Ambulatory Surgical Center Quality and Access Act of 2013 - Amends title XVIII (Medicare) of the Social Security Act to require alignment of updates for ambulatory surgical center (ASC) services under a revised prospective payment system (PPS) with updates for hospital outpatient department (OPD) services.
Revises requirements for the reporting and applying of quality measure data by ASCs and hospital OPDs.
Directs the Secretary of Health and Human Services (HHS) to establish an ASC value-based purchasing program under which each ASC that the Secretary determines meets (or exceeds) performance standards established, with respect to selected quality measures, for the performance period for a calendar year is eligible for shared savings in the form of a payment increase determined according to a specified formula.
Revises requirements for the composition of the expert outside advisory panel the Secretary is required to consult during the annual review of the clinical integrity of the groups and payment weights in the PPS for hospital OPD services. Requires the panel to include suppliers subject to the PPS as well as at least one ASC representative.
Requires the Secretary, when excluding from a final rule updating ASC lists a procedure whose inclusion was requested during the public comment period, to cite in the final rule specific criteria based on which the procedure was excluded. Requires the Secretary also to identify the peer reviewed research or the evidence upon which the exclusion is based if certain of those criteria are cited for it. Prohibits the Secretary from using or citing as a criterion or a basis for an exclusion that the procedure can only be reported using a Current Procedural Terminology (CPT) unlisted surgical procedure code.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2500 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 2500
To amend title XVIII of the Social Security Act to modernize payments
for ambulatory surgical centers under the Medicare program, and for
other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 25, 2013
Mr. Nunes (for himself, Mr. Larson of Connecticut, Mr. Buchanan, Mr.
Bucshon, Mr. Burgess, Mr. Cole, Mr. Griffin of Arkansas, Mr. Hall, Mr.
Larsen of Washington, Mr. Marchant, Mr. Michaud, Mr. Nugent, Mr.
Pascrell, Mr. Roe of Tennessee, Ms. Linda T. Sanchez of California, Mr.
Schweikert, Mr. David Scott of Georgia, Mr. Sessions, Mr. Smith of
Washington, Mr. Veasey, Mr. Whitfield, and Mr. Stivers) 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 title XVIII of the Social Security Act to modernize payments
for ambulatory surgical centers under the Medicare 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.
This Act may be cited as the ``Ambulatory Surgical Center Quality
and Access Act of 2013''.
SEC. 2. ALIGNING UPDATES FOR AMBULATORY SURGICAL CENTER SERVICES WITH
UPDATES FOR OPD SERVICES.
Section 1833(i)(2)(D) of the Social Security Act (42 U.S.C.
1395l(i)(2)(D)) is amended--
(1) by redesignating clause (vi) as clause (vii);
(2) in the first sentence of clause (v), by inserting
before the period the following: ``and, in the case of 2014 or
a subsequent year, by the adjustment described in subsection
(t)(3)(G) for the respective year''; and
(3) by inserting after clause (v) the following new clause:
``(vi) In implementing the system described
in clause (i) for 2014 and each subsequent
year, there shall be an annual update under
such system for the year equal to the OPD fee
schedule increase factor specified under
subsection (t)(3)(C)(iv) for such year,
adjusted in accordance with clauses (iv) and
(v).''.
SEC. 3. TRANSPARENCY OF QUALITY REPORTS AND APPLICATION OF VALUE-BASED
PURCHASING TO ASCS.
(a) Quality Measures.--Paragraph (7) of section 1833(i) of the
Social Security Act (42 U.S.C. 1395l(i)) is amended by adding at the
end the following new subparagraphs:
``(C) To the extent that quality measures
implemented by the Secretary under this paragraph for
ambulatory surgical centers and under section
1833(t)(17) for hospital outpatient departments are
applicable to the provision of surgical services in
both ambulatory surgical centers and hospital
outpatient departments, the Secretary shall make
reported data on such centers and departments available
on the website `Medicare.gov' in a manner that will
permit side-by-side comparisons on such measures for
ambulatory surgical centers and hospital outpatient
departments in the same geographic area.
``(D) For each procedure covered for payment in an
ambulatory surgical center, the Secretary shall
publish, along with the quality reporting comparisons
provided for in subparagraph (C), comparisons of the
Medicare payment and beneficiary copayment amounts for
the procedure when performed in ambulatory surgical
centers and hospital outpatient departments in the same
geographic area.
``(E) The Secretary shall ensure that an ambulatory
surgery center and a hospital has the opportunity to
review, and submit any corrections for, the data to be
made public with respect to the ambulatory surgery
center under subparagraph (C) prior to such data being
made public.''.
(b) Ambulatory Surgical Center Value-Based Purchasing Program.--
Section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) is
amended by adding at the end the following new paragraph:
``(8) Value-based purchasing program.--
``(A) Establishment.--The Secretary shall establish
an ambulatory surgical center value-based purchasing
program (in this subsection referred to as the
`Program') under which, subject to subparagraph (I),
each ambulatory surgical center that the Secretary
determines meets (or exceeds) the performance standards
under subparagraph (D) for the performance period (as
established under subparagraph (E)) for a calendar year
is eligible, from the amounts made available in the
total shared savings pool under subparagraph (I)(iv),
for shared savings under subparagraph (I), which shall
be in the form, after application of the adjustments
under clauses (iv), (v), and (vi) of paragraph (2)(D),
of an increase in the amount of payment determined
under the payment system under paragraph (2)(D) for
surgical services furnished by such center during the
subsequent year, by the value-based percentage amount
under subparagraph (H) specified by the Secretary for
such center and year.
``(B) Program start date.--The Program shall apply
to payments for procedures occurring on or after
January 1, 2015.
``(C) Measures.--
``(i) In general.--For purposes of the
Program, the Secretary shall select measures
from the measures specified under paragraph
(7).
``(ii) Availability of measure and data.--
The Secretary may not select a measure under
this paragraph for use under the Program with
respect to a performance period for a calendar
year unless such measure has been included, and
the reported data available, on the website
`Medicare.gov', for at least 1 year prior to
the beginning of such performance period.
``(iii) Measure not applicable unless asc
furnishes services appropriate to measure.--A
measure selected under this paragraph for use
under the Program shall not apply to an
ambulatory surgical center if such center does
not furnish services appropriate to such
measure.
``(D) Performance standards.--
``(i) Establishment.--The Secretary shall
establish performance standards with respect to
measures selected under subparagraph (C)(i) for
a performance period for a calendar year.
``(ii) Achievement and improvement.--The
performance standards established under clause
(i) shall include levels of achievement and
improvement.
``(iii) Timing.--The Secretary shall
establish and announce the performance
standards under clause (i) not later than 60
days prior to the beginning of the performance
period for the calendar year involved.
``(E) Performance period.--For purposes of the
Program, the Secretary shall establish the performance
period for a calendar year. Such performance period
shall begin and end prior to the beginning of such
calendar year.
``(F) ASC performance score.--The Secretary shall
develop a methodology for assessing the total
performance of each ambulatory surgery center based on
performance standards with respect to the measures
selected under subparagraph (C) for a performance
period (as established under subparagraph (E)). Using
such methodology, the Secretary shall provide for an
assessment (in this subsection referred to as the `ASC
performance score') for each ambulatory surgical center
for each performance period. The methodology shall
provide that the ASC performance score is determined
using the higher of its achievement or improvement
score for each measure.
``(G) Appeals.--The Secretary shall establish a
process by which ambulatory surgery centers may appeal
the calculation of the ambulatory surgery center's
performance with respect to the performance standards
established under subparagraph (D) and the ambulatory
surgery center performance score under subparagraph
(E). The Secretary shall ensure that such process
provides for resolution of appeals in a timely manner.
``(H) Calculation of value-based incentive
payment.--
``(i) Value-based percentage amount.--For
purposes of subparagraph (A), the Secretary
shall specify a value-based percentage amount
for an ambulatory surgical center for a
calendar year.
``(ii) Requirements.--In specifying the
value-based percentage amount for each
ambulatory surgical center for a calendar year
under clause (i), the Secretary shall ensure
that such percentage is based on--
``(I) the ASC performance score of
the ambulatory surgery center under
subparagraph (F); and
``(II) the amount of the total
savings pool made available under
subparagraph (I)(iii)(I) for such year.
``(I) Annual calculation of shared savings funding
for value-based incentive payments.--
``(i) Determining bonus pool.--In each year
of the Program, ambulatory surgery centers
shall be eligible to receive payment for shared
savings under the Program only if for such year
the sum of--
``(I) the estimated amount of
expenditures under this title for
Medicare fee-for-service beneficiaries
(as defined in section 1899(h)(3)) for
surgical services for which payment is
made under the payment system under
paragraph (2), adjusted for beneficiary
characteristics, and
``(II) the estimated amount of
expenditures under this title for
Medicare fee-for-service beneficiaries
(as so defined) for the same surgical
services for which payment is made
under the prospective payment system
under subsection (t), adjusted for
beneficiary characteristics,
is at least the percent specified by the
Secretary below the applicable benchmark
determined for such year under clause (ii). For
purposes of this subparagraph, such sum shall
be referred to as `estimated expenditures'. The
Secretary shall determine the appropriate
percent described in the preceding sentence to
account for normal variation in volume of
services under this title and to account for
changes in the coverage of services in
ambulatory surgery centers and hospital
outpatient departments during the performance
period involved.
``(ii) Establish and update benchmark.--For
purposes of clause (i), the Secretary shall
calculate a benchmark for each year described
in such clause equal to the product of--
``(I) estimated expenditures
described in clause (i) for such year,
and
``(II) the average annual growth in
estimated expenditures for the most
recent three years.
Such benchmark shall be reset at the start of
each calendar year, and adjusted for changes in
enrollment under the Medicare fee-for-service
program.
``(iii) Payments based on shared savings.--
If the requirement under clause (i) is met for
a year--
``(I) 50 percent of the total
savings pool estimated under clause
(iv) for such year shall be made
available for shared savings to be paid
to ambulatory surgical centers under
this paragraph;
``(II) a percent (as determined
appropriate by the Secretary, in
accordance with subparagraph (H)) of
such amount made available for such
year shall be paid as shared savings to
each ambulatory surgery center that is
determined under the Program to have
met or exceeded performance scores for
such year; and
``(III) all funds made available
under subclause (I) for such year shall
be used and paid as sharing savings for
such year in accordance with subclause
(II).
``(iv) Estimate of the total savings
pool.--For purposes of clause (iii), the
Secretary shall estimate for each year of the
Program the total savings pool as the product
of--
``(I) the conversion factor for
such year determined by the Secretary
under the payment system under
paragraph (2)(D) divided by the
conversion factor calculated under
subsection (t)(3)(C) for such year for
covered OPD services, multiplied by
100, and
``(II)(aa) the product of the
estimated Medicare expenditures for
surgical services described in clause
(i)(I) furnished during such year to
Medicare fee-for-service beneficiaries
(as defined in section 1899(h)(3)) for
which payment is made under subsection
(t) and the average annual growth in
the estimated Medicare expenditures for
such services furnished to Medicare
fee-for-service beneficiaries (as so
defined) for which payment is made
under subsection (t) in the most recent
available 3 years, less
``(bb) the estimated Medicare
expenditures for surgical services
described in clause (i)(I) furnished to
Medicare fee-for-service beneficiaries
for which payment was made under
subsection (t) in the most recent year.
``(J) No effect in subsequent calendar years.--The
value-based percentage amount under subparagraph (H)
and the percent determined under subparagraph
(I)(iii)(I) shall apply only with respect to the
calendar year involved, and the Secretary shall not
take into account such amount or percentage in making
payments to an ambulatory surgery center under this
section in a subsequent calendar year.''.
SEC. 4. ADVISORY PANEL ON HOSPITAL OUTPATIENT PAYMENT REPRESENTATION.
(a) ASC Representative.--The second sentence of section
1833(t)(9)(A) of the Social Security Act (42 U.S.C. 1395l(t)(9)(A)) is
amended by inserting ``and suppliers subject to the prospective payment
system (including at least one ambulatory surgical center
representative)'' after ``an appropriate selection of representatives
of providers''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on the date of the enactment of this Act.
SEC. 5. REASONS FOR EXCLUDING ADDITIONAL PROCEDURES FROM ASC APPROVED
LIST.
(a) In General.--Section 1833(i)(1) of the Social Security Act (42
U.S.C. 1395l(i)(1)) is amended by adding at the end the following: ``In
updating such lists for application in years beginning after the date
of the enactment of this sentence, for each procedure that was
requested to be included in such lists during the public comment period
but which the Secretary does not propose (in the final rule updating
such lists) to so include in such lists, Secretary shall cite in such
final rule the specific criteria in paragraph (b) or (c) of section
416.166 of title 42, Code of Federal Regulations, based on which the
procedure was excluded. If paragraph (b) of such section is cited for
exclusion of a procedure, the Secretary shall identify the peer
reviewed research or the evidence upon which such determination is
based. The Secretary may not use or cite section 416.166(c)(7) of such
title as criteria or a basis for exclusion of a procedure from such
lists.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to lists of ambulatory surgery procedures for application in
years beginning after the date of the enactment of this Act.
<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 Subcommittee on Health.
Referred to the Subcommittee on Health.
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