Medicare Physician Payment Reform and Quality Improvement Act of 2006 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to revise physician payment requirements under the Medicare program, including the physician payment update and quality measures for physicians' services.
Terminates application of the sustainable growth rate (SGR), replacing it with a single conversion factor, the Medicare economic index (MEI) minus 1%.
Requires the Secretary of Health and Human Services to provide for the selection of quality performance measures (Q-measures) for assessing physician, non-physician practitioner, and supplier services and determining ratings for them. Requires such Q-measures to be developed in conjunction with physician specialty organizations and consensus-building organizations.
Eliminates specified limitations on the balance billing of highest income beneficiaries.
Revises requirements for the quality improvement program (QIO), including program administration, data disclosure, use of evaluation and competition, quality improvement funding, and qualifications for QIOs under part B (Peer Review) of SSA title XI.
Amends SSA title XIX (Medicaid) to permit alternative quality improvement programs under such program.
Terminates the availability of funds from the MA Regional Plan Stabilization Fund.
Directs the Board of Trustees of the Federal Hospital Insurance Trust Fund and of the Federal Supplementary Medical Insurance Trust Fund to monitor and examine the extent to which the different Medicare funding mechanisms provide an appropriate alignment with the program goals of the respective parts.
Provides for a one-year delay in Medicare adjustments in payments for imaging services.
Eliminates the three-year phase-in for implementation of the reduction in Medicare part B premium subsidies for higher income beneficiaries (thus requiring immediate application of the reduction adjustment).
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5866 Introduced in House (IH)]
109th CONGRESS
2d Session
H. R. 5866
To amend titles XI and XVIII of the Social Security Act to reform
physician payment under the Medicare Program, to modernize the quality
improvement organization (QIO) program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 24, 2006
Mr. Burgess (for himself, Mr. Norwood, Mr. Weldon of Florida, and Mr.
Boustany) introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on
Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend titles XI and XVIII of the Social Security Act to reform
physician payment under the Medicare Program, to modernize the quality
improvement organization (QIO) program, and for other purposes.
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 ``Medicare Physician
Payment Reform and Quality Improvement Act of 2006''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE PHYSICIAN PAYMENT REFORM
Sec. 101. Medicare physician payment update reform.
Sec. 102. Voluntary reporting of quality measures for physicians'
services.
Sec. 103. Removing limitations on balance billing with beneficiary
notice for highest income beneficiaries.
TITLE II--QUALITY IMPROVEMENT ORGANIZATION (QIO) MODERNIZATION
Sec. 201. Quality improvement activities.
Sec. 202. Improved program administration.
Sec. 203. Data disclosure.
Sec. 204. Use of evaluation and competition.
Sec. 205. Quality improvement funding.
Sec. 206. Qualifications for QIOs.
Sec. 207. Coordination with medicaid.
TITLE III--MEDICARE SAVINGS AND OTHER PROVISIONS
Sec. 301. Elimination of stabilization fund for regional PPOs.
Sec. 302. Ongoing examination of medicare funding.
Sec. 303. One-year delay in medicare adjustments in payments for
imaging services; IOM study on utilization
and appropriateness of imaging services.
Sec. 304. Eliminating phase-in for implementation of reduction in part
B premium subsidy for higher income
beneficiaries.
Sec. 305. Exclusion of indirect graduate medical education payment in
computation of payments to medicare
advantage organizations.
TITLE I--MEDICARE PHYSICIAN PAYMENT REFORM
SEC. 101. MEDICARE PHYSICIAN PAYMENT UPDATE REFORM.
(a) Substitution of MEI Increase for SGR Adjustments.--Section
1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is amended--
(1) in paragraph (1)(A), by inserting ``and before 2007''
after ``beginning with 2001'';
(2) in paragraph (1)(A), by inserting before the period at
the end the following: ``, and for years beginning with 2007,
multiplied by the update established under paragraph (7)
applicable to the year involved''; and
(3) in paragraph (4)--
(A) in the heading by striking ``years beginning
with 2001'' and inserting ``2001, 2002, and 2003''; and
(B) in subparagraph (A), by inserting ``and ending
with 2003'' after ``beginning with 2001''; and
(4) by adding at the end the following new paragraph:
``(7) Update beginning with 2007.--The update to the single
conversion factor established in paragraph (1)(C) for 2007 and
each succeeding year shall be the percentage increase in the
MEI (as defined in section 1842(i)(3)) for the year involved
minus 1 percentage point.''.
(b) Ending Application of Sustainable Growth Rate (SGR).--Section
1848(f)(1)(B) of such Act (42 U.S.C. 1395w-4(f)(1)(B)) is amended by
inserting ``(and before 2006)'' after ``each succeeding year''.
(c) Effective Date.--The amendments made by this section shall
apply to payment for services furnished on or after January 1, 2007.
SEC. 102. VOLUNTARY REPORTING OF QUALITY MEASURES FOR PHYSICIANS'
SERVICES.
(a) Reporting Program.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended by adding at the end the following new
subsection:
``(k) Quality Improvement.--
``(1) Selection of quality measures (q measures).--
``(A) In general.--Not later than January 1, 2009,
the Secretary shall provide for the selection of
quality measures (in this subsection referred to as `Q-
measures') consistent with and in accordance with this
paragraph and paragraph (2).
``(B) Level of measurement.--Q-measures shall be
measures that provide for assessment of quality in the
provision of services to individuals enrolled under
this part at the level of a billing unit under this
part.
``(C) Characteristics of measures.--To the extent
feasible and practicable, Q measures shall--
``(i) include a mixture of outcome
measures, process measures (such as furnishing
a service), and structural measures (such as
the use of physician extenders, disease
management, and health information technology
for submission of measures);
``(ii) include measures of care furnished
to frail individuals over the age of 75 and to
individuals with multiple complex chronic
conditions;
``(iii) be evidence-based, if pertaining to
clinical care;
``(iv) be consistent, valid, practicable,
and not overly burdensome to collect;
``(v) be relevant to physicians and other
practitioners and individuals enrolled under
this part;
``(vi) include measures that, taken as a
whole, provide a balanced measure of
performance of a billing unit under this part;
and
``(vii) include measures that capture
individuals' assessment of clinical care
provided.
``(D) Fairness.--To the extent feasible and
practicable, this subsection shall be implemented in a
manner that--
``(i) takes into account differences in
individual health status;
``(ii) takes into account individual's
compliance with orders;
``(iii) does not directly or indirectly
encourage patient selection or de-selection by
billing units under this part;
``(iv) reduces health disparities across
groups and areas; and
``(v) uses appropriate statistical
techniques to ensure valid results.
``(E) Application to non-physician practitioners
and other suppliers for which payment is made under or
in relation to physician fee schedule.--Insofar as
physicians' services under this section are furnished
by non-physician practitioner or a supplier other than
a physician--
``(i) any reference in this subsection to a
physician shall be a reference to such
practitioner or supplier; and
``(ii) any reference to a physician
specialty organization is deemed a reference to
a specialty organization representing the
speciality of such practitioners or suppliers.
``(F) Development.--In developing Q measures, the
Secretary shall provide for--
``(i) measurement of quality by stratified
groups and the review of the absolute level of
quality provided by a physician or medical
group; and
``(ii) including practicing physicians with
expertise in eliminating racial and ethnic
health disparities in the design,
implementation and evaluation of the program.
``(2) Selection process for measures.--
``(A) Submission of proposed measures to consensus-
building organization.--
``(i) By physician specialty
organizations.--The Secretary shall request
each physician specialty organization to submit
to the consensus-building organization by
January 1, 2008, proposed Q measures described
in clauses (i) through (vi) of paragraph (1)(C)
that would be applicable to core clinical
services that billing units under this part
practicing in the specialty provide to
individuals enrolled under this part.
``(ii) By secretary.--If the physician
specialty organization for a physician
specialty has not submitted proposed Q measures
under clause (i) by January 1, 2008, the
Secretary shall submit, as soon as possible but
not later than February 1, 2008, proposed Q
measures described in clauses (i) through (vi)
of paragraph (1)(C) for such specialty to the
consensus-building organization.
``(iii) Consensus-building organization
defined.--For purposes of this paragraph, the
term `consensus-building organization' means an
organization, such as the National Quality
Forum, that the Secretary identifies as--
``(I) having experience in using a
process (such as the process described
in OMB circular A-119 published in the
Federal Register on February 10, 1998)
for reaching a group consensus with
respect to measures, such as Q
measures, relating to performance of
those providing health care services;
and
``(II) including in such process
representatives of the Secretary,
practicing physicians (and, as provided
under paragraph (1)(E), practicing non-
physician practitioners and other
suppliers), practitioners with
experience in the care of the frail
elderly and individuals with multiple
complex chronic conditions,
organizations and individuals
representative of the specialty
involved, individuals enrolled under
this part, experts in health care
quality, and individuals with
experience in the delivery of health
care in urban, rural, and frontier
areas and to underserved populations
and those who serve a disproportionate
number of minority patients.
``(B) Recommendations by consensus-building
organization.--The consensus-building organization that
receives proposed measures under subparagraph (A) is
requested to submit to the Secretary by May 1, 2008,
recommendations respecting the Q measures described in
clauses (i) through (vi) of paragraph (1)(C) to be
implemented under this subsection.
``(C) Secretarial selection.--The Secretary shall
select Q measures described in paragraph (1)(C) for
purposes of this subsection consistent with the
following:
``(i) Use of recommendations for clinical
care measures submitted by certain
organizations.--Except as provided in clause
(ii), the Secretary shall not select a Q
measure described in clauses (i) through (vi)
of paragraph (1)(C) and relating to clinical
care unless that measure has been submitted by
a physician specialty organization (or through
a physician-consensus building process, such as
the Physician Consortium for Performance
Improvement) and recommended by the consensus-
building organization under subparagraph (B).
``(ii) Provision by regulation.--The
Secretary may by regulation select--
``(I) Q measures described in
clauses (i) through (vi) of paragraph
(1)(C) and relating to clinical care
that do not meet the requirements of
clause (i) only if the Secretary
determines that there were no, or
insufficient, recommendations regarding
such Q measures under such clause and
only if the Secretary takes into
account research-based peer-reviewed
medical publications in selecting such
measures; and
``(II) Q measures described in
clause (vii) or (viii) of paragraph
(1)(C) and Q measures described in
clause (i) through (vi) of such
paragraph that do not relate to
clinical care.
``(D) Periodic revision of selection.--The
Secretary shall provide for the periodic revision and
selection of Q measures consistent with the provisions
of this paragraph and paragraph (1) and the application
of such revised Q measures on a prospective basis for a
following year.
``(3) Ratings of physicians based on measures.--
``(A) Ratings and identification of quality
performance.--
``(i) In general.--The Secretary shall
determine a single rating of each billing unit
under this part based on Q measures selected
under paragraph (2) and information reported
under paragraph (4). Such a rating shall be
determined for a billing unit based on its
performance on Q measures relative to the
performance of its peers taking into account
the voluntary nature of the reporting system
under this subsection.
``(ii) No direct disclosure of rating.--
Subject to subparagraph (B), the Secretary
shall not make such ratings of identifiable
billing units under this part available other
than to the respective unit.
``(iii) Improvement and performance
thresholds.--For specification of improvement
and performance thresholds, see paragraph
(5)(C).
``(B) Disclosure of performance in relation to
performance thresholds.--
``(i) In general.--Subject to the
succeeding provisions of this subparagraph,
each year the Secretary shall make widely
available to the public the following
information regarding a billing unit's
performance on the Q measures:
``(I) Whether the unit was a new
billing unit or otherwise had
insufficient data to provide for a
measurement of whether it met the
performance objectives under paragraph
(5)(C).
``(II) For any other unit, whether
the unit met the performance objectives
under such paragraph.
``(ii) Limitation during first 2 years.--
During 2009 and 2010, the Secretary shall not
make the information under clause (i) with
respect to an identifiable billing unit
available other than to the respective unit.
``(iii) Physician notification and
opportunity for comment or appeal.--Before
making information under clause (i) available
with respect to a billing unit under this part
for years beginning with 2010, the Secretary
shall notify the unit of the performance on Q
measures (including information on the unit's
performance in relation to performance
objectives and aggregate information regarding
the performance of peers) and provide the
opportunity for the unit to provide written
comments regarding the unit's performance. The
Secretary shall respond in writing to the
comments and seek to reach agreement on the
unit's performance and shall establish a formal
appeals process in the event of continued
disagreement concerning such performance. Upon
conclusion of the appeals process, if the unit
provides comments relating directly to the
final determination under clause (i) respecting
such performance, the Secretary shall disclose
such comments with the disclosure of the
information under such clause.
``(iv) Application of hipaa privacy
rules.--Nothing in this subparagraph shall be
construed as changing or affecting the
application of rules promulgated under section
264(c) of the Health Insurance Portability and
Accountability Act of 1996.
``(C) Peers defined.--For purposes of this
subsection, the term `peers' means, with respect to a
billing unit under this part that practices in a
specialty in an MA region (as established under section
1858(a)(2)), other billing units under this part that
practice in the same specialty in the same region, or,
beginning with the update for 2013, or in the United
States.
``(4) Reporting on performance beginning with 2008.--
Beginning with 2008, each billing unit under this part may
submit information on performance on the Q measures selected
under this subsection with respect to individuals enrolled
under this part. Such information shall be submitted in a form
and manner and time specified by the Secretary, which may
include submission as part of claims data under this part. The
Secretary shall provide a process for auditing the accuracy of
the information submitted under this paragraph.
``(5) Informational performance standards and thresholds.--
``(A) In general.--For purposes of disclosure under
paragraph (3)(B), the Secretary shall establish quality
performance objectives for billing units under this
part.
``(B) Disclosure.--For purposes of paragraph
(3)(B), such a billing unit is considered to meet
performance objectives for a year if, based on the
unit's rating under paragraph (3)(A), the unit's
performance meets or exceeds the performance thresholds
specified by the Secretary under subparagraph (C).
``(C) Improvement standards and performance
thresholds.--The Secretary shall specify the
performance thresholds under subparagraphs (B) before
the beginning of the year involved.
``(D) Treatment of cases of insufficient
information.--A billing unit is deemed to meet
performance objectives under subparagraphs (B) and (C)
if the unit complied with the reporting requirement
under paragraph (4) but there was insufficient
information, as determined by the Secretary, to provide
a valid measure of performance.
``(6) Review of additional expenses.--Not later than
January 1, 2010, and after consultation with the medical
community, the Secretary shall review, and report to Congress
on, the extent to which billing unit compliance with the
reporting provisions of paragraph (4) results in increased work
and practice expenses to billing units and whether
participating billing units showed a demonstrable improvement
in the delivery of quality health care.
``(7) Physician and beneficiary education.--During 2008,
the Secretary shall establish a program to educate billing
units under this part and individuals enrolled under this part
about the voluntary quality disclosure system under this
subsection and recommendations on training opportunities to
improve ratings and performance on Q measures .
``(8) Annual report on growth in volume of physicians'
services.--
``(A) In general.--The Secretary shall report to
the Medicare Payment Advisory Commission and Congress
by April 1 of each year (beginning with 2008)
information on the growth in volume of services per
enrollee and growth in expenditures per enrollee, based
upon services and expenditures for which payment is
based, or related to, the fee schedule established
under this section.
``(B) Details.--The information under subparagraph
(A) shall--
``(i) be disaggregated by type of service,
by geographic area, and by specialty of
physicians (or, if applicable, of non-physician
practitioners or suppliers);
``(ii) distinguish between growth in
expenditures due to price change versus volume
change and intensity change, including growth
due to the development and improvement of
procedures; and
``(iii) identify types of service or
geographic areas where changes in volume or
expenditures are inappropriate or unjustified,
taking into account clinical outcomes.
``(C) Recommendations.--Each such report shall
include recommendations to respond to inappropriate
growth in service volume. Such recommendations may
include regulatory or legislative changes, or both.
``(D) Medpac response.--The Medicare Payment
Advisory Committee shall review each report submitted
under this paragraph, including recommendations
included under subparagraph (C). The Commission shall
include in its report to Congress in June following
each such report an analysis of the Secretary's
findings and recommendations.
``(9) Evaluation; report.--
``(A) Evaluation.--The Secretary shall provide for
an evaluation of the operation of this subsection
during the 5-year period in which this subsection is
first applied. Such evaluation shall review the impact
of this subsection on improving the quality of services
and on access to such services and on the fairness of
its implementation. Such evaluation shall include a
study of the extent to which--
``(i) payment policies under this section
exacerbate or diminish racial and ethnic health
disparities; and
``(ii) there has been improvement in
meeting performance measures for racial and
ethnic minorities through the operation of this
section.
The Secretary is authorized to enter into a contract
with the Institute of Medicine of the National Academy
of Sciences for the conduct of the evaluation under
this subparagraph.
``(B) Report.--The Secretary shall submit to
Congress a report on such evaluation by not later than
September 30, 2012.
``(10) Waiver of administrative and judicial review.--There
shall be no administrative or judicial review under section
1869 or otherwise of--
``(A) the selection of Q measures under paragraphs
(1) and (2);
``(B) the development and computation of ratings
under paragraph (3)(A), standards and thresholds under
paragraph (5)(C), and the application of such standards
and thresholds under paragraphs (3)(B) and (5)(B); and
``(C) the definition of peers and new billing units
under this subsection.''.
(b) Conforming MedPAC Duties.--Section 1805(b)(2) of such Act (42
U.S.C. 1395b-6(b)(2)) is amended by adding at the end the following new
subparagraph:
``(D) Review of report on growth in physician
services.--Specifically, under section 1848(k)(8)(D),
the Commission shall review and make recommendations
concerning the Secretary's report on the growth of
physicians' services under section 1848.''.
SEC. 103. REMOVING LIMITATIONS ON BALANCE BILLING WITH BENEFICIARY
NOTICE FOR HIGHEST INCOME BENEFICIARIES.
(a) In General.--Section 1848(g) of the Social Security Act (42
U.S.C. 1395w-4(g)) is amended--
(1) in paragraph (1)(A), in the matter before clause (i),
by inserting ``, subject to subparagraph (D),'' after
``enrolled under this part'';
(2) in paragraph (1), by adding at the end the following
new subparagraph:
``(D) Exception for highest income beneficiaries.--
Subparagraph (A) shall not apply with respect to
physicians' services furnished in a month to an
individual with respect to whom and for such month a
reduction in premium subsidy is in effect under section
1839(i) if the individual furnishing such services
provides the advance notice of such non-participation
and non-acceptance of assignment under paragraph (8)
and (for services furnished on or after January 1,
2008) submits information in accordance with subsection
(k)(4).''; and
(3) by adding at the end the following new paragraph:
``(8) Notice of non-participation and non-acceptance of
assignment.--For purposes of paragraph (1)(D), the advance
notice of non-participation and non-acceptance of assignment
shall be, with respect to an item or service furnished under
this part by (or under the supervision of) a physician, a
notice (that may be in the form of a posting in a conspicuous
place in a physician's office or on patient information forms)
that is posted or otherwise furnished in a manner so as to
inform the individual receiving the item or service that--
``(A) the physician furnishing (or supervising the
furnishing of) the items or service is not a
participating physician and does not accept assignment
with respect to the service; and
``(B) because of such non-acceptance, in the case
of physicians' services furnished in a month to an
individual with respect to whom and for such month a
reduction in premium subsidy is in effect under section
1839(i), the charge imposed is not limited and may
exceed the limiting charge described in paragraph
(2).''.
(b) Conforming Amendment to Private Contract Provisions.--Section
1802 of such Act (42 U.S.C. 1395a) is amended by adding at the end the
following new paragraph:
``(6) Exception for highest income beneficiaries.--The
previous provisions of this subsection shall not apply to
physicians' services furnished in a month to an individual with
respect to whom and for such month a reduction in premium
subsidy is in effect under section 1839(i) if the advance
notice described in section 1848(g)(8) has been provided and
(for services furnished on or after January 1, 2008) the
physician furnishing the services submits information in
accordance with section 1848(k)(4).''.
(c) Conforming Amendment to Participation Provisions.--Section
1842(h) of such Act (42 U.S.C. 1395u) is amended by adding at the end
the following new paragraph:
``(8) The previous provisions of this subsection, insofar as they
limit the charges that a participating physician may impose, shall not
apply to physicians' services furnished in a month to an individual
with respect to whom and for such month a reduction in premium subsidy
is in effect under section 1839(i) if the advance notice described in
section 1848(g)(8) has been provided and (for services furnished on or
after January 1, 2008) the physician furnishing the services submits
information in accordance with section 1848(k)(4).''.
(d) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2008.
(e) Review and Report on Impact.--
(1) Review.--The Secretary of Health and Human Services
shall monitor and review the impact of the amendments made by
this section on the access of medicare beneficiaries to
physicians' services.
(2) Report.--Not later than January 1, 2009, the Secretary
shall submit to Congress a report on such review and shall
include such recommendations regarding changes in the
amendments made by this section (such as reducing the income
threshold applied for purposes of determining applicability of
such amendments and thereby expanding the application of such
amendments) as the Secretary deems appropriate.
TITLE II--QUALITY IMPROVEMENT ORGANIZATION (QIO) MODERNIZATION
SEC. 201. QUALITY IMPROVEMENT ACTIVITIES.
(a) Inclusion of Quality Improvement Functions.--Section 1154(a) of
the Social Security Act (42 U.S.C. 1320c-3(a)) is amended by adding at
the end the following new paragraph: ``
``(18) The organization shall offer quality improvement
assistance to providers, practitioners, Medicare Advantage
organizations offering Medicare Advantage plans under part C of
title XVIII, and prescription drug sponsors offering
prescription drug plans under part D of such title, including
the following:
``(A) Education on quality improvement initiatives,
strategies and techniques.
``(B) Instruction on how to collect, submit,
aggregate and interpret data on measures that may be
used for quality improvement, public reporting and
payment.
``(C) Instruction on how to conduct root-cause
analyses.
``(D) Technical assistance for providers and
practitioners in beneficiary education to facilitate
patient self-management.
``(E) Facilitating cooperation among various local
stakeholders in quality improvement.
``(F) Facilitating adoption of procedures that
encourage timely candid feedback from patients and
their families concerning perceived problems.
``(G) Guidance on redesigning clinical processes,
including the adoption and effective use of health
information technology, to improve the coordination,
effectiveness, and safety of care.
``(H) Assistance in improving the quality of care
delivered in rural and frontier areas and reducing
health care disparities among racial and ethnic
minorities, as well as gender disparities.''.
(b) Medicare Quality Accountability Program.--Paragraph (14) of
section 1154(a) of such Act (42 U.S.C. 1320c-3(a)) is amended to read
as follows: ``
``(14)(A) The organization shall conduct an appropriate
review of all written complaints about the quality of services
(for which payment may otherwise be made under title XVIII) not
meeting professionally recognized standards of health care, if
the complaint is filed with the organization by an individual
entitled to benefits for such services under such title (or a
person acting on the individual's behalf). Before the
organization concludes that the quality of services does not
meet professionally recognized standards of health care, the
organization must provide the practitioner or person concerned
with reasonable notice and opportunity for discussion.
``(B) The organization shall establish and operate a
Medicare quality accountability program consistent with the
following:
``(i) The organization shall actively educate
Medicare beneficiaries of their right to bring quality
concerns to Quality Improvement Organizations.
``(ii) The organization shall report findings of
its investigations to complainants, the beneficiary
involved, or their representative, whether the
complaint findings involve physicians or institutional
providers, practitioners, or Medicare Advantage plans,
but such complaint findings may not be used in any form
in a medical malpractice action.
``(iii) The organization shall assist providers,
practitioners, and plans in adopting best practices for
soliciting and welcoming feedback about patient
concerns, and assist providers, practitioners, and
plans in remedying patient-reported problems that are
confirmed by the organization and shall report findings
of patient reported problems to the provider,
practitioner, or plan involved before disclosing
investigation results to the patient or patient's
representative.
``(iv) The organization shall determine whether the
complaint allegations about clinical quality of care
are confirmed and assist provider, practitioners, and
plans in remedying confirmed complaints.
``(v) The organization shall respond supportively
to quality problems caused by unsafe systems, and refer
for enforcement providers who are unwilling or unable
to improve.
``(vi) The organization shall publish annual
quality reports in each State in which the organization
operates, including aggregate complaint data and
provider performance on standardized quality measures.
``(vii) The organization shall promote beneficiary
awareness of standardized quality measures that may be
used for evaluating care and for choosing providers,
practitioners and plans
``(C) The Secretary shall monitor and report to Congress,
regarding--
``(i) the reliability of complaint determinations
by Quality Improvement Organizations;
``(ii) the effect of disclosure of complaint
findings on the availability of primary- and specialty-
care physician reviewers;
``(iii) changes resulting from the systems change
process described in subparagraph (B)(v); and
``(iv) trends in civil litigation filed by
complainants.''.
SEC. 202. IMPROVED PROGRAM ADMINISTRATION.
Part B of title XI of the Social Security Act is amended by adding
at the end the following new section:
``program administration
``Sec. 1164. (a) Improved Program Management.--
``(1) Report on management of the qio program.--The
Comptroller General of the United States shall submit to
Congress, no later than March 31, 2010, a report on the
implementation by the Secretary and the Director of the Office
of Management and Budget of this part and their overall
management of the program under this part.
``(2) Program management.--The report under paragraph (1)
shall include a review of all of the following:
``(A) Implementation of the priorities,
recommendations, and strategies of the strategic
advisory committee under subsection (c)(1).
``(B) Implementation of appropriate program and
contractor evaluation.
``(C) Ensuring timely issuance of statements of
work.
``(D) Ensuring timely and priority QIO access to
Medicare data for quality improvement purposes.
``(E) Ensuring timely apportionment of funding.
``(F) Ensuring funding levels for new work are
added to the QIO contract, as described in the second
sentence of section 1159(b)(1).
``(G) The process of developing the apportionment
request and determining the funding allocation to QIOs.
``(H) The identification of and progress towards
measures of effective management by the Secretary of
the QIO program.
``(I) A review of the experience and qualifications
of staff of the Centers for Medicare & Medicaid
Services in overseeing the program.
``(3) Innovation.--The Secretary shall ensure that such
staff Quality Improvement Organizations are provided maximum
freedom in designing and applying intervention strategies for
local quality improvement.
``(b) Assuring Data Access.--The Secretary shall ensure that
Quality Improvement Organizations have timely, top priority access to
Medicare data for all parts of Medicare pertinent to the contract
activities, in a form allowing the data to be integrated and analyzed
by such organizations according to the needs of partners and
beneficiaries in each jurisdiction.
``(c) Setting Strategic Priorities.--
``(1) Appointment of strategic advisory committee.--The
Secretary shall appoint an independent strategic advisory
committee, composed of national quality measurement and
improvement experts, representatives of beneficiaries, health
care providers, and practitioners, and organizations holding
contracts under this part.
``(2) Duties of committee.--Such committee shall set
national strategic priorities for improvement in the quality of
care, consistent with the Institute of Medicine's six aims for
health care improvement, including safety, effectiveness,
patient centeredness, timeliness, efficiency and equity, and
update these in time to permit preparation of a draft statement
of work and funding request for each program cycle under this
part.
``(3) Independent evaluation.--The committee should ensure
that the Quality Improvement Organization program is evaluated
by an independent entity using a study design, such as to a
crossover design, to allow for a reliable assessment of program
performance in a way that does not have an adverse impact on
providers, practitioners, and plans that may work with the
Organization.
``(4) Funding.--The Secretary shall allocate funds for the
strategic advisory committee from the portion of the additional
funding provided under the second sentence of section
1159(b)(1).
``(d) Taking Into Account Recommendations From Stakeholders in
Statements of Work.--Each statement of work under this part for a
contract period beginning on or after August 1, 2008, shall include a
task for the contracting Quality Improvement Organization to convene
stakeholders to identify high priority quality problems for work in the
contract period that are relevant to Medicare beneficiaries in the
State. Each such organization shall propose, as part of such statement,
one or more projects to the Secretary taking into consideration the
recommendations of such stakeholders recommendations, along with
suggested performance measures to evaluate progress on such item.
``(e) Allocation of Resources to Priority Areas.--The Secretary
shall allocate at least 20 percent of the additional funding that is
provided under the second sentence of section 1159(b)(1) to promote
improvement in one or more locally defined priority areas identified
under subsection (d).''.
SEC. 203. DATA DISCLOSURE.
Section 1160 of the Social Security Act (42 U.S.C. 1320c-9) is
amended--
(1) in subsection (a)(3), by striking ``subsection (b)''
and inserting ``subsections (b) and (f)''; and
(2) by adding at the end the following new subsection:
``(f)(1) An organization with a contract with the Secretary under
this part may share individual-specific data with a physician treating
the individual, for quality improvement and patient safety purposes.
``(2) The Secretary shall promulgate, not later than 30 days after
the date of the enactment of this subsection, a regulation that permits
the sharing of data under paragraph (1).
``(3) Nothing in this subsection shall be construed to limit,
alter, or affect the requirements imposed the regulations promulgated
under section 264(c) of the Health Insurance Portability and
Accountability Act of 1996.''.
SEC. 204. USE OF EVALUATION AND COMPETITION.
Section 1153 of the Social Security Act (42 U.S.C. 1320c-2) is
amended--
(1) by amending paragraph (3) of subsection (c) to read as
follows:
``(3) subject to subsection (k), the contract shall be for
an initial term of five years and shall be renewable for each 5
years thereafter;''; and
(2) by adding at the end the following new subsection:
``(k)(1) Subject to the succeeding provisions of this subsection,
at the end of each contract period under subsection (c)(3), the
contract shall be subject to open competition.
``(2) Before publishing a request for proposal for a contract
period, the Secretary shall, in consultation with the strategic
advisory committee appointed under section 1164(c)(1), establish
measurable goals for each task to be included in such proposal. The
contract shall include a performance threshold by which an organization
holding a contract under this section may demonstrate excellent
performance. The Secretary may not establish such performance
thresholds in such a way as to predetermine or limit either the number
or percentage of organizations which may demonstrate excellent
performance.
``(3) The Secretary shall publish the request for proposals no
later than four months prior to the beginning of such contract period.
``(4) The Secretary shall utilize the strategic advisory committee
appointed under section 1164(c)(1) to qualify the validity,
reliability, and feasibility of measures to be used in evaluating the
performance of organizations holding a contract under this section.
Before any performance measure may be used for such purpose, it must
have been designated by such committee to be valid, reliable, and
feasible for use under similar circumstances, as demonstrated in at
least one reliable and valid study.
``(5) In the case of an open competition for a contract under this
section, if an organization bidding for the contract demonstrates
excellent performance in fulfilling the terms of such a contract during
the previous contract period, the Secretary shall award the bidder a
bonus equivalent to ten percent of the total possible score for the
proposal.
``(6) The Secretary may not reduce the amount of a contract award
below the amount proposed by the bidder prevailing in a competitive
bidding process.
``(7) The Secretary shall design the process for performance
evaluation of contracts under this section--
``(A) to avoid interfering with the work of contractors
with plans, providers, and practitioners;
``(B) to hold harmless and not penalize contractors when
performance is impaired or delayed by failures of the
Secretary, personnel of the Department of Health and Human
Services, or contractors of the Secretary to provide timely
deliverables by other entities;
``(C) to use a continuous measurement strategy with
provision for frequent performance updates for evaluating
interim progress; and
``(D) to require that evaluation metrics be monitored and
adjusted based on experience or evolving science over the
course of a contract cycle.
``(8) At the end of each 5-year contract term, the Secretary may,
without full and open competition, extend the term for an additional
period of 5 years if the Secretary determines that the organization
holding the contract has achieved excellent performance during the
previous 5-year term. But in no case shall an organization be allowed
to maintain such a contract for a period of longer than 10 years
without being subject to full and open competition.''.
SEC. 205. QUALITY IMPROVEMENT FUNDING.
Section 1159 of the Social Security Act (42 U.S.C. 1320c-8) is
amended--
(1) by inserting ``(a)'' before ``Expenses incurred''; and
(2) by adding at the end the following new subsection:
``(b)(1) The aggregate annual funding under contracts under this
part for fiscal year 2007 and each subsequent fiscal year shall not be
less than $421,666,000. In addition, there are authorized to be
appropriated for contract periods in subsequent fiscal years such
additional amounts funds as may be necessary to adequately fund any
resource needs over the amount provided under the previous sentence.
``(2) At least 80 percent of the funding under this part in a
contract period shall be expended in support of core contracts held by
organizations under this part.
``(3) The Secretary shall determine the resource needs for a
contract period in consultation with representatives from existing
contractors. The determination shall take into account factors
including any new work added via contract modification during the
course of the contract period or added from one contract cycle to the
next cycle. New work includes--
``(A) additional core contract tasks, requirements,
deliverables, and performance thresholds;
``(B) technical assistance for additional providers,
practitioners, and health plans and additional provider
settings;
``(C) increased outreach and communications to Medicare
beneficiaries, providers, practitioners, and plans; and
``(D) increased volume of medical reviews.
``(4) With respect to the apportionment of funds under this part
for a contract period--
``(A) the Secretary shall submit a proposed apportionment
to the Director of the Office of Management and Budget no later
than 1 year before the first date of the contract period;
``(B) such Director shall approve or deny the proposed
apportionment no later than 9 months before the first date of
such contract period;
``(C) for tasks the Secretary proposes to continue from the
previous contract period, if the apportionment is not
authorized by the deadline specified in subparagraph (B),
funding shall continue for the next contract period at a level
no less than the level for the previous contract period,
increased by the percentage increase in the consumer price
index for all urban consumers during the preceding 12-month
period.
``(5) Organizations with a contract under this part may enter into
contracts with public or private entities including providers,
practitioners, and payers other than Secretary, to provide quality
improvement or other forms of technical assistance if there were
arrangements made to avoid potential conflicts of interest.
``(6) Such organizations shall have the ability to meet the terms
of a contract by allocating funds to functions established by the
Secretary at its discretion. The Secretary shall review the allocation
of these funds and whether the organization met the functions and goals
set out for the organization, regardless of allocation of funds at the
initial acceptance of the contract.''.
SEC. 206. QUALIFICATIONS FOR QIOS.
(a) In General.--Section 1153(b) of the Social Security Act (42
U.S.C. 1320c-2(b)) is amended by adding at the end the following new
paragraph:
``(4) The Secretary shall not enter into or renew a contract under
this section with an entity unless the following requirements are met:
``(A) The entity's governing body must reflect
representation of consumers and other stakeholders.
``(B) The entity must have demonstrated success in
facilitating clinical and administrative system redesign to
improve the coordination, effectiveness, and safety of health
care, and in facilitating cooperation among stakeholders in
quality improvement.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contract periods beginning after the date of the enactment of
this Act.
SEC. 207. COORDINATION WITH MEDICAID.
(a) Permitting Alternative Quality Improvement Program.--Section
1902(a)(30) of the Social Security Act (42 U.S.C. 1396a(a)(30)) is
amended by striking ``and'' at the end of subparagraph (A), by adding
``and'' and the end of subparagraph (B), and by adding at the end the
following new subparagraph:
``(C) provide, at the discretion of the State plan,
for a quality improvement program in place of the
program described in subparagraph (A), in whole or in
part, that--
``(i) establishes priorities for achieving
significant measurable improvement in the
quality of health care services provided to
individuals eligible under this title, and
reviews such priorities at least every five
years for the purpose of making appropriate
revisions;
``(ii) provides quality improvement
assistance to providers and practitioners
consistent with such priorities; and
``(iii) provides for an annual report to
the Secretary on quality performance under such
plan of providers and practitioners using
nationally standardized quality measures;''.
(b) Role of QIOs.--Section 1902(d) of such Act (42 U.S.C. 1396a(d))
is amended--
(1) by inserting ``(1)'' after ``(d)''; and
(2) by adding at the end the following new paragraph:
``(2) If a State contracts with a Quality Improvement Organization
having a contract with the Secretary under part B of title XI for the
performance of quality improvement program activities required by
subsection (a)(30)(C), such requirements shall be deemed to be met for
those activities by delegation to such an Organization if the contract
provides for the performance of activities not inconsistent with part B
of title XI and provides for such assurances of satisfactory
performance by such an entity or organization as the Secretary may
prescribe.''.
(c) Funding.--Section 1903(a)(3)(C) of such Act (42 U.S.C.
1396b(a)(3)(C)) is amended--
(1) in clause (i), by striking ``1902(d)'' and inserting
``1902(d)(1)''; and
(2) by adding at the end the following new clause:
``(iii) 75 percent of the sums expended
with respect to costs incurred during such
quarter (as found necessary by the Secretary
for the proper and efficient administration of
the State plan) as are attributable to the
performance of quality improvement program
activities by a Quality Improvement
Organization under a contract entered into
under section 1902(d)(2); and''.
(d) Effective Date.--The amendments made by this section shall
apply to contract periods beginning after the date of the enactment of
this Act
TITLE III--MEDICARE SAVINGS AND OTHER PROVISIONS
SEC. 301. ELIMINATION OF STABILIZATION FUND FOR REGIONAL PPOS.
(a) In General.--Except as provided in subsection (b), no funds
shall be available for obligation, on or after the date of the
enactment of this Act, from the MA Regional Plan Stabilization Fund
(under section 1858(e) of the Social Security Act).
(b) Availability of Freed up Funds.--Amounts in such MA Regional
Plan Stabilization Fund that are not otherwise obligated shall be
transferred and deposited into the Medicare Supplementary Medical
Insurance Trust Fund under section 1841 of the Social Security Act (42
U.S.C. 1395t) without additional appropriation to cover additional
expenditures resulting from the amendments made by section title I of
this Act.
SEC. 302. ONGOING EXAMINATION OF MEDICARE FUNDING.
(a) Examination by Board of Trustees.--The Board of Trustees of the
Federal Hospital Insurance Trust Fund and of the Federal Supplementary
Medical Insurance Trust Fund shall monitor and examine the extent to
which the different funding mechanisms under parts A, B, and D of title
XVIII of the Social Security Act provide an appropriate alignment with
the program goals of the respective parts. Such examination shall
include an examination of each of the following:
(1) The extent to which, as volume of services increases in
physician settings under such part B, there is a corresponding
reduction in similar services provided in a hospital setting
under such part A.
(2) The extent to which, as a result of increased
coordination between physicians and the delivery of
prescription drugs under such part D, particularly with respect
to individuals with chronic conditions, there will there be a
decrease in hospitalizations under such part A.
(3) The extent to which other changes in physician or other
health care practice results in a shifting of expenditures
among the various parts.
(b) Inclusion in Annual Reports.--In each annual report submitted
to the Congress after the date of the enactment of this Act under
section 1817(b)(2) or section 1841(b)(2) of the Social Security Act (42
U.S.C. 1395i(b)(2), 1395t(b)(2)), such Board of Trustees shall include
information on the matters described in subsection (a).
SEC. 303. ONE-YEAR DELAY IN MEDICARE ADJUSTMENTS IN PAYMENTS FOR
IMAGING SERVICES; IOM STUDY ON UTILIZATION AND
APPROPRIATENESS OF IMAGING SERVICES.
(a) Delay.--Subsections (b)(4)(A), (c)(2)(B)(v)(I), and
(c)(2)(B)(v)(II) of section 1848 of the Social Security Act (42 U.S.C.
1395w-4), as amended by section 5102 of the Deficit Reduction Act of
2005 (Public Law 109-171) are each amended by striking ``2007'' and
inserting ``2008''.
(b) Study and Report on Utilization and Appropriateness of Imaging
Services.--
(1) In general.--The Secretary of Health and Human Services
shall request (and shall enter into a contract with) the
Institute of Medicine to conduct a study of the utilization and
appropriateness of imaging services described in section
1848(b)(4)(B) of the Social Security Act (42 U.S.C. 1395w-
4(b)(4)(B)) under the Medicare program and to submit to the
Secretary, not later than April 1, 2007, a report on such
study, including recommendations regarding changes in medicare
payment for such services. Such study shall include an
examination of--
(A) the role of medical malpractice in the
utilization of such services;
(B) the impact of utilization of such services in
reducing or increasing the subsequent delivery of
services;
(C) the impact of increased disease as a factor in
utilization of such services; and
(D) a delineation of factors in utilization and
appropriateness by site of service, by modality, and by
specialty.
(2) Report.--The Secretary shall submit to Congress the
report submitted under paragraph (1).
SEC. 304. ELIMINATING PHASE-IN FOR IMPLEMENTATION OF REDUCTION IN PART
B PREMIUM SUBSIDY FOR HIGHER INCOME BENEFICIARIES.
Section 1839(i)(3) of the Social Security Act (42 U.S.C.
1395r(i)(3)) is amended--
(1) in subparagraph (A), by striking ``Subject to
subparagraph (B), the'' and inserting ``The'';
(2) in subparagraph (A)(i), by striking ``subparagraph
(C)'' and inserting ``subparagraph (B)'';
(3) by striking subparagraph (B); and
(4) by redesignating subparagraph (C) as subparagraph (B).
SEC. 305. EXCLUSION OF INDIRECT GRADUATE MEDICAL EDUCATION PAYMENT IN
COMPUTATION OF PAYMENTS TO MEDICARE ADVANTAGE
ORGANIZATIONS.
(a) In General.--Section 1853(c)(1)(D)(i) of the Social Security
Act (42 U.S.C. 1395w-23(c)(1)(D)(i)) is amended by inserting ``or under
section 1886(d)(5)(B)'' after ``1886(h)''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to payment for years beginning with 2007 and the Secretary of
Health and Human Services shall provide for the application of clause
(i) of section 1853(c)(1)(D) of the Social Security Act, as so amended,
for 2007.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Sponsor introductory remarks on measure. (CR H6022-6023)
Referred to the Subcommittee on Health.
Sponsor introductory remarks on measure. (CR H6275-6276)
Sponsor introductory remarks on measure. (CR H6526-6532)
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