Comprehensive Care Payment Innovation Act - Amends title XVIII (Medicare) of the Social Security Act (SSA) to direct the Secretary of Health and Human Services (HHS) to provide for bundled payments for integrated care furnished by a qualified entity, during an episode of care for applicable conditions involving a hospitalization, to an individual entitled to, or enrolled for, benefits under Medicare part A (Hospital Insurance) and enrolled for benefits under Medicare part B (Supplementary Medical Insurance), but not enrolled under Medicare part C (Medicare+Choice Program) or in a PACE (Programs of All-Inclusive Care for the Elderly) program.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3796 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 3796
To amend title XVIII of the Social Security Act to provide for bundled
payments for certain episodes of care surrounding a hospitalization,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 19, 2013
Mrs. Black (for herself and Mr. Neal) introduced the following bill;
which was referred to the Committee on Ways and Means, and in addition
to the Committee on Energy and Commerce, 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 provide for bundled
payments for certain episodes of care surrounding a hospitalization,
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 ``Comprehensive Care Payment
Innovation Act''.
SEC. 2. PERMANENT, NATIONAL VOLUNTARY PAYMENT BUNDLING.
Title XVIII of the Social Security Act is amended by inserting
after section 1866E (42 U.S.C. 1395cc-5) the following new section:
``national voluntary payment bundling
``Sec. 1866F. (a) Establishment and Implementation.--
``(1) In general.--The Secretary shall provide for bundled
payments under this section for integrated care furnished by a
qualified entity during an episode of care to an applicable
beneficiary for applicable conditions involving a
hospitalization.
``(2) Deadline.--The Secretary shall implement this section
not later than January 1, 2015.
``(3) Applicable beneficiary defined.--In this section, the
term `applicable beneficiary' means an individual who is
entitled to, or enrolled for, benefits under part A and
enrolled for benefits under part B, but not enrolled under part
C or in a PACE program under section 1894, and who is admitted
to a hospital for an applicable condition.
``(b) Qualified Entity and Application Process.--
``(1) Definitions.--In this section:
``(A) In general.--The term `qualified entity'
means a qualified applicant that has an application
approved by the Secretary to receive bundled payments
for furnishing applicable services to applicable
individuals under this section.
``(B) Qualified applicant.--The term `qualified
applicant' means a corporation, partnership, or limited
liability company, that is authorized in writing by a
group of providers of services and suppliers, including
at least a hospital, that are otherwise participating
under this title to act as their agent for the purpose
of receiving and distributing bundled payments on their
behalf under this section. A qualified applicant may
(but is not required to) be a provider of services or
supplier that is otherwise participating under this
title.
``(2) Application.--
``(A) In general.--A qualified applicant may submit
to the Secretary an application to become a qualified
entity to receive bundled payments under this section.
``(B) Contents.--An application under subparagraph
(A) with respect to a group of providers of services
and suppliers--
``(i) shall contain such information and
assurances as the Secretary may specify,
including with respect to the requirements
under subsection (c)(1); and
``(ii) shall indicate the applicable
conditions with respect to which the group
seeks to furnish applicable services during the
episode of care involved and the bundled
payment methodology under subsection (g) or (h)
under which the group would be paid for such
services.
``(3) Choice among applicable conditions.--A qualified
entity may select one or more applicable conditions for bundled
payments under this section. Nothing in this section shall be
construed as requiring, or authorizing the Secretary to
require, a qualified entity to select any particular applicable
condition under this section.
``(4) Expedited application process for qualified
applicants successfully participating in the cmi bundled
payment demonstration.--In the case of any qualified applicant
that the Secretary determines has successfully participated in
any of the payment and service delivery models tested by the
Center for Medicare and Medicaid Innovation under section 1115A
through the Bundled Payments for Care Improvement (BPCI)
Initiative, the Secretary shall provide for an expedited
application process under this subsection.
``(c) Requirements for Qualified Entities.--
``(1) Requirements.--
``(A) In general.--The Secretary shall develop
requirements for qualified entities to receive bundled
payments for furnishing applicable services for
applicable conditions during an episode of care under
this section.
``(B) Agreement period.--Under such requirements, a
qualified entity shall agree to receive bundled
payments for the furnishing of such services for a 5-
year period (each such year in such period referred to
in this section as an `agreement year').
``(C) Beneficiary transparency.--Such requirements
shall ensure transparency between a qualified entity
and applicable beneficiaries such that notice is
provided to an applicable beneficiary sufficiently in
advance, to the extent practicable, of the
beneficiary's inpatient admission for the applicable
condition and episode of care involved. Such a notice
shall include--
``(i) appropriate notice of bundled
payments for the applicable condition for the
episode of care involved; and
``(ii) a statement informing the
beneficiary of the beneficiary's right to
select the providers of services and suppliers
furnishing items and services related to the
episode of care.
``(D) Methodology and measures for quality and
efficiency arrangements.--Insofar as a qualified entity
uses or seeks to implement a quality and efficiency
arrangement under subsection (i), the qualified entity
shall specify in the application to the Secretary in
detail the methodology for allocating savings under the
arrangement and the specific measures to be used to
assess the quality of care under the arrangement.
``(2) Provision of data by secretary.--
``(A) Claims data.--The Secretary shall furnish to
a group of providers of services and suppliers
interested in submitting an application under
subsection (b)(2) claims data under parts A and B,
including complete claims files, for applicable
conditions relating to the providers and suppliers in
the group that are sufficiently specific to permit such
group to determine whether to submit such application.
Such claims data shall also be furnished to a qualified
entity monthly during the agreement period described in
paragraph (1)(B) of any approved application with
respect to an applicable condition.
``(B) Quality data.--The Secretary shall furnish to
a qualified entity data on quality measures with
respect to any applicable condition under an approved
application during the agreement period for the entity
for each episode of care and across the continuum of
care.
``(d) Applicable Conditions.--
``(1) Initial conditions.--In this section, the term
`applicable condition' means any of the following procedures
furnished as part of inpatient hospital services:
``(A) Hip/Knee joint replacement.
``(B) Lumbar spine fusion.
``(C) Coronary artery bypass graft.
``(D) Heart valve replacement.
``(E) Percutaneous coronary intervention with
stent.
``(F) Colon resection.
``(2) Discretion to add conditions.--Such term also
includes such additional procedures or conditions as the
Secretary may select. In selecting such procedures or
conditions, the Secretary may take into consideration the
factors described in section 1866D(a)(2)(B).
``(e) Applicable Services; Episode of Care.--In this section:
``(1) Applicable services.--The term `applicable services'
means the following items and services:
``(A) Acute care inpatient services.
``(B) Physicians' services delivered in and outside
of an acute care hospital setting.
``(C) Outpatient hospital services.
``(D) Post-acute care services, including home
health services, skilled nursing services, inpatient
rehabilitation services, and inpatient hospital
services furnished by a long-term care hospital.
``(E) Other services the Secretary determines
appropriate.
``(2) Episode of care.--
``(A) In general.--Subject to subparagraph (B), the
term `episode of care' means, with respect to an
applicable condition and an applicable beneficiary, the
period consisting of--
``(i) the 3 days prior to the admission of
the applicable beneficiary to a hospital with
respect to the applicable condition;
``(ii) the duration of the applicable
beneficiary's initial inpatient stay in such
hospital for the applicable condition; and
``(iii) the 90 days following the discharge
of the applicable beneficiary from such
hospital.
``(B) Establishment of period by the secretary.--
The Secretary, as appropriate, may establish a period
(other than the period described in subparagraph (A))
for an episode of care under this section based on data
analyses.
``(3) Discharging hospital.--The term `discharging
hospital' means, with respect to applicable services in an
episode of care, the hospital referred to in paragraph (2)(A).
``(f) Bundled Payment Development.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall develop bundled payments
for qualified entities. A bundled payment shall provide for
comprehensive payment for the costs of applicable services
furnished to an applicable beneficiary during an episode of
care for an applicable condition, including readmissions
related to the applicable condition but excluding unrelated
readmissions, under either a fee-for-service model with shared
savings and losses (under subsection (g)) or under a
prospective payment model for advanced qualified entities
(under subsection (h)). Bundled payments shall be based on the
spending targets computed under paragraph (2).
``(2) Computation of spending targets.--
``(A) In general.--The Secretary shall compute
under this paragraph, for each qualified entity for
each applicable condition for an episode of care
beginning in an agreement year (beginning with 2015)
that is attributable to a discharging hospital, a
spending target equal to the updated amount computed
under subparagraph (C) for that entity, episode, and
year.
``(B) Initial weighted average calculation for
discharging hospitals.--
``(i) In general.--Using fee-for-service
claims data from the base period (as defined in
subparagraph (D)), subject to clause (ii), the
Secretary shall first calculate a base average
spending target for each applicable condition
for each discharging hospital equal to a
weighted average of spending under parts A and
B for all applicable services for such
applicable condition associated with initial
admissions to such hospital computed as the sum
of the following (with respect to such
hospital):
``(I) 60 percent of the
standardized spending per episode in
the most recent year in the base
period.
``(II) 30 percent of the
standardized spending per episode in
the previous year.
``(III) 10 percent of the
standardized spending per episode in
the second previous year.
``(ii) Exclusion of outliers and
standardization.--In calculating the amount of
the base average spending target for an
applicable condition under clause (i) for a
discharging hospital, the Secretary shall--
``(I) exclude from the calculation
payments for episodes of care for the
applicable condition that exceed the
95th percentile of all such spending
for such episodes of care and
applicable condition, as estimated by
the Secretary, based on the most recent
data available; and
``(II) standardize the spending
made in each year in the base period to
each provider of service or supplier to
remove the spending adjustments in
effect in such year relating to
provider or supplier location (such as
area wage indices) and provider type
(such as indirect medical education
adjustments and disproportionate share
hospital adjustments).
``(C) Trending the spending targets based on
national growth rates to agreement year; periodic
rebasing for new agreement periods.--
``(i) In general.--The Secretary shall
update the base average spending targets for
all discharging hospitals under subparagraph
(B) for each applicable condition and agreement
year based on trends in the national fee-for-
service claims data for applicable services
furnished during an episode of care for an
applicable condition from the base period to
the agreement year involved. Such update shall
not vary by discharging hospital.
``(ii) Periodic rebasing for new agreement
periods.--At the start of each new agreement
period, the Secretary shall update the base
period and calculate new spending targets under
the previous provisions of this paragraph for a
discharging hospital and applicable conditions,
including providing for adjustments by provider
location and provider type of the type
described in subparagraph (B)(ii)(II).
``(D) Base period defined.--In this paragraph,
except as provided in subparagraph (C)(ii), the term
`base period' means the most recent 3-year period for
which complete data are available to carry out this
subsection.
``(g) Fee-for-Service Bundled Payment Model With Shared Savings and
Shared Losses.--
``(1) Fee-for-service-based payment.--If the payment model
under this subsection is selected by a qualified entity, the
Secretary shall pay providers of services and suppliers of the
entity for applicable services for an applicable condition
during an episode of care amounts payable under parts A and B
for such services in the same manner as such providers and
suppliers would otherwise be paid under such parts (referred to
in this subsection as `fee-for-service payments').
``(2) Shared savings and losses.--
``(A) Computation of each qualified entity's actual
standardized average spending per episode of care.--In
applying this subsection, in calculating the actual
standardized average fee-for-service spending per
episode of care for a discharging hospital for each
applicable condition in each agreement year, the
Secretary shall exclude outlier episodes of care
described in subsection (f)(2)(B)(ii)(I), as estimated
by the Secretary, based on data applicable to payments
in the agreement year and shall standardize such
spending per episode of care in the manner provided in
subsection (f)(2)(B)(ii)(II). For the purpose of
identifying outlier episodes of care for each
applicable condition, the percentile ranking of each
episode of care and applicable condition and the 95th
percentile shall be based on payments standardized by
adjustments for provider location and provider type of
the type described in subsection (f)(2)(B)(ii)(II).
``(B) Computation of gross shared savings and
shared losses for each applicable condition for each
discharging hospital.--For purposes of applying
subparagraph (C), if actual standardized average fee-
for-service payments to a qualified entity for all
episodes of care for an applicable condition in an
agreement year for a discharging hospital, as
calculated under subparagraph (A), are--
``(i) less than the applicable spending
target under subsection (f)(2)(C) for such
condition, year, and hospital, there shall be a
gross shared savings for such applicable
condition, year, and hospital equal to 60
percent of the difference between such actual
average payments and the spending target for
such condition, year, and hospital; or
``(ii) greater than such applicable
spending target, there shall be a gross shared
loss for such applicable condition, year, and
hospital equal to 60 percent of such
difference.
``(C) Retrospective reconciliation.--
``(i) Totaling gross shared savings and
losses for all conditions and all discharging
hospitals for a qualified entity.--At the end
of each agreement year for each qualified
entity, for purposes of applying clauses (ii)
and (iii), the Secretary shall aggregate the
gross shared savings and the gross shared
losses under subparagraph (B) of such entity
for the year for all applicable conditions and
for all discharging hospitals.
``(ii) Payment to entity of net savings.--
Subject to clause (iv) and subsection (j)(3)
(relating to quality performance thresholds),
if such aggregate gross shared savings exceeds
such aggregate gross shared losses for a
qualified entity for an agreement year, the
Secretary shall pay to the qualified entity a
lump sum amount equal to such excess for such
year.
``(iii) Collection from entity of net
losses.--Subject to clause (iv), if such
aggregate gross shared losses exceeds such
aggregate gross shared savings for a qualified
entity for an agreement year, the qualified
entity shall pay to the Secretary (and the
Secretary shall collect from the entity) a lump
sum amount equal to such excess for such year.
``(iv) Cap on payments.--In no case shall
the payment under clause (ii) or (iii) with
respect to a qualified entity for an agreement
year exceed 10 percent of the aggregate
spending target for that qualified entity for
all applicable conditions and all discharging
hospitals for that year.
``(h) Prospective Bundled Payment Model for Advanced Qualified
Entities.--
``(1) In general.--Subject to approval by the Secretary, if
the payment model under this subsection is selected, a
qualified entity may elect to receive a prospective bundled
payment for each episode of care for each applicable condition
and discharging hospital in the agreement year equal to the
spending target for such episode, year, and hospital under
subsection (f)(2) and the provisions of subsection (g) do not
apply. Such spending target shall be adjusted, in the same
manner described in subsection (g)(2)(B), in order to take into
account outlier episodes of care and standardized adjustments
for provider location and provider type of the type described
in subsection (f)(2)(B)(ii)(II).
``(2) Rule of construction.--Nothing in this section shall
be construed as prohibiting a qualified entity that receives
bundled payments under this subsection from participating in an
accountable care organization under section 1899.
``(3) Relationship to bpci.--The Secretary may not
terminate the Bundled Payments for Care Improvement initiative
conducted pursuant to section 1115A until the prospective
bundled payment model is implemented under this subsection.
``(i) Quality and Efficiency Arrangements.--
``(1) In general.--Subject to subsection (c)(1)(D)
(relating to application requirements for notice of quality and
efficiency arrangements and their structure) and subsection
(j)(3) (relating to minimum quality performance thresholds),
qualified entities participating in either the fee-for-service
bundled payment model under subsection (g) or the prospective
bundled payment model under subsection (h) may enter into
quality and efficiency arrangements under which physicians and
other health care practitioners work to improve the quality and
efficiency of care under this title.
``(2) Types of arrangements.--The arrangements under
paragraph (1) shall take into account the utilization of the
resources of providers of services and suppliers and may
provide for a distribution of a portion of any shared savings
(or internal saving, as the case may be) realized under this
section to qualifying providers and suppliers.
``(j) Quality Measures.--
``(1) Selection; development.--
``(A) Selection.--For each applicable condition,
the Secretary shall select quality measures related to
care provided by providers of services and suppliers
through qualified entities to which bundled payments
are made under this section. In selecting quality
measures, to the extent appropriate and practicable,
the Secretary shall choose measures that--
``(i) are endorsed and validated by the
entity with a contract under section 1890;
``(ii) pertain to the National Quality
Strategy's six priorities;
``(iii) are used by the Secretary under
other provisions of this title; and
``(iv) minimize the incremental data
extraction and reporting burden on providers
and suppliers.
``(B) Development of electronically specified
episodic measures.--The Secretary shall develop
longitudinal quality and efficiency measures to assess
performance of qualified entities with respect to
patient outcomes and the care provided for each
applicable condition across the associated episodes of
care. Such measures shall be electronically specified
for submittal through the use of qualified electronic
health records (as defined in section 3000(13) of the
Public Health Service Act (42 U.S.C. 300jj(13))).
``(2) Reporting on quality measures.--
``(A) In general.--A qualified entity shall submit
data to the Secretary on quality measures selected
under paragraph (1) for each agreement year in a form
and manner specified by the Secretary consistent with
the succeeding provisions of this paragraph.
``(B) Submission of data through electronic health
record.--To the extent practicable, such data shall be
submitted through the use of a qualified electronic
health record (as defined in section 3000(13) of the
Public Health Service Act (42 U.S.C. 300jj(13))).
``(C) Submission of data used in other programs.--
Insofar as quality measures established under paragraph
(1) are the same as those measures used by the
Secretary under other provisions of this title, such as
those selected under section 1886(b)(3)(B)(viii), the
Secretary shall use existing processes for the
submission of data for such measures under this
paragraph.
``(3) Quality performance thresholds.--
``(A) Establishment.--For each applicable
condition, the Secretary shall establish minimum
quality performance thresholds for the measures
established under paragraph (1). In the case of a
quality and efficiency arrangement, such performance
thresholds shall be developed using the quality
measures identified by the qualified entity in its
application under subsection (c)(1)(D) if approved by
the Secretary.
``(B) Loss of shared savings payment and quality
and efficiency arrangements for failure to meet minimum
quality performance thresholds.--If a qualified entity
fails to meet the minimum quality performance
thresholds established under subparagraph (A) for an
agreement year--
``(i) no payment may be made to the entity
under subsection (g)(2)(C)(ii) with respect to
that year; and
``(ii) the entity may not implement any
quality and efficiency arrangement under
subsection (i) for that year.
``(k) Waivers.--
``(1) In general.--The Secretary shall waive such
provisions of this title and title XI as may be necessary to
carry out the program, including the following:
``(A) With respect to authorizing quality and
efficiency arrangements between qualified entities and
providers of services and suppliers, section 1877(a)
(relating to physician self-referral), paragraphs (1)
and (2) of sections 1128A(b) (relating to the
gainsharing civil money penalties), and paragraphs (1)
and (2) of section 1128B(b) (relating to the anti-
kickback statute).
``(B) Section 1128A(a)(5) of the Act (relating to
the inducement civil money penalties).
``(C) Section 1861(i) (relating to the 3-day acute
hospitalization prerequisite before eligibility for
post-hospital extended care services).
``(D) With respect to home health services--
``(i) sections 1814(a)(2)(C) and
1835(a)(2)(A) (relating to the requirement that
an individual be confined to home in order to
be eligible for benefits for home health
services);
``(ii) limitations on the amount,
frequency, and duration on home health
services; and
``(iii) prohibitions of free preoperative
home safety assessments by home health agencies
for patients scheduled to undergo surgery (such
as under Advisory Opinion No. 06-01 of the
Inspector General of the Department of Health
and Human Services).
``(2) Authority to modify waivers under certain
circumstances.--
``(A) In general.--In the case of a qualified
entity with respect to which one or more waivers under
paragraph (1) is in effect, if upon a review of the
performance or an audit of the entity the Secretary
finds a pattern of deficiencies or harm to applicable
beneficiaries, the Secretary may modify or revoke any
such waiver at any time as applied to that qualified
entity.
``(B) Termination of certain waivers in the case of
excess shared losses.--
``(i) In general.--Subject to the process
described in clause (ii), in the case of a
qualified entity that has selected the payment
model under subsection (g) and has gross shared
losses exceeding the cap under subsection
(g)(2)(C)(iv) with respect to an applicable
condition, the Secretary shall terminate
waivers described in paragraphs (1)(C) and
(1)(D) with respect to such qualified entity
and applicable condition.
``(ii) Pre-termination notice.--The
Secretary shall establish a process whereby a
qualified entity is furnished notice of any
deficiency that may give rise to a termination
of waivers under clause (i) not later than 6
months before the proposed effective date of
the termination.
``(l) Independent Evaluation and Reports on Program.--
``(1) Independent evaluation.--The Secretary shall conduct
an independent evaluation of the impact of providing bundled
payments to qualified entities under this section. Such
evaluation shall include an examination of the extent to which
the bundling of payments this section have resulted in--
``(A) improved health outcomes;
``(B) improved access to care for applicable
beneficiaries;
``(C) reduced spending under this title; and
``(D) improvement in performance on quality
measures selected under subsection (j)(1)(A).
``(2) Reports.--
``(A) Interim report.--Not later than March 1,
2018, the Secretary shall submit to Congress a report
on the initial results of the independent evaluation
conducted under paragraph (1).
``(B) Final report.--Not later than March 1, 2020,
the Secretary shall submit to Congress a report on the
final results of the independent evaluation conducted
under paragraph (1) and may include recommendations for
the expansion of bundled payment methodologies and
applicable conditions under this section as the
Secretary determines to be appropriate.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, 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 Ways and Means, and in addition to the Committee on Energy and Commerce, 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.
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