Center
under section 6 of the Better Care, Lower Cost Act.
``(ii) A regional or national Center of Innovation (COIN)
of the Department of Veterans Affairs Health Services
Research and Development Service to identify and implement
best practices--
``(I) to increase access to, and implementation of,
prevention and wellness tools;
``(II) to integrate physical and behavior health care with
social services;
``(III) to promote evidence-based medicine and patient
engagement;
``(IV) to coordinate care across providers and care
settings;
``(V) to allow more patients to be cared for in their homes
and communities;
``(VI) to reduce hospital readmissions;
``(VII) to improve health outcomes for patients with
chronic conditions; and
``(VIII) to report on quality improvement and cost
measures.
``(iii) A regional or national Telehealth Resource Center
of the Health Resources and Services Administration (HRSA)
Office for the Advancement of Telehealth to create an
interactive, online resource for qualified BCP professionals
who may need additional training or assistance in managing
the needs of a complex patient population, including--
``(I) continuing training and education and mentoring for
qualified BCP professionals at any level of licensure;
``(II) clinician support for complex patients by an expert
panel;
``(III) remote access to regional, national, and
international experts in the field;
``(IV) forums for best practices to be discussed among
qualified BCP professionals;
``(V) inter-professional education supporting optimal
communication between members of a chronic care team; and
``(VI) continuing training on the use of telehealth, remote
patient monitoring, and other such enabling technologies.
``(J) The qualified BCP shall demonstrate to the Secretary
that it meets person-centeredness criteria specified by the
Secretary in collaboration with accreditation organizations,
including the use of patient and caregiver assessments and
the use of individual patient-centered chronic care plans for
each enrollee (as described in subsection (d)(2)).
``(K) The qualified BCP may identify and respond to unique
cultural, social, and economic needs of a community that
impact access to, and quality of, healthcare.
``(L) The qualified BCP shall provide care across settings,
including in the home as needed.
``(M) The qualified BCP shall demonstrate financial
solvency (as determined by the Secretary).
``(N) The qualified BCP shall demonstrate the ability to
partner with providers of social and behavioral health
services within the community.
``(O) The qualified BCP shall engage in continuing
education on chronic care, on an ongoing basis (as determined
necessary by the Chronic Care Innovation Center under the
partnership under subparagraph (J)(i)), in collaboration with
the Agency for Healthcare Research and Quality, the Health
Resources and Services Administration, and the Department of
Veterans Affairs.
``(f) Implementing Value-based Insurance Design.--
``(1) In general.--
``(A) Election.--A qualified BCP may elect to provide
value-based Medicare coverage in accordance with this
subsection.
``(B) Inclusion of original medicare fee-for-service
program benefits.--Subject to subparagraph (C), enrollees in
a qualified BCP that elects to provide value-based Medicare
coverage under this subsection shall receive such coverage
that includes items and services for which benefits are
available under parts A and B to individuals entitled to
benefits under part A and enrolled under part B, with cost-
sharing for those items and services as described in
subparagraph (C).
``(C) Cost sharing.--Cost-sharing described in this
subparagraph, with respect to an enrollee in a qualified BCP
that makes such an election, is varied cost-sharing approved
by the Secretary to incentivize the use of high-value, high-
quality services that have been clinically proven to benefit
BCP eligible individuals.
``(D) Changes in coverage.--The Secretary, in consultation
with experts in the field, shall establish a process for
qualified BCPs to submit value-based Medicare coverage
changes that encourage and incentivize the use of evidence-
based practices that will drive better outcomes while
ensuring patient protections and access are maintained.
``(E) No requirement for coverage of long-term care
services.--In no case shall
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a qualified BCP be required to provide to enrollees coverage
for long-term care services.
``(2) Qualified bcp participation.--
``(A) Continued access.--Subject to subparagraph (B),
enrollees in a qualified BCP shall continue to have access to
all providers of services and suppliers under this title.
``(B) No application of varied cost-sharing for
nonparticipating providers of services and suppliers.--
``(i) In general.--The varied cost-sharing under paragraph
(1)(B) shall only apply to items and services furnished by
qualified BCP professionals of a qualified BCP that makes an
election under paragraph (1). In the case where items and
services are furnished by a provider of services or supplier
who is not such a qualified BCP professional, the cost-
sharing applicable for those items and services will be the
cost-sharing as required under parts A and B, or an
actuarially equivalent level of cost-sharing as determined by
the Secretary.
``(ii) Notification.--A BCP eligible individual shall be
notified and counseled prior to the time of enrollment on
potential changes in out-of-pocket costs that may occur if
care is provided by a provider of services or supplier that
is not a qualified BCP professional.
``(3) Limitations on out-of-pocket expenses outside a
qualified bcp.--
``(A) In general.--Out-of-pocket costs, including
individual beneficiary copayments, with respect to items and
services furnished by a provider of services or supplier who
is not a qualified BCP professional shall not exceed what
would otherwise have been paid with respect to the item or
service under the original Medicare fee-for-service program
under parts A and B for the same services or an actuarially
equivalent level of cost-sharing as determined by the
Secretary, or, in the case of a dual eligible individual,
under the Medicaid program under title XIX.
``(B) Prohibition on coverage of cost-sharing for certain
items and services furnished to an enrollee outside of a
qualified bcp under medigap policies.--For provisions
relating to prohibition on coverage of cost-sharing for items
and services (other than emergent services, as defined by the
Secretary) furnished to an enrollee outside of a qualified
BCP under medigap policies, see section 1882(z).
``(4) Prescription drug coverage.--
``(A) Drug plan option.--
``(i) In general.--A health plan certified as a qualified
BCP may provide enrollees with a drug plan option
specifically designed to reflect the medication needs of
enrollees.
``(ii) Application of part d provisions.--
``(I) In general.--Except as otherwise provided in this
section, the provisions of part D shall apply to a drug plan
option offered by a qualified BCP under clause (i) in the
same manner as such provisions apply to a prescription drug
plan offered by a PDP sponsor under such part.
``(II) Limitation of enrollment.--A qualified BCP offering
such a drug plan option may limit enrollment in the drug plan
option to enrollees in the qualified BCP.
``(III) Waiver.--The Secretary may waive such provisions of
part D as are necessary to carry out this section.
``(B) Agreement with prescription drug plans.--A qualified
BCP managed by a group of providers of services may enter
into an agreement with a PDP sponsor of a prescription drug
plan under part D to establish and encourage individuals
enrolled in the qualified BCP to enroll in a prescription
drug plan under such part that is better suited to the needs
of chronically ill individuals.
``(C) Limitation.--A drug plan option offered by a
qualified BCP under subparagraph (A)(i) shall not have the
authority to increase out-of-pocket limits otherwise
applicable under part D.
``(g) Payments and Treatment of Savings.--
``(1) Payments to qualified bcps on a capitated basis.--
``(A) In general.--In the case of a qualified BCP under
this section, the Secretary shall make prospective monthly
payments of a capitation amount for each BCP eligible
individual enrolled in the qualified BCP in the same manner
and from the same sources as payments are made to a Medicare
Advantage organization under section 1853. Such payments
shall be subject to adjustment in the manner described in
section 1853(a)(2) or section 1876(a)(1)(E), as the case may
be.
``(B) Capitation amount.--The capitation amount to be
applied under this paragraph for a qualified BCP for each
enrollee for a year shall be \1/12\ of the benchmark rate
under subparagraph (C)(ii) for the year (or the relevant rate
under subparagraph (C)(i) for the first year of the program
under this section) (referred to in this paragraph as the
`per member per month payment'), as adjusted under clause
(iii).
``(C) Determining the rate using risk relevant control
group.--
``(i) Relevant rate.--
``(I) Identification of beneficiary grouping.--Using claims
data, the Secretary shall identify a group of beneficiaries
who have similar health risk characteristics, and have sought
care in the same county, multi-county, or State level (as
determined appropriate by the Secretary to establish a
payment area) to the population the qualified BCP is tasked
with serving. To the extent feasible for a statistically
valid control group, the health risk of such group shall
reflect social characteristics, such as income, as well as
medical risk.
``(II) Determination of relevant rate.--The per capita
spending amounts under this title and, as appropriate, title
XIX, of the group of beneficiaries identified under subclause
(I) shall determine the `relevant rate' that will serve as
the basis of the benchmark for participating qualified BCPs.
``(ii) Benchmark rate.--The Secretary shall establish the
benchmark rate for a qualified BCP service area for each year
of the program by updating the relevant rate determined under
clause (i) with the projected change in per capita spending
for the group of beneficiaries identified under clause (i)(I)
for the payment area described in such clause, as determined
by the Chief Actuary of the Centers for Medicare & Medicaid
Services.
``(iii) Adjustment for health status.--
``(I) Comparison of health status.--The Secretary shall
establish a risk score mechanism to compare the health status
of an enrollee in a qualified BCP to the average health risk
of group of beneficiaries identified under clause (i)(I).
``(II) Inclusion of number of conditions.--The Secretary
shall provide that a risk score under the mechanism under
this clause, with respect to an individual, includes an
indicator for the number of chronic conditions with which the
individual has been diagnosed.
``(III) Use of 2 years of diagnosis data.--The Secretary
shall ensure that such risk score, with respect to an
individual reflects not less than 2 years of diagnosis data,
to the extent available.
``(IV) Adjustment for health status.--The per member per
month payment to the qualified BCP for each enrollee shall be
adjusted depending on how the individual risk profile of the
enrollee compares to the average health status of such group
of beneficiaries. If an enrollee has a risk profile that is
not as severe as the average health status of such group of
beneficiaries, then the per member per month shall be
decreased to reflect the `healthier' status of the enrollee.
If an enrollee has a risk profile that is more severe, then
the per member per month payment to the qualified BCP shall
be increased to reflect the more acutely ill status of the
enrollee.
``(D) Shared risk payments for certain qualified bcps
during first 3 years of the program.--
``(i) In general.--This subparagraph shall only apply to
qualified BCPs offered by a group of providers of services
and suppliers during the first 3 years of the program under
this section.
``(ii) Sharing of risk to alleviate outliers.--The
Secretary shall determine shared risk payments and
recoupments under this subparagraph for a qualified BCP
described in clause (i) as follows:
``(I) Determination of gain or loss.--The Secretary shall,
for each of the first 3 years of the program under this
section, determine the percentage of gain or loss for the
qualified BCP in providing benefits to enrollees under this
section.
``(II) Gain or loss greater than 5 percent.--If the
Secretary determines the qualified BCP has a gain or loss for
the year of greater than 5 percent, the qualified BCP shall
bear 100 percent of the risk or reward of such loss or gain.
``(III) Gain or loss of not less than 2 and not greater
than 5 percent.--If the Secretary determines the qualified
BCP has a gain or loss for the year of not less than 2
percent but not greater than 5 percent--
``(aa) the qualified BCP shall bear 80 percent of the risk
or reward, as applicable, of such loss or gain; and
``(bb) the Secretary shall bear 20 percent of the risk or
reward, as applicable, of such loss or gain.
``(IV) Gain or loss between 0 and 2 percent.--If the
Secretary determines the qualified BCP has a gain or loss for
the year of greater than 0 percent but less than 2 percent--
``(aa) the qualified BCP shall bear 50 percent of the risk
or reward, as applicable, of such loss or gain; and
``(bb) the Secretary shall bear 50 percent of the risk or
reward, as applicable, of such loss or gain.
``(iii) Provision of information.--A qualified BCP shall
provide to the Secretary such information as the Secretary
determines is necessary to carry out this subparagraph.
``(E) Bid submission.--Beginning with the fourth year of
the program, a qualified BCP shall submit a bid for
participation in the program for the year that reflects the
experience of the qualified BCP--
``(i) in managing the care of the enrolled population; and
``(ii) in managing such care given the relevant rate
determined under subparagraph (C).
``(F) Quality bonus system.--
``(i) In general.--The Secretary shall establish a quality
bonus system whereby the Secretary distributes bonus payments
to qualified BCPs that meet the requirements described in
clause (iii) and other standards specified by the Secretary,
which may include a focus on quality measurement and
improvement, delivering patient-centered care, and practicing
in integrated health systems, including training in
community-based settings. In developing such standards, the
Secretary shall collaborate with relevant stakeholders,
including program accrediting bodies, certifying boards,
training programs, health care organizations, health care
purchasers, and patient and consumer groups.
``(ii) Determination of quality bonuses.--Quality bonuses
to the BCP shall be based on
[[Page S377]]
a comparison of the quality of care provided by the qualified
BCP to enrollees to the quality of care provided to
beneficiaries not enrolled in a qualified BCP or a Medicare
Advantage plan under part C in the same region. For not less
than the first 5 years of the program under this section,
quality measures for the geographic region shall be based on
local standards of care, and not on a national standard. For
subsequent years, appropriate national standards shall be
considered for inclusion in the comparison of the quality of
care under this subparagraph.
``(iii) Requirements.--A qualified BCP is eligible for
quality bonuses under this subparagraph if--
``(I) the qualified BCP meets quality performance standards
under subsection (h)(3); and
``(II) the qualified BCP meets the requirements under
subsection (e)(2).
``(h) Quality and Other Reporting Requirements.--
``(1) In general.--The Secretary shall develop and
implement, with assistance and input of relevant experts in
the field and the National Strategy for Quality Improvement
in Health Care, appropriate measures for BCP eligible
individuals. The Secretary shall determine appropriate
measures under this title and title XIX to assess the quality
of care furnished by a qualified BCP, as well as those
measures that are no longer appropriate and shall be removed
from use. Such measures shall include measures--
``(A) of clinical processes and outcomes;
``(B) of patient and, where practicable, caregiver
experience of care, including measurement that enhances
patient activation and engagement;
``(C) of utilization (such as rates of hospital admissions
for ambulatory care sensitive conditions);
``(D) of care coordination, management, and transitions;
and
``(E) that appropriately align with the National Strategy
for Quality Improvement in Health Care.
The Secretary may use existing measures under this title,
title XIX, or any other health care program, as appropriate,
under this paragraph.
``(2) Reporting requirements.--A qualified BCP shall submit
data in a form and manner specified by the Secretary which is
not overly burdensome to the qualified BCP, on measures the
Secretary determines necessary for the qualified BCP to
report in order to evaluate the quality of care furnished by
the qualified BCP. Such data reporting shall emphasize
`patient-centered measurement' and may include the functional
status of patients, case management and care transitions
across health care settings, including hospital discharge
planning and post-hospital discharge follow-up by qualified
BCP professionals, as the Secretary determines appropriate.
``(3) Quality performance standards.--The Secretary shall
establish quality performance standards to assess the quality
of care furnished by qualified BCPs. The Secretary shall seek
to improve the quality of care furnished by qualified BCPs
over time by specifying higher standards, new measures, or
both for purposes of assessing such quality of care. The
Secretary shall also include a process for retiring measures
that are no longer adequately contributing to improving
standards of care at the greatest possible value.
``(4) Other reporting requirements and call for
alignment.--The Secretary shall, as the Secretary determines
appropriate, incorporate and align reporting requirements and
incentive payments related to the physician quality reporting
system under section 1848, including those related to
reporting on quality measures under subsection (m) of that
section, reporting requirements under subsection (o) of that
section relating to meaningful use of electronic health
records, the establishment of a value-based payment modifier
under subsection (p) of that section, and other similar
initiatives under that section, and may use alternative
criteria than would otherwise apply under section 1848 for
determining whether to make such payments to qualified BCP
professionals. The incentive payments described in the
preceding sentence shall not be taken into consideration when
calculating any payments otherwise made under subsection (g).
``(i) Beneficiary Protections.--The Secretary shall ensure
that, to the extent consistent with this section, a qualified
BCP offers beneficiary protections applicable to
beneficiaries under this title and, as applicable, title XIX.
``(j) Payment of Medicare Cost-sharing for Dual Eligible
Individuals.--In the case of a dual eligible individual
enrolled in a qualified BCP, the Secretary may provide for
the payment of medicare cost-sharing (as defined in section
1905(p)(3)) that would otherwise be available under the State
plan under title XIX if the individual was not enrolled in
the qualified BCP.
``(k) Definitions.--In this section:
``(1) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(A) A model under section 1115A (other than a health care
innovation award).
``(B) An accountable care organization under section 1899.
``(C) A demonstration under section 1866C.
``(D) A demonstration required by Federal law.
``(E) A qualified BCP.
``(2) Hospital.--The term `hospital' means a subsection (d)
hospital (as defined in section 1886(d)(1)(B)).
``(3) Qualified bcp professional.--The term `qualified BCP
professional' means a certified and licensed professional of
medical or behavioral health services that is participating
in a qualified BCP.''.
(b) Federal Assumption of Medicaid Costs for Full Benefit
Dual Eligible Individuals Enrolled in a Qualified BCP.--Title
XIX of the Social Security Act is amended by inserting after
section 1943 the following new section:
``federal assumption of medicaid costs for full benefit eligible
individuals enrolled in a qualified bcp
``Sec. 1944. (a) State Contribution.--
``(1) In general.--The State shall provide for payment to
the Secretary for each month in an amount determined under
paragraph (2)(A) for each applicable dual eligible BCP
enrollee for such State.
``(2) State contribution amount.--
``(A) In general.--Subject to subparagraph (C), the amount
determined under this paragraph for a State for a month in a
year is equal to the product described in subparagraph (A) of
section 1935(c)(1) for the State for the month, except that
the reference in such subparagraph to the total number of
full-benefit dual eligible individuals shall be deemed a
reference to the total number of applicable dual eligible BCP
enrollees.
``(B) Form and manner of payment.--The provisions of
subparagraphs (B) through (D) of section 1935(c)(1) shall
apply to payment by a State to the Secretary under this
paragraph in the same manner as such subparagraphs apply to
payment under section 1935(c)(1)(A).
``(C) Application of different factors.--In applying
subparagraph (A), the following shall be substituted under
paragraphs (2) and (3) of section 1935(c):
``(i) The base year State Medicaid per capita expenditures
for covered part D drugs described in subparagraph (A)(i)(I)
of such paragraph (2) shall be deemed to be the per capita
expenditures for health care items and services that would
apply (including any medicare cost-sharing), with respect to
an applicable dual eligible BCP enrollee, if such an
individual received benefits only under title XVIII (and not
the State plan under this title).
``(ii) Any reference to expenditures for covered part D
drugs or for prescription drug benefits shall be deemed a
reference to the expenditures for health care items and
services described in clause (i).
``(iii) Any reference to 2003 or 2004 shall be deemed a
reference to 2017 or 2018, respectively.
``(iv) Any reference to a full-benefit-dual-eligible
individual shall be deemed a reference to an applicable dual
eligible BCP enrollee.
``(v) The applicable growth factor under section 1935(c)(4)
for a year, with respect to a State, shall be the average
annual percentage change (to that year from the previous
year) of the expenditures of the State under the State plan
under title XIX.
``(vi) The factor described in section 1935(c)(5) is deemed
to be 90 percent.
``(3) Applicable dual eligible bcp enrollee.--For purposes
of this section, the term `applicable dual eligible BCP
enrollee' means, with respect to a State, an individual
described in subparagraph (A)(ii) of section 1935(c)(6)
(taking into account the application of subparagraph (B) of
such section) for such State who is enrolled in a qualified
BCP under section 1899B. Such term includes, in the case of
medical assistance for medicare cost-sharing under a State
plan under this title, an individual who is a qualified
medicare beneficiary (as defined in section 1905(p)(1)), a
qualified disabled and working individual (described in
section 1905(s)), an individual described in section
1902(a)(10)(E)(iii), or otherwise entitled to such medicare
cost-sharing and who is enrolled in such a qualified BCP.
``(b) Coordination of Benefits.--
``(1) Medicare as primary payor.--In the case of an
applicable dual eligible BCP enrollee, notwithstanding any
other provision of this title, medical assistance is not
available under this title for health care items or services
(or for any cost-sharing respecting such health care items
and services), and the rules under this title relating to the
provision of medical assistance for such health care items
and services shall not apply. The provision of benefits with
respect to such health care items and services shall not be
considered as the provision of care or services under the
plan under this title. No payment may be made under section
1903(a) for health care items and services for which medical
assistance is not available pursuant to this paragraph.
``(2) Coverage of long-term care services.--In the case of
medical assistance under this title with respect to coverage
of long-term care services furnished to an applicable dual
eligible BCP enrollee, the State may elect to provide such
medical assistance in the manner otherwise provided in the
case of individuals who are not full-benefit dual eligible
individuals or through an arrangement with such qualified
BCP. In no case shall a qualified BCP be required to provide
to enrollees coverage of long-term care services.''.
(c) State Marketing Materials for Dually Eligible
Individuals.--
(1) State plan requirement.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)) is amended--
[[Page S378]]
(A) in paragraph (80), by striking ``and'' at the end;
(B) in paragraph (81), by striking the period at the end
and inserting ``; and''; and
(C) by inserting after paragraph (81) the following:
``(82) provide that any marketing materials distributed by
the State that are directed at dual eligible individuals (as
defined in section 1915(h)(2)(B)) include information on
qualified BCPs offered under section 1899B.''.
(2) Effective date.--The amendments made by this section
shall apply to calendar quarters beginning on or after
January 1, 2017, without regard to whether or not final
regulations to carry out such amendments have been
promulgated by such date.
(d) Prohibition on Coverage of Cost-sharing for Certain
Items and Services Furnished to an Enrollee Outside of a
Qualified BCP Under Medigap Policies.--Section 1882 of the
Social Security Act (42 U.S.C. 1395ss) is amended by adding
at the end the following new subsection:
``(z) Prohibition on Coverage of Cost-sharing for Certain
Items and Services Furnished to an Enrollee Outside of a
Qualified BCP and Development of New Standards for Medicare
Supplemental Policies.--
``(1) Development.--The Secretary shall request the
National Association of Insurance Commissioners to review and
revise the standards for benefit packages under subsection
(p)(1), taking into account the changes in benefits resulting
from the enactment of the Better Care, Lower Cost Act and to
otherwise update standards to include the requirements for
cost sharing described in paragraph (2). Such revisions shall
be made consistent with the rules applicable under subsection
(p)(1)(E) with the reference to the `1991 NAIC Model
Regulation' deemed a reference to the NAIC Model Regulation
as published in the Federal Register on December 4, 1998, and
as subsequently updated by the National Association of
Insurance Commissioners to reflect previous changes in law
and the reference to `date of enactment of this subsection'
deemed a reference to the date of enactment of the Better
Care, Lower Cost Act To the extent practicable, such revision
shall provide for the implementation of revised standards for
benefit packages as of January 1, 2017.
``(2) Cost sharing requirements.--The cost sharing
requirements described in this paragraph are that,
notwithstanding any other provision of law, no medicare
supplemental policy may provide for coverage of cost sharing
with respect to items and services (other than emergent
services, as defined by the Secretary) furnished to an
individual enrolled in a qualified BCP under section 1899B by
a provider of services or supplier that is not a qualified
BCP professional (as defined in section 1899B(k)).
``(3) Renewability.--The renewability requirement under
subsection (q)(1) shall be satisfied with the renewal of the
revised package under paragraph (1) that most closely matches
the policy in which the individual was enrolled prior to such
revision.''.
SEC. 4. CHRONIC SPECIAL NEEDS PLANS.
Section 1859 of the Social Security Act (42 U.S.C. 1395w-
28) is amended--
(1) in subsection (f)(4)--
(A) by striking ``In the case of'' and inserting ``Subject
to subsection (h), in the case of''; and
(B) by adding at the end the following flush text:
``Notwithstanding any other provision of this section, on or
after January 1, 2014, the Secretary shall establish
procedures for the transition of those individuals to a
Medicare Advantage plan qualified BCP in accordance with
subsection (h).''; and
(2) by adding at the end the following new subsection:
``(h) Medicare Advantage Plan Qualified BCPs.--
``(1) In general.--A Medicare Advantage plan that is
certified as a qualified BCP (referred to in this subsection
as a `Medicare Advantage plan qualified BCP')--
``(A) is deemed to be a specialized MA plan for special
needs individuals described in subsection (b)(6)(B)(iii); and
``(B) may enroll such special needs individuals.
``(2) Specialized benefit packages.--A Medicare Advantage
plan qualified BCP shall have the flexibility to offer
specialized benefit packages to enrollees described in
subsection (b)(6)(B)(iii), consistent with the value-based
insurance requirements under section 1899B(f).
``(3) Application of bcp requirements.--A Medicare
Advantage plan qualified BCP shall be subject to all
requirements applicable to a qualified BCP under section
1899B, including enrollment periods under subsection (c) of
that section, applicable criteria relating to network
adequacy, requirements with respect to individual patient-
centered chronic care plans under subsection (d)(2) of that
section, applicable criteria with respect to care management
processes, and quality reporting under subsection (h) of that
section.
``(4) Application of part c requirements.--The provisions
of this part, including the provisions relating to
specialized MA plans for special needs individuals described
in subsection (b)(6)(B)(iii), shall apply to a Medicare
Advantage plan qualified BCP to the extent they are
consistent with the provisions of section 1899B.''.
SEC. 5. IMPROVEMENTS TO WELCOME TO MEDICARE VISIT AND ANNUAL
WELLNESS VISITS.
(a) Welcome to Medicare Visit.--Section 1861(ww)(1) of the
Social Security Act (42 U.S.C. 1395x(ww)(1)) is amended by
adding at the end the following new sentence: ``In the case
of a BCP eligible individual (as defined in section
1899B(b)), such term includes a standardized functional and
health risk assessment (as described in section 1899B(d)(1))
furnished by a qualified BCP professional (as defined in
section 1899B(k)).''.
(b) Annual Wellness Visit.--Section 1861(hhh)(1) of the
Social Security Act (42 U.S.C. 1395x(h)(1)) is amended--
(1) in subparagraph (A), by striking ``and'' at the end;
(2) in subparagraph (B), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(C) in the case of a BCP eligible individual (as defined
in section 1899B(b)), that includes a standardized functional
and health risk assessment (as described in section
1899B(d)(1)) furnished by a qualified BCP professional (as
defined in section 1899B(k)).''.
(c) Effective Date.--The amendments made by this section
shall apply to services furnished on or after the date that
is one year after the date of enactment of this Act.
SEC. 6. CHRONIC CARE INNOVATION CENTERS.
(a) Designation.--Not later than October 1, 2016, the
Secretary, acting through the Agency for Healthcare Research
and Quality, shall designate and provide core funding for not
less than three Chronic Care Innovation Centers. The
Secretary shall develop a process for entities seeking to
become a Chronic Care Innovation Center, and shall ensure
sufficient geographic representation among those entities
selected. The main objectives of such Centers shall include
the following:
(1) Improving the understanding of how to measure, monitor,
and understand quality and efficiency for a patient
population with substantial disease burden.
(2) Rigorously examining alternative and innovative systems
and strategies for efficiently improving quality and outcomes
for common, serious, and chronic illnesses.
(3) Developing and applying improved methodologies for
informing policymakers regarding heterogeneity in the
effectiveness and safety of proposed interventions, and
assessing barriers to the implementation of high-priority
care.
(4) Studying organization and management practices that
result in higher quality of care.
(5) Defining and improving quality of care for patients
with the chronic diseases prevalent in primary care settings.
(6) Understanding the influence of race, ethnicity, and
cultural factors on access, quality, and outcomes (such as
clinical, patient-centered, health care utilization, and
costs).
(7) Evaluating new technology to enhance access to, and
quality of care (such as telemedicine).
(8) Assessing the use of patient self-management and
behavioral interventions as a means of improving outcomes for
Medicare beneficiaries with complex chronic conditions.
(9) Understanding how management of care is affected when
patients have multiple chronic conditions in which evidence
or recommended guidelines are lacking, conflict with, or
complicate overall care management.
(10) Characterizing coordination of care within and across
healthcare systems, including the Department of Veterans
Affairs, the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), the Medicaid program
under title XIX of such Act, and private sector programs for
veterans with complex chronic conditions.
(b) Requirements.--In order to be designated a Chronic Care
Innovation Center under this section, each eligible entity
must meet the following requirements:
(1) Develop and implement a sustained research agenda in
the field of chronic care.
(2) Collaborate with local schools of public health and
universities to cary out its mission.
(3) Actively engage in the development of new, best
practices for the delivery of care to the chronically ill.
(4) Actively engage in the development and routine updating
of quality measures for the chronically ill.
(5) Have the ability to convene experts practiced in the
needs of a chronically ill patient, including
pharmacologists, psychiatrists, cardiologists,
pulmonologists, rheumatologists, nutritionists and
dieticians, social workers, and physical therapists.
(6) Partner with the Secretary of Health and Human Services
and the Secretary of Veterans Affairs (including the Center
for Health Services Research in Primary Care of the
Department of Veterans Affairs Health Services Research and
Development Service), the medical community, medical schools,
and public health departments through the Agency for
Healthcare Research and Quality, the Health Resources and
Services Administration, and the Association of American
Medical Colleges to routinely develop new, forward thinking,
and evidence-based curricula that addresses the tremendous
need for team-based care and chronic care management. Such
curricula shall include palliative medicine, chronic care
management, leadership and team-based skills and planning,
and leveraging technology as a care tool.
(c) Oversight and Evaluation.--
[[Page S379]]
(1) In general.--The Agency for Healthcare Research and
Quality shall be responsible for oversight and evaluation of
all Chronic Care Innovation Centers under this section.
(2) Reports.--Not less frequently than every 3 years, the
Agency for Healthcare Research and Quality shall submit to
the Secretary of Health and Human Services and to Congress a
report containing the findings of oversight and evaluations
conducted under paragraph (1).
(d) Contract Authority.--In order to carry out this
section, the Secretary may contract with existing Centers of
Innovation (COINs) of the Department of Veterans Affairs
Health Services Research and Development Service that meet
the requirements described in subsection (c).
(e) Authorization.--There are authorized to be appropriated
such sums as are necessary to carry out this section.
SEC. 7. CURRICULA REQUIREMENTS FOR DIRECT AND INDIRECT
GRADUATE MEDICAL EDUCATION PAYMENTS.
(a) Direct Graduate Medical Education Payments.--Section
1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is
amended by adding at the end the following new paragraph:
``(9) New curricula requirements.--
``(A) Development.--The Secretary shall engage with the
medical community and medical schools in developing curricula
that meets the following requirements:
``(i) The curricula is new, forward thinking, and evidence-
based.
``(ii) The curricula addresses the need for team-based care
and chronic care management.
``(iii) The curricula includes palliative medicine, chronic
care management, leadership and team-based skills and
planning, and leveraging technology as a care tool.
``(B) Rural areas.--The curricula developed under
subparagraph (A) shall include appropriate focus on care
practices required for rural and underserved areas.
``(C) Limitation.--Notwithstanding the preceding provisions
of this subsection, for cost reporting periods beginning on
or after the date that is 5 years after the date of enactment
of the Better Care, Lower Cost Act, if a hospital has not
begun to implement curricula that meets the requirements
described in subparagraph (A), payments otherwise made to a
hospital under this subsection may be reduced by a percentage
determined appropriate by the Secretary. For purposes of the
preceding sentence, successful development and implementation
of such curricula shall be determined by program accrediting
bodies.''.
(b) Indirect Graduate Medical Education Payments.--Section
1886(d)(5)(B) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(B)) is amended--
(1) by redesignating clause (x), as added by section
5505(b) of the Patient Protection and Affordable Care Act
(Public Law 111-148), as clause (xi) and moving such clause 6
ems to the left; and
(2) by adding at the end the following new clause:
``(xii) Notwithstanding the preceding provisions of this
subparagraph, effective for discharges occurring on or after
the date that is 5 years after the date of enactment of the
Better Care, Lower Cost Act, if a hospital has not begun to
implement curricula that meets the requirements described in
subsection (h)(9)(A), as determined in accordance with
subsection (h)(9)(C), payments otherwise made to a hospital
under this subparagraph may be reduced by a percentage
determined appropriate by the Secretary.''.
____________________