[Congressional Record Volume 161, Number 97 (Wednesday, June 17, 2015)]
[House]
[Pages H4479-H4481]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
STRENGTHENING MEDICARE ADVANTAGE THROUGH INNOVATION AND TRANSPARENCY
FOR SENIORS ACT OF 2015
Mr. BRADY of Texas. Mr. Speaker, I move to suspend the rules and pass
the bill (H.R. 2570) to establish a demonstration program requiring the
utilization of Value-Based Insurance Design to demonstrate that
reducing the copayments or coinsurance charged to Medicare
beneficiaries for selected high-value prescription medications and
clinical services can increase their utilization and ultimately improve
clinical outcomes and lower health care expenditures, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 2570
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 ``Strengthening Medicare
Advantage through Innovation and Transparency for Seniors Act
of 2015''.
SEC. 2. TREATMENT OF PATIENT ENCOUNTERS IN AMBULATORY
SURGICAL CENTERS IN DETERMINING MEANINGFUL EHR
USE.
Section 1848(o)(2) of the Social Security Act (42 U.S.C.
1395w-4(o)(2)) is amended by adding at the end of the
following new subparagraph:
``(D) Treatment of patient encounters at ambulatory
surgical centers.--
``(i) In general.--Subject to clause (ii), for a payment
year after 2015 any patient encounter of an eligible
professional occurring at an ambulatory surgical center
(described in section 1833(i)(1)(A)) shall not be treated as
a patient encounter in determining whether an eligible
professional qualifies as a meaningful EHR user.
Notwithstanding any other provision of law, the Secretary may
implement this clause by program instruction or otherwise.
``(ii) Sunset.--Clause (i) shall no longer apply as of the
first payment year that begins more than 3 years after the
date the Secretary determines, through notice and comment
rulemaking, that certified EHR technology is applicable to
the ambulatory surgical center setting.''.
SEC. 3. VALUE-BASED INSURANCE DESIGN DEMONSTRATION PROGRAM.
(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a 3-year demonstration program to test the use of
value-based insurance design methodologies (as defined in
subsection (c)(1)) under eligible Medicare Advantage plans
offered by Medicare Advantage organizations under part C of
title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et
seq.). The Secretary may extend the program to a duration of
4 or 5 years, as determined necessary by the Secretary in
coordination with the Centers for Medicare and Medicaid
Innovation.
(b) Demonstration Program Design.--
(1) Selection of medicare advantage sites and eligible
medicare advantage plans.--Not later than two years after the
date of the enactment of this Act, the Secretary shall--
(A) select at least two Medicare Advantage sites with
respect to which to conduct the demonstration program under
this section; and
(B) approve eligible Medicare Advantage plans to
participate in such demonstration program.
In selecting Medicare Advantage sites under subparagraph (A),
the Secretary shall take into account area differences as
well as the availability of health maintenance organization
plans and preferred provider organization plans offered in
such sites.
(2) Start of demonstration.--The demonstration program
shall begin not later than the third plan year beginning
after the date of the enactment of this Act.
(3) Eligible medicare advantage plans.--For purposes of
this section, the term ``eligible Medicare Advantage plan''
means a Medicare Advantage plan under part C of title XVIII
of the Social Security Act (42 U.S.C. 1395w-21 et seq.) that
meets the following requirements:
(A) The plan is an Medicare Advantage regional plan (as
defined in paragraph (4) of section 1859(b) of such Act (42
U.S.C. 1395w-28(b))) or Medicare Advantage local plan (as
defined in paragraph (5) of such section) offered in the
Medicare Advantage region selected under paragraph (1)(A).
(B) The plan has--
(i)(I) a quality rating under section 1853(o) of such Act
(42 U.S.C. 1395w-23(o)) of 4 stars or higher based on the
most recent data available for such year, or (II) in the case
of a specialized Medicare Advantage plan for special needs
individuals, as defined in section 1859(b)(6)(A) of such Act
(42 U.S.C. 1395w-28(b)(6)(A)), a quality rating under section
1853(o) of such Act (42 U.S.C. 1395w-23(o)) equal to or
higher than the national average for special needs plans
(excluding Institutional-Special needs plans) based on the
most recent data available for such year; and
(ii) at least 20 percent of the population to whom the plan
is offered in a service area consists of subsidy eligible
individuals (as defined in section 1860D-14(a)(3)(A) of the
Social Security Act (42 U.S.C. 1395w-114(a)(3)(A))).
(4) Disclosure to beneficiaries.--The Secretary shall
provide to each individual eligible to enroll under a
Medicare Advantage plan approved to participate under the
demonstration program during a plan year for which the plan
is so selected--
(A) notification that the plan is participating in such
demonstration program;
(B) background information on the demonstration program;
(C) clinical data derived from the studies resulting from
the demonstration program; and
(D) notification of the potential benefits that the
individual will receive, and of the other potential impacts
that the individual will experience, on account of the
participation of the plan in the demonstration program.
(c) Value-Based Insurance Design Methodologies.--
(1) Definition.--For purposes of this section, the term
``value-based insurance design methodology'' means a
methodology for identifying specific prescription
medications, and clinical services that are payable under
title XVIII of the Social Security Act, for which the
reduction of copayments, coinsurance, or both, would improve
the management of specific chronic clinical conditions
because of the high value and effectiveness of such
medications and services for such specific chronic clinical
conditions, as approved by the Secretary.
(2) Use of methodologies to reduce copayments and
coinsurance.--A Medicare Advantage organization offering an
eligible Medicare Advantage plan approved to participate
under the demonstration program, for each plan year for which
the plan is so selected and using value-based insurance
design methodologies--
(A) shall identify each prescription medication and
clinical service covered under such plan for which the plan
proposes to reduce or eliminate the copayment or coinsurance,
with respect to the management of specific chronic clinical
conditions (as specified by the Secretary) of Medicare
Advantage eligible individuals (as defined in section
1851(a)(3) of the Social Security Act (42 U.S.C. 1395w-
21(a)(3))) enrolled under such plans, for such plan year;
(B) may, for such plan year, reduce or eliminate
copayments, coinsurance, or both for such prescription
medication and clinical services so identified with respect
to the management of such conditions of such individuals--
(i) if such reduction or elimination is evidence-based and
for the purpose of encouraging such individuals in such plan
to use such prescription medications and clinical services
(such as preventive care, primary care, specialty visits,
diagnostic tests, procedures, and durable medical equipment)
with respect to such conditions; and
(ii) for the purpose of encouraging such individuals in
such plan to use health care providers that such organization
has identified with respect to such plan year as being high
value providers; and
(C) if a reduction or elimination is applied pursuant to
subparagraph (B), with respect to such medication and
clinical services, shall, for such plan year, count toward
the deductible applicable to such individual under such plan
amounts that would have been payable by the individual as
copayment or coinsurance for such medication and services if
the reduction or elimination had not been applied.
(3) Prohibition of increases of copayments and
coinsurance.--In no case may any Medicare Advantage plan
participating in the demonstration program increase, for any
plan year for which the plan is so participating, the amount
of copayments or coinsurance for any item or service covered
under such plan for purposes of discouraging the use of such
item or service.
(d) Report on Implementation.--
(1) In general.--Not later than 1 year after the date on
which the demonstration program under this section begins
under subsection (b)(2), the Secretary shall submit to
Congress a report on the status of the implementation of the
demonstration program.
(2) Elements.--The report required by paragraph (1) shall,
with respect to eligible Medicare Advantage plans
participating in the demonstration program for the first plan
year of such program, include the following:
(A) A list of each medication and service identified
pursuant to subsection (c)(2)(A) for such plan with respect
to such plan year.
(B) For each such medication or service so identified, the
amount of the copayment or coinsurance required under such
plan with respect to such plan year for such medication or
service and the amount of the reduction of such copayment or
coinsurance from a previous plan year.
(C) For each provider identified pursuant to subsection
(c)(2)(B)(ii) for such plan with respect to such plan year, a
statement of the amount of the copayment or coinsurance
required under such plan with respect to such plan year and
the amount of the reduction of such copayment or coinsurance
from the previous plan year.
(e) Review and Assessment of Utilization of Value-Based
Insurance Design Methodologies.--
(1) In general.--The Secretary shall enter into a contract
or agreement with an independent entity to review and assess
the implementation of the demonstration program under this
section. The review and assessment shall include the
following:
(A) An assessment of the utilization of value-based
insurance design methodologies
[[Page H4480]]
by Medicare Advantage plans participating under such program.
(B) An analysis of whether reducing or eliminating the
copayment or coinsurance for each medication and clinical
service identified pursuant to subsection (c)(2)(A) resulted
in increased adherence to medication regimens, increased
service utilization, improvement in quality metrics, better
health outcomes, and enhanced beneficiary experience.
(C) An analysis of the extent to which costs to Medicare
Advantage plans under part C of title XVIII of the Social
Security Act participating in the demonstration program is
less than costs to Medicare Advantage plans under such part
that are not participating in the demonstration program.
(D) An analysis of whether reducing or eliminating the
copayment or coinsurance for providers identified pursuant to
subsection (c)(2)(B)(ii) resulted in improvement in quality
metrics, better health outcomes, and enhanced beneficiary
experience.
(E) An analysis, for each provider so identified, the
extent to which costs to Medicare Advantage plans under part
C of title XVIII of the Social Security Act participating in
the demonstration program is less than costs to Medicare
Advantage plans under such part that are not participating in
the demonstration program.
(F) Such other matters as the Secretary considers
appropriate.
(2) Report.--The contract or agreement entered into under
paragraph (1) shall require such entity to submit to the
Secretary a report on the review and assessment conducted by
the entity under such paragraph in time for the inclusion of
the results of such report in the report required by
paragraph (3). Such report shall include a description, in
clear language, of the manner in which the entity conducted
the review and assessment.
(3) Report to congress.--Not later than 4 years after the
date on which the demonstration program begins under
subsection (b)(2), the Secretary shall submit to Congress a
report on the review and assessment of the demonstration
program conducted under this subsection. The report shall
include the following:
(A) A description of the results of the review and
assessment included in the report submitted pursuant to
paragraph (2).
(B) Such recommendations as the Secretary considers
appropriate for enhancing the utilization of the
methodologies applied under the demonstration program to all
Medicare Advantage plans under part C of title XVIII of the
Social Security Act so as to reduce copayments and
coinsurance under such plans paid by Medicare beneficiaries
for high-value prescription medications and clinical services
for which coverage is provided under such plans and to
otherwise improve the quality of health care provided under
such plans.
(4) Oversight report.--Not later than three years after the
date of the enactment of this Act, the Comptroller General of
the United States shall submit to Congress a report on the
demonstration program that includes an assessment, with
respect to individuals enrolled under Medicare Advantage
plans approved to participate under the demonstration
program, of the impact that the age, co-morbidities, and
geographic regions of such individuals had upon the
implementation of the demonstration program by the plans with
respect to such individuals.
(f) Savings.--In no case may any reduction in beneficiary
copayments or coinsurance resulting from the implementation
of the demonstration program under this section result in
expenditures under parts A, B, and D of the title XVIII of
the Social Security Act that are greater than such
expenditures without application of this section.
(g) Expansion of Demonstration Program.--Taking into
account the review and assessment conducted under subsection
(e), the Secretary may, through notice and comment
rulemaking, expand (including implementation on a nationwide
basis) the duration and scope of the demonstration program
under title XVIII of the Social Security Act, other than
under the original medicare fee-for-service program under
parts A and B of such title, to the extent determined
appropriate by the Secretary, if the requirements of
paragraphs (1), (2) and (3) of subsection (c) of section
1115A of the Social Security Act (42 U.S.C. 1315a), as
applied to the testing of a model under subsection (b) of
such section, applied to the demonstration under this
section.
(h) Waiver Authority.--The Secretary may waive such
provisions of titles XI and XVIII of the Social Security Act
as may be necessary to carry out the demonstration program
under this section.
(i) Implementation Funding.--For purposes of carrying out
the demonstration program under this section, the Secretary
shall provide for the transfer from the Federal Hospital
Insurance Trust Fund under section 1817 of the Social
Security Act (42 U.S.C. 1395i) and the Federal Supplementary
Insurance Trust Fund under section 1841 of the Social
Security Act (42 U.S.C. 1395t), including the Medicare
Prescription Drug Account in such Trust Fund, in such
proportion as determined appropriate by the Secretary, of
such sums as may be necessary.
SEC. 4. TREATMENT OF INFUSION DRUGS FURNISHED THROUGH DURABLE
MEDICAL EQUIPMENT.
Section 1842(o)(1) of the Social Security Act (42 U.S.C.
1395u(o)(1)) is amended--
(1) in subparagraph (C), by inserting ``(and including a
drug or biological described in subparagraph (D)(i) furnished
on or after January 1, 2017)'' after ``2005''; and
(2) in subparagraph (D)--
(A) by striking ``infusion drugs'' and inserting ``infusion
drugs or biologicals'' each place it appears; and
(B) in clause (i)--
(i) by striking ``2004'' and inserting ``2004, and before
January 1, 2017''; and
(ii) by striking ``for such drug''.
SEC. 5. SENSE OF CONGRESS REGARDING THE IMPLEMENTATION AND
DISTRIBUTION OF QUALITY INCENTIVE PAYMENTS TO
MEDICARE ADVANTAGE PLANS.
It is the sense of Congress that--
(1) the Secretary of Health and Human Services has
incorrectly interpreted subsection (n) of section 1853 of the
Social Security Act (42 U.S.C. 1395w-23) as prohibiting the
provision of any Medicare quality incentive payments under
subsection (o) of such section with respect to Medicare
Advantage plans that exceed the payment benchmark cap under
such subsection (n) for the area served by such plans; and
(2) the Secretary should immediately apply quality
incentive payments under such subsection (o) with respect to
such Medicare Advantage plans without regard to the limits
set forth in such subsection (n).
SEC. 6. MEDICARE IMPROVEMENT FUND.
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``during and after
fiscal year 2020, $0'' and inserting ``after fiscal year
2020, $220,000,000''.
SEC. 7. NON-INCLUSION OF DME INFUSION DRUGS UNDER DME
COMPETITIVE ACQUISITION PROGRAMS.
(a) In General.--Section 1847(a)(2)(A) of the Social
Security Act (42 U.S.C. 1395w-3(a)(2)(A)) is amended--
(1) by striking ``and excluding'' and inserting ``,
excluding''; and
(2) by inserting before the period at the end the
following: ``, and excluding drugs and biologicals described
in section 1842(o)(1)(D)''.
(b) Conforming Amendment.--Section 1842(o)(1)(D)(ii) of the
Social Security Act (42 U.S.C. 1395u(o)(1)(D)(ii)) is amended
by striking ``2007'' and inserting ``2007, and before the
date of the enactment of the Strengthening Medicare Advantage
through Innovation and Transparency for Seniors Act of
2015''.
The SPEAKER pro tempore (Mr. Hardy). Pursuant to the rule, the
gentleman from Texas (Mr. Brady) and the gentleman from New York (Mr.
Rangel) each will control 20 minutes.
The Chair recognizes the gentleman from Texas.
General Leave
Mr. BRADY of Texas. Mr. Speaker, I ask unanimous consent that all
Members may have 5 legislative days within which to revise and extend
their remarks and to include extraneous material on H.R. 2570,
currently under consideration.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Texas?
There was no objection.
Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may
consume.
I stand in strong support of H.R. 2570, the Strengthening Medicare
Advantage through Innovation and Transparency for Seniors Act.
This package is comprised of two policies, and I will let the
sponsors, who have worked so hard, speak to them in more depth.
The Electronic Health Fairness Act of 2015, as marked up by the
committee back in February, brings fairness to physicians who are
practicing in the ASC setting by reducing meaningful use burdens for
sites of service that were left out of the EHR technology requirements.
This exemption only lasts until the ASCs are able to catch up, and then
everybody will be on an equal footing regarding meaningful use
requirements.
The bill then establishes a new demonstration program based on value-
based insurance design. This proposal would give plans the ability to
adjust benefits based on their enrollees' needs. The one-size-fits-all
policies in Medicare Advantage create the need for different types of
plans that wouldn't be necessary if regular Medicare Advantage plans
could adjust their benefit structures to better serve our seniors.
Reducing copays or cost sharing for beneficiaries for the sake of
better healthcare outcomes is right in line with the principles that I
support as all seniors are different and should be served as such, so
that all have an opportunity for positive health outcomes.
The bill also includes a policy that changes the way Medicare pays
for drugs that doctors prescribe that are infused through durable
medical equipment items. This change means that Medicare payments will
be more market based.
[[Page H4481]]
The policy does take away the potential that these rates could change
significantly in the future by exempting the drugs from DME competitive
bidding. I am committed to ensuring that beneficiaries who need these
drugs are able to continue to get them in their homes, and I will
certainly monitor the impact.
I want to thank Ways and Means members Mrs. Black of Tennessee and
Mr. Blumenauer of Oregon for their continued leadership in improving
Medicare Advantage. Their very hard work will ensure that seniors, for
years to come, will enjoy better healthcare choices and more options at
that.
Mr. Speaker, I reserve the balance of my time.
Mr. RANGEL. Mr. Speaker, I yield myself such time as I may consume.
I join with the gentleman from Texas in supporting H.R. 2570.
Representative Diane Black and Representative Earl Blumenauer have
worked hard on this issue.
This legislation will allow the Secretary of HHS to conduct a
demonstration, giving managed care organizations the ability to offer
plans with a variety of benefit structures that would lower the cost
sharing for high-value service. We think it makes a lot of sense, and I
concur.
I reserve the balance of my time.
{time} 1730
Mr. BRADY of Texas. Mr. Speaker, I yield 2 minutes to the gentlewoman
from Tennessee (Mrs. Black), a key member of the Committee on Ways and
Means and a healthcare professional herself.
Mrs. BLACK. Mr. Speaker, as a nurse for over 40 years, I understand
the challenge of helping Americans find affordable healthcare coverage,
but the sad truth is, even for those who do have health coverage, high
deductibles and out-of-pocket costs can leave too many Americans
functionally uninsured.
When families are forced to choose between buying groceries and
filling a prescription, their health is sidelined, and they risk facing
even higher medical costs down the road. That is why I authored H.R.
2570, the Strengthening Medicare Advantage Through Innovation and
Transparency for Seniors Act. Our bill directs CMS to set up a pilot
project for what is known as Value-Based Insurance Design, or otherwise
known as VBID.
Instead of the current one-size-fits-all approach to cost sharing,
VBID embraces the idea that by lowering a patient's out-of-pocket costs
for essential prescription drugs and services, customers will then be
motivated to stick with their regimen and stay healthier. This will, in
turn, decrease the overall long-term costs to our healthcare system and
provide a higher quality of care for our patients.
My bill also helps our providers by offering ambulatory surgical
centers relief from the electronic health records' meaningful use
mandate. While this recordkeeping system may make sense in a hospital
setting, it doesn't always work for a small, outpatient surgical
facility. Providers who practice medicine in these settings should not
be penalized as a result.
I thank Congressman Blumenauer and Congresswoman Cathy McMorris
Rodgers for their strong commitment to VBID policy.
I urge a ``yes'' vote on H.R. 2570.
Mr. RANGEL. I yield myself the balance of my time to close.
Mr. Speaker, at this time I concur with the gentleman from Texas.
Members have worked hard in perfecting these bills, and I support H.R.
2570.
I yield back the balance of my time.
Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may
consume.
This is a very good bill. It is a good improvement to Medicare
Advantage, and it is really a case of Republicans and Democrats finding
common ground and doing it in a way that helps seniors with their
choices and really tailoring health care to them.
I strongly urge support for this bill.
Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Texas (Mr. Brady) that the House suspend the rules and
pass the bill, H.R. 2570, as amended.
The question was taken; and (two-thirds being in the affirmative) the
rules were suspended and the bill, as amended, was passed.
The title of the bill was amended so as to read: ``A bill to amend
title XVIII of the Social Security Act with respect to the treatment of
patient encounters in ambulatory surgical centers in determining
meaningful EHR use, establish a demonstration program requiring the
utilization of Value-Based Insurance Design to demonstrate that
reducing the copayments or coinsurance charged to Medicare
beneficiaries for selected high-value prescription medications and
clinical services can increase their utilization and ultimately improve
clinical outcomes and lower health care expenditures, and for other
purposes.''.
A motion to reconsider was laid on the table.
____________________