Freshman Value & Innovation In Health Care Amendment

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AMENDMENT NO.llll

Calendar No.lll

Purpose: To modernize America’s health care system. IN THE SENATE OF THE UNITED STATES—111th Cong., 1st Sess.

H. R. 3590

To amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain other Federal employees, and for other purposes.

Referred to the Committee on llllllllll and ordered to be printed Ordered to lie on the table and to be printed intended to be proposed by AMENDMENT llllllllll to the amendment (No. 2786) proposed by Mr. REID Viz: 1

On page 1134, strike line 3 and insert the following:

2 title).

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2

Subtitle G—Modernizing America’s Health Care System

3

PART I—IMPROVING QUALITY AND VALUE

4

THROUGH DELIVERY SYSTEM REFORM

5

SEC. 3601. QUALITY REPORTING FOR PSYCHIATRIC HOS-

1

6 7

PITALS.

(a) IN GENERAL.—Section 1886(s) of the Social Se-

8 curity Act, as added by section 3401(f), is amended by 9 adding at the end the following new paragraph: 10 11 12 13

‘‘(4) QUALITY

REPORTING.—

‘‘(A) REDUCTION

IN UPDATE FOR FAILURE

TO REPORT.—

‘‘(i) IN

GENERAL.—Under

the system

14

described in paragraph (1), for rate year

15

2014 and each subsequent rate year, in the

16

case of a psychiatric hospital or psychiatric

17

unit that does not submit data to the Sec-

18

retary in accordance with subparagraph

19

(C) with respect to such a rate year, any

20

annual update to a standard Federal rate

21

for discharges for the hospital during the

22

rate year, and after application of para-

23

graph (2), shall be reduced by 2 percent-

24

age points.

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‘‘(ii) SPECIAL

RULE.—The

application

2

of this subparagraph may result in such

3

annual update being less than 0.0 for a

4

rate year, and may result in payment rates

5

under the system described in paragraph

6

(1) for a rate year being less than such

7

payment rates for the preceding rate year.

8

‘‘(B)

NONCUMULATIVE

APPLICATION.—

9

Any reduction under subparagraph (A) shall

10

apply only with respect to the rate year involved

11

and the Secretary shall not take into account

12

such reduction in computing the payment

13

amount under the system described in para-

14

graph (1) for a subsequent rate year.

15

‘‘(C) SUBMISSION

OF QUALITY DATA.—For

16

rate year 2014 and each subsequent rate year,

17

each psychiatric hospital and psychiatric unit

18

shall submit to the Secretary data on quality

19

measures specified under subparagraph (D).

20

Such data shall be submitted in a form and

21

manner, and at a time, specified by the Sec-

22

retary for purposes of this subparagraph.

23 24 25

‘‘(D) QUALITY ‘‘(i) IN

MEASURES.—

GENERAL.—Subject

to clause

(ii), any measure specified by the Secretary

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under this subparagraph must have been

2

endorsed by the entity with a contract

3

under section 1890(a).

4

‘‘(ii) EXCEPTION.—In the case of a

5

specified area or medical topic determined

6

appropriate by the Secretary for which a

7

feasible and practical measure has not

8

been endorsed by the entity with a contract

9

under section 1890(a), the Secretary may

10

specify a measure that is not so endorsed

11

as long as due consideration is given to

12

measures that have been endorsed or

13

adopted by a consensus organization iden-

14

tified by the Secretary.

15

‘‘(iii) TIME

FRAME.—Not

later than

16

October 1, 2012, the Secretary shall pub-

17

lish the measures selected under this sub-

18

paragraph that will be applicable with re-

19

spect to rate year 2014.

20

‘‘(E) PUBLIC

AVAILABILITY OF DATA SUB-

21

MITTED.—The

22

dures for making data submitted under sub-

23

paragraph (C) available to the public. Such pro-

24

cedures shall ensure that a psychiatric hospital

25

and a psychiatric unit has the opportunity to

Secretary shall establish proce-

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review the data that is to be made public with

2

respect to the hospital or unit prior to such

3

data being made public. The Secretary shall re-

4

port quality measures that relate to services

5

furnished in inpatient settings in psychiatric

6

hospitals and psychiatric units on the Internet

7

website of the Centers for Medicare & Medicaid

8

Services.’’.

9

(b)

CONFORMING

AMENDMENT.—Section

10 1890(b)(7)(B)(i)(I) of the Social Security Act, as added 11 by

section

3014,

is

amended

by

inserting

12 ‘‘1886(s)(4)(D),’’ after ‘‘1886(o)(2),’’. 13

SEC. 3602. PILOT TESTING PAY-FOR-PERFORMANCE PRO-

14

GRAMS FOR CERTAIN MEDICARE PROVIDERS.

15

(a) IN GENERAL.—Not later than January 1, 2016,

16 the Secretary of Health and Human Services (in this sec17 tion referred to as the ‘‘Secretary’’) shall, for each pro18 vider described in subsection (b), conduct a separate pilot 19 program under title XVIII of the Social Security Act to 20 test the implementation of a value-based purchasing pro21 gram for payments under such title for the provider. 22

(b) PROVIDERS DESCRIBED.—The providers de-

23 scribed in this paragraph are the following: 24

(1) Psychiatric hospitals (as described in clause

25

(i) of section 1886(d)(1)(B) of such Act (42 U.S.C.

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1395ww(d)(1)(B))) and psychiatric units (as de-

2

scribed in the matter following clause (v) of such

3

section).

4 5 6 7 8 9

(2) Long-term care hospitals (as described in clause (iv) of such section). (3) Rehabilitation hospitals (as described in clause (ii) of such section). (4) PPS-exempt cancer hospitals (as described in clause (v) of such section).

10

(5) Hospice programs (as defined in section

11

1861(dd)(2) of such Act (42 U.S.C. 1395x(dd)(2))).

12

(c) WAIVER AUTHORITY.—The Secretary may waive

13 such requirements of titles XI and XVIII of the Social 14 Security Act as may be necessary solely for purposes of 15 carrying out the pilot programs under this section. 16

(d) NO ADDITIONAL PROGRAM EXPENDITURES.—

17 Payments under this section under the separate pilot pro18 gram for value based purchasing (as described in sub19 section (a)) for each provider type described in paragraphs 20 (1) through (5) of subsection (b) for applicable items and 21 services under title XVIII of the Social Security Act for 22 a year shall be established in a manner that does not re23 sult in spending more under each such value based pur24 chasing program for such year than would otherwise be 25 expended for such provider type for such year if the pilot

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7 1 program were not implemented, as estimated by the Sec2 retary. 3

(e) EXPANSION

OF

PILOT PROGRAM.—The Secretary

4 may, at any point after January 1, 2018, expand the dura5 tion and scope of a pilot program conducted under this 6 subsection, to the extent determined appropriate by the 7 Secretary, if— 8 9

(1) the Secretary determines that such expansion is expected to—

10

(A) reduce spending under title XVIII of

11

the Social Security Act without reducing the

12

quality of care; or

13

(B) improve the quality of care and reduce

14

spending;

15

(2) the Chief Actuary of the Centers for Medi-

16

care & Medicaid Services certifies that such expan-

17

sion would reduce program spending under such title

18

XVIII; and

19

(3) the Secretary determines that such expan-

20

sion would not deny or limit the coverage or provi-

21

sion of benefits under such title XIII for Medicare

22

beneficiaries.

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SEC. 3603. PLANS FOR A VALUE-BASED PURCHASING PRO-

2

GRAM FOR AMBULATORY SURGICAL CEN-

3

TERS.

4

Section 3006 of this Act is amended by adding at

5 the end the following new subsection: 6 7

‘‘(f) AMBULATORY SURGICAL CENTERS.— ‘‘(1) IN

GENERAL.—The

Secretary shall develop

8

a plan to implement a value-based purchasing pro-

9

gram for payments under the Medicare program

10

under title XVIII of the Social Security Act for am-

11

bulatory surgical centers (as described in section

12

1833(i) of the Social Security Act (42 U.S.C.

13

1395l(i))).

14

‘‘(2) DETAILS.—In developing the plan under

15

paragraph (1), the Secretary shall consider the fol-

16

lowing issues:

17

‘‘(A) The ongoing development, selection,

18

and modification process for measures (includ-

19

ing under section 1890 of the Social Security

20

Act (42 U.S.C. 1395aaa) and section 1890A of

21

such Act, as added by section 3014), to the ex-

22

tent feasible and practicable, of all dimensions

23

of quality and efficiency in ambulatory surgical

24

centers.

25 26

‘‘(B) The reporting, collection, and validation of quality data.

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‘‘(C) The structure of value-based payment

2

adjustments, including the determination of

3

thresholds or improvements in quality that

4

would substantiate a payment adjustment, the

5

size of such payments, and the sources of fund-

6

ing for the value-based bonus payments.

7

‘‘(D) Methods for the public disclosure of

8

information on the performance of ambulatory

9

surgical centers.

10

‘‘(E) Any other issues determined appro-

11

priate by the Secretary.

12

‘‘(3) CONSULTATION.—In developing the plan

13

under paragraph (1), the Secretary shall—

14 15

‘‘(A) consult with relevant affected parties; and

16

‘‘(B) consider experience with such dem-

17

onstrations that the Secretary determines are

18

relevant to the value-based purchasing program

19

described in paragraph (1).

20

‘‘(4) REPORT

TO CONGRESS.—Not

later than

21

January 1, 2011, the Secretary shall submit to Con-

22

gress a report containing the plan developed under

23

paragraph (1).’’.

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SEC. 3604. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.

Section 1866D of the Social Security Act, as added

4 by section 3023, is amended— 5

(1) in paragraph (a)(2)(B), in the matter pre-

6

ceding clause (i), by striking ‘‘8 conditions’’ and in-

7

serting ‘‘10 conditions’’;

8 9

(2) by striking subsection (c)(1)(B) and inserting the following:

10

‘‘(B) EXPANSION.—The Secretary may, at

11

any point after January 1, 2016, expand the

12

duration and scope of the pilot program, to the

13

extent determined appropriate by the Secretary,

14

if—

15 16

‘‘(i) the Secretary determines that such expansion is expected to—

17

‘‘(I) reduce spending under title

18

XVIII of the Social Security Act with-

19

out reducing the quality of care; or

20

‘‘(II) improve the quality of care

21

and reduce spending;

22

‘‘(ii) the Chief Actuary of the Centers

23

for Medicare & Medicaid Services certifies

24

that such expansion would reduce program

25

spending under such title XVIII; and

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‘‘(iii) the Secretary determines that

2

such expansion would not deny or limit the

3

coverage or provision of benefits under this

4

title for individuals.’’; and

5 6 7 8

(3) by striking subsection (g). SEC. 3605. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS PROGRAM.

Section 1899 of the Social Security Act, as added by

9 section 3022, is amended by adding at the end the fol10 lowing new subsections: 11 12

‘‘(i) OPTION TO USE OTHER PAYMENT MODELS.— ‘‘(1) IN

GENERAL.—If

the Secretary determines

13

appropriate, the Secretary may use any of the pay-

14

ment models described in paragraph (2) or (3) for

15

making payments under the program rather than

16

the payment model described in subsection (d).

17

‘‘(2) PARTIAL

18

‘‘(A) IN

CAPITATION MODEL.— GENERAL.—Subject

to subpara-

19

graph (B), a model described in this paragraph

20

is a partial capitation model in which an ACO

21

is at financial risk for some, but not all, of the

22

items and services covered under parts A and

23

B, such as at risk for some or all physicians’

24

services or all items and services under part B.

25

The Secretary may limit a partial capitation

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model to ACOs that are highly integrated sys-

2

tems of care and to ACOs capable of bearing

3

risk, as determined to be appropriate by the

4

Secretary.

5

‘‘(B) NO

6

TURES.—Payments

7

services under this title for beneficiaries for a

8

year under the partial capitation model shall be

9

established in a manner that does not result in

10

spending more for such ACO for such bene-

11

ficiaries than would otherwise be expended for

12

such ACO for such beneficiaries for such year

13

if the model were not implemented, as esti-

14

mated by the Secretary.

15

‘‘(3) OTHER

16

ADDITIONAL PROGRAM EXPENDI-

to an ACO for items and

PAYMENT MODELS.—

‘‘(A) IN

GENERAL.—Subject

to subpara-

17

graph (B), a model described in this paragraph

18

is any payment model that the Secretary deter-

19

mines will improve the quality and efficiency of

20

items and services furnished under this title.

21

‘‘(B) NO

ADDITIONAL PROGRAM EXPENDI-

22

TURES.—Subparagraph

23

shall apply to a payment model under subpara-

24

graph (A) in a similar manner as such subpara-

(B) of paragraph (2)

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graph (B) applies to the payment model under

2

paragraph (2).

3

‘‘(j) INVOLVEMENT

IN

PRIVATE PAYER

AND

OTHER

4 THIRD PARTY ARRANGEMENTS.—The Secretary may give 5 preference to ACOs who are participating in similar ar6 rangements with other payers. 7

‘‘(k) TREATMENT

OF

PHYSICIAN GROUP PRACTICE

8 DEMONSTRATION.—During the period beginning on the 9 date of the enactment of this section and ending on the 10 date the program is established, the Secretary may enter 11 into an agreement with an ACO under the demonstration 12 under section 1866A, subject to rebasing and other modi13 fications deemed appropriate by the Secretary.’’. 14 15 16 17 18 19 20 21

SEC. 3606. INCENTIVES TO IMPLEMENT ACTIVITIES TO REDUCE DISPARITIES.

Section 1311(g)(1) of this Act is amended— (1) in subparagraph (C), by striking ‘‘; and’’ and inserting a semicolon; (2) in subparagraph (D), by striking the period and inserting ‘‘; and’’; and (3) by adding at the end the following:

22

‘‘(E) the implementation of activities to re-

23

duce health and health care disparities, includ-

24

ing through the use of language services, com-

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munity outreach, and cultural competency

2

trainings.’’.

3 4

SEC. 3607. NATIONAL DIABETES PREVENTION PROGRAM.

Part P of title III of the Public Health Service Act

5 42 U.S.C. 280g et seq.), as amended by section 5405, is 6 amended by adding at the end the following: 7

‘‘SEC. 399V-2. NATIONAL DIABETES PREVENTION PROGRAM.

8

‘‘(a) IN GENERAL.—The Secretary, acting through

9 the Director of the Centers for Disease Control and Pre10 vention, shall establish a national diabetes prevention pro11 gram (referred to in this section as the ‘program’) tar12 geted at adults at high risk for diabetes in order to elimi13 nate the preventable burden of diabetes. 14

‘‘(b) PROGRAM ACTIVITIES.—The program described

15 in subsection (a) shall include— 16 17

‘‘(1) a grant program for community-based diabetes prevention program model sites;

18

‘‘(2) a program within the Centers for Disease

19

Control and Prevention to determine eligibility of en-

20

tities to deliver community-based diabetes prevention

21

services;

22 23

‘‘(3) a training and outreach program for lifestyle intervention instructors; and

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‘‘(4) evaluation, monitoring and technical as-

2

sistance, and applied research carried out by the

3

Centers for Disease Control and Prevention.

4

‘‘(c) ELIGIBLE ENTITIES.—To be eligible for a grant

5 under subsection (b)(1), an entity shall be a State or local 6 health department, a tribal organization, a national net7 work of community-based non-profits focused on health 8 and wellbeing, an academic institution, or other entity, as 9 the Secretary determines. 10

‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—For the

11 purpose of carrying out this section, there are authorized 12 to be appropriated such sums as may be necessary for 13 each of fiscal years 2010 through 2014.’’. 14 15

SEC. 3608. SELECTION OF EFFICIENCY MEASURES.

Sections 1890(b)(7) and 1890A of the Social Security

16 Act, as added by section 3014, are amended by striking 17 ‘‘quality’’ each place it appears and inserting ‘‘quality and 18 efficiency’’. 19

SEC. 3609. REGIONAL TESTING OF PAYMENT AND SERVICE

20

DELIVERY MODELS UNDER THE CENTER FOR

21

MEDICARE AND MEDICAID INNOVATION.

22

Section 1115A(a) of the Social Security Act, as added

23 by section 3021, is amended by inserting at the end the 24 following new paragraph:

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‘‘(5) TESTING

WITHIN CERTAIN GEOGRAPHIC

2

AREAS.—For

3

ice delivery models under this section, the Secretary

4

may elect to limit testing of a model to certain geo-

5

graphic areas.’’.

purposes of testing payment and serv-

6

SEC. 3610. ADDITIONAL IMPROVEMENTS UNDER THE CEN-

7

TER FOR MEDICARE AND MEDICAID INNOVA-

8

TION.

9

Section 1115A(a) of the Social Security Act, as added

10 by section 3021, is amended— 11 12

(1) in subsection (b)(2)— (A) in subparagraph (A)—

13

(i) in the second sentence, by striking

14

‘‘the preceding sentence may include’’ and

15

inserting ‘‘this subparagraph may include,

16

but are not limited to,’’; and

17

(ii) by inserting after the first sen-

18

tence the following new sentence: ‘‘The

19

Secretary shall focus on models expected to

20

reduce program costs under the applicable

21

title while preserving or enhancing the

22

quality of care received by individuals re-

23

ceiving benefits under such title.’’; and

24

(B) in subparagraph (C), by adding at the

25

end the following new clause:

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‘‘(viii)

Whether

the

model

dem-

2

onstrates effective linkage with other pub-

3

lic sector or private sector payers.’’;

4 5 6

(2) in subsection (b)(4), by adding at the end the following new subparagraph: ‘‘(C) MEASURE

SELECTION.—To

the ex-

7

tent feasible, the Secretary shall select meas-

8

ures under this paragraph that reflect national

9

priorities for quality improvement and patient-

10

centered care consistent with the measures de-

11

scribed in 1890(b)(7)(B).’’; and

12

(3) in subsection (c)—

13

(A) in paragraph (1)(B), by striking ‘‘care

14

and reduce spending; and’’ and inserting ‘‘pa-

15

tient care without increasing spending;’’;

16

(B) in paragraph (2), by striking ‘‘reduce

17

program spending under applicable titles.’’ and

18

inserting ‘‘reduce (or would not result in any

19

increase in) net program spending under appli-

20

cable titles; and’’; and

21

(C) by adding at the end the following:

22

‘‘(3) the Secretary determines that such expan-

23

sion would not deny or limit the coverage or provi-

24

sion of benefits under the applicable title for applica-

25

ble individuals.

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18 1 In determining which models or demonstration projects to 2 expand under the preceding sentence, the Secretary shall 3 focus on models and demonstration projects that improve 4 the quality of patient care and reduce spending.’’. 5 6 7

SEC. 3611. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM.

(a) IN GENERAL.—Section 1848(m) of the Social Se-

8 curity Act (42 U.S.C. 1395w–4(m)) is amended by adding 9 at the end the following new paragraph: 10

‘‘(7) ADDITIONAL

11

‘‘(A) IN

INCENTIVE PAYMENT.—

GENERAL.—For

2011 through

12

2014, if an eligible professional meets the re-

13

quirements described in subparagraph (B), the

14

applicable quality percent for such year, as de-

15

scribed in clauses (iii) and (iv) of paragraph

16

(1)(B), shall be increased by 0.5 percentage

17

points.

18

‘‘(B)

REQUIREMENTS

DESCRIBED.—In

19

order to qualify for the additional incentive pay-

20

ment described in subparagraph (A), an eligible

21

professional shall meet the following require-

22

ments:

23

‘‘(i) The eligible professional shall—

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‘‘(I) satisfactorily submit data on

2

quality measures for purposes of para-

3

graph (1) for a year; and

4

‘‘(II) have such data submitted

5

on their behalf through a Maintenance

6

of Certification Program (as defined

7

in subparagraph (C)(i)) that meets—

8

‘‘(aa) the criteria for a reg-

9

istry (as described in subsection

10

(k)(4)); or

11

‘‘(bb) an alternative form

12

and manner determined appro-

13

priate by the Secretary.

14

‘‘(ii) The eligible professional, more

15

frequently than is required to qualify for or

16

maintain board certification status—

17

‘‘(I) participates in such a Main-

18

tenance of Certification program for a

19

year; and

20

‘‘(II) successfully completes a

21

qualified Maintenance of Certification

22

Program practice assessment (as de-

23

fined in subparagraph (C)(ii)) for

24

such year.

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‘‘(iii) A Maintenance of Certification

2

program submits to the Secretary, on be-

3

half of the eligible professional, informa-

4

tion—

5

‘‘(I) in a form and manner speci-

6

fied by the Secretary, that the eligible

7

professional has successfully met the

8

requirements of clause (ii) (which may

9

be in the form of a structural meas-

10

ure);

11

‘‘(II) if requested by the Sec-

12

retary, on the survey of patient expe-

13

rience with care (as described in sub-

14

paragraph (C)(ii)(II)); and

15

‘‘(III) as the Secretary may re-

16

quire, on the methods, measures, and

17

data used under the Maintenance of

18

Certification Program and the quali-

19

fied Maintenance of Certification Pro-

20

gram practice assessment.

21 22

‘‘(C) DEFINITIONS.—For purposes of this paragraph:

23

‘‘(i) The term ‘Maintenance of Certifi-

24

cation Program’ means a continuous as-

25

sessment program, such as qualified Amer-

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21 1

ican Board of Medical Specialties Mainte-

2

nance of Certification program or an

3

equivalent program (as determined by the

4

Secretary), that advances quality and the

5

lifelong learning and self-assessment of

6

board certified specialty physicians by fo-

7

cusing on the competencies of patient care,

8

medical knowledge, practice-based learning,

9

interpersonal and communication skills and

10

professionalism. Such a program shall in-

11

clude the following:

12

‘‘(I) The program requires the

13

physician to maintain a valid, unre-

14

stricted medical license in the United

15

States.

16

‘‘(II) The program requires a

17

physician to participate in educational

18

and self-assessment programs that re-

19

quire an assessment of what was

20

learned.

21

‘‘(III) The program requires a

22

physician to demonstrate, through a

23

formalized, secure examination, that

24

the physician has the fundamental di-

25

agnostic skills, medical knowledge,

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and clinical judgment to provide qual-

2

ity care in their respective specialty.

3

‘‘(IV) The program requires suc-

4

cessful completion of a qualified Main-

5

tenance

6

practice assessment as described in

7

clause (ii).

8

‘‘(ii) The term ‘qualified Maintenance

9

of Certification Program practice assess-

10

ment’ means an assessment of a physi-

11

cian’s practice that—

of

Certification

Program

12

‘‘(I) includes an initial assess-

13

ment of an eligible professional’s prac-

14

tice that is designed to demonstrate

15

the physician’s use of evidence-based

16

medicine;

17 18

‘‘(II) includes a survey of patient experience with care; and

19

‘‘(III) requires a physician to im-

20

plement a quality improvement inter-

21

vention to address a practice weak-

22

ness identified in the initial assess-

23

ment under subclause (I) and then to

24

remeasure to assess performance im-

25

provement after such intervention.’’.

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(b) AUTHORITY.—Section 3002(c) of this Act is

2 amended by adding at the end the following new para3 graph: 4

‘‘(3) AUTHORITY.—For years after 2014, if the

5

Secretary of Health and Human Services determines

6

it to be appropriate, the Secretary may incorporate

7

participation in a Maintenance of Certification Pro-

8

gram and successful completion of a qualified Main-

9

tenance of Certification Program practice assess-

10

ment into the composite of measures of quality of

11

care furnished pursuant to the physician fee sched-

12

ule payment modifier, as described in section

13

1848(p)(2) of the Social Security Act (42 U.S.C.

14

1395w–4(p)(2)).’’.

15

(c) ELIMINATION

16 17

BILIZATION

OF

MA REGIONAL PLAN STA-

FUND.—

(1) IN

GENERAL.—Section

1858 of the Social

18

Security Act (42 U.S.C. 1395w–27a) is amended by

19

striking subsection (e).

20

(2) TRANSITION.—Any amount contained in the

21

MA Regional Plan Stabilization Fund as of the date

22

of the enactment of this Act shall be transferred to

23

the Federal Supplementary Medical Insurance Trust

24

Fund.

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SEC. 3612. IMPROVEMENT IN PART D MEDICATION THER-

2

APY MANAGEMENT (MTM) PROGRAMS.

3

(a) IN GENERAL.—Section 1860D–4(c)(2) of the So-

4 cial Security Act (42 U.S.C. 1395w–104(c)(2)) is amend5 ed— 6

(1) by redesignating subparagraphs (C), (D),

7

and (E) as subparagraphs (E), (F), and (G), respec-

8

tively; and

9 10 11

(2) by inserting after subparagraph (B) the following new subparagraphs: ‘‘(C)

REQUIRED

INTERVENTIONS.—For

12

plan years beginning on or after the date that

13

is 2 years after the date of the enactment of the

14

Patient Protection and Affordable Care Act,

15

prescription drug plan sponsors shall offer

16

medication therapy management services to tar-

17

geted beneficiaries described in subparagraph

18

(A)(ii) that include, at a minimum, the fol-

19

lowing to increase adherence to prescription

20

medications or other goals deemed necessary by

21

the Secretary:

22

‘‘(i) An annual comprehensive medica-

23

tion review furnished person-to-person or

24

using telehealth technologies (as defined by

25

the Secretary) by a licensed pharmacist or

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25 1

other qualified provider. The comprehen-

2

sive medication review—

3

‘‘(I) shall include a review of the

4

individual’s medications and may re-

5

sult in the creation of a recommended

6

medication action plan or other ac-

7

tions in consultation with the indi-

8

vidual and with input from the pre-

9

scriber to the extent necessary and

10

practicable; and

11

‘‘(II) shall include providing the

12

individual with a written or printed

13

summary of the results of the review.

14

The Secretary, in consultation with rel-

15

evant stakeholders, shall develop a stand-

16

ardized format for the action plan under

17

subclause (I) and the summary under sub-

18

clause (II).

19

‘‘(ii) Follow-up interventions as war-

20

ranted based on the findings of the annual

21

medication review or the targeted medica-

22

tion enrollment and which may be provided

23

person-to-person or using telehealth tech-

24

nologies (as defined by the Secretary).

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26 1

‘‘(D)

ASSESSMENT.—The

prescription

2

drug plan sponsor shall have in place a process

3

to assess, at least on a quarterly basis, the

4

medication use of individuals who are at risk

5

but not enrolled in the medication therapy man-

6

agement program, including individuals who

7

have experienced a transition in care, if the pre-

8

scription drug plan sponsor has access to that

9

information.

10

‘‘(E)

AUTOMATIC

ENROLLMENT

WITH

11

ABILITY TO OPT-OUT.—The

12

plan sponsor shall have in place a process to—

13

‘‘(i) subject to clause (ii), automati-

14

cally enroll targeted beneficiaries described

15

in subparagraph (A)(ii), including bene-

16

ficiaries identified under subparagraph

17

(D), in the medication therapy manage-

18

ment program required under this sub-

19

section; and

20

‘‘(ii) permit such beneficiaries to opt-

21 22

prescription drug

out of enrollment in such program.’’. (b) RULE

OF

CONSTRUCTION.—Nothing in this sec-

23 tion shall limit the authority of the Secretary of Health 24 and Human Services to modify or broaden requirements 25 for a medication therapy management program under part

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27 1 D of title XVIII of the Social Security Act or to study 2 new models for medication therapy management through 3 the Center for Medicare and Medicaid Innovation under 4 section 1115A of such Act, as added by section 3021. 5

SEC. 3613. EVALUATION OF TELEHEALTH UNDER THE CEN-

6

TER FOR MEDICARE AND MEDICAID INNOVA-

7

TION.

8

Section 1115A(b)(2)(B) of the Social Security Act,

9 as added by section 3021, is amended by adding at the 10 end the following new clause: 11

‘‘(xix) Utilizing, in particular in enti-

12

ties located in medically underserved areas

13

and facilities of the Indian Health Service

14

(whether operated by such Service or by an

15

Indian tribe or tribal organization (as

16

those terms are defined in section 4 of the

17

Indian Health Care Improvement Act)),

18

telehealth services—

19

‘‘(I) in treating behavioral health

20

issues (such as post-traumatic stress

21

disorder) and stroke; and

22

‘‘(II) to improve the capacity of

23

non-medical providers and non-spe-

24

cialized medical providers to provide

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28 1

health

2

chronic complex conditions.’’.

3

for

patients

with

SEC. 3614. REVISIONS TO THE EXTENSION FOR THE RURAL

4

COMMUNITY

5

PROGRAM.

6

services

HOSPITAL

DEMONSTRATION

(a) IN GENERAL.—Subsection (g) of section 410A of

7 the Medicare Prescription Drug, Improvement, and Mod8 ernization Act of 2003 (Public Law 108–173; 117 Stat. 9 2272), as added by section 3123(a) of this Act, is amend10 ed to read as follows: 11

‘‘(g) FIVE-YEAR EXTENSION

OF

DEMONSTRATION

GENERAL.—Subject

to the succeeding

12 PROGRAM.— 13

‘‘(1) IN

14

provisions of this subsection, the Secretary shall con-

15

duct the demonstration program under this section

16

for an additional 5-year period (in this section re-

17

ferred to as the ‘5-year extension period’) that be-

18

gins on the date immediately following the last day

19

of the initial 5-year period under subsection (a)(5).

20

‘‘(2)

EXPANSION

OF

DEMONSTRATION

21

STATES.—Notwithstanding

22

the 5-year extension period, the Secretary shall ex-

23

pand the number of States with low population den-

24

sities determined by the Secretary under such sub-

25

section to 20. In determining which States to include

subsection (a)(2), during

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29 1

in such expansion, the Secretary shall use the same

2

criteria and data that the Secretary used to deter-

3

mine the States under such subsection for purposes

4

of the initial 5-year period.

5

‘‘(3) INCREASE

IN MAXIMUM NUMBER OF HOS-

6

PITALS

7

PROGRAM.—Notwithstanding

8

ing the 5-year extension period, not more than 30

9

rural community hospitals may participate in the

10 11

PARTICIPATING

IN

THE

DEMONSTRATION

subsection (a)(4), dur-

demonstration program under this section. ‘‘(4) HOSPITALS

IN DEMONSTRATION PROGRAM

12

ON DATE OF ENACTMENT.—In

13

community hospital that is participating in the dem-

14

onstration program under this section as of the last

15

day of the initial 5-year period, the Secretary—

the case of a rural

16

‘‘(A) shall provide for the continued par-

17

ticipation of such rural community hospital in

18

the demonstration program during the 5-year

19

extension period unless the rural community

20

hospital makes an election, in such form and

21

manner as the Secretary may specify, to dis-

22

continue such participation; and

23

‘‘(B) in calculating the amount of payment

24

under subsection (b) to the rural community

25

hospital for covered inpatient hospital services

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30 1

furnished by the hospital during such 5-year ex-

2

tension period, shall substitute, under para-

3

graph (1)(A) of such subsection—

4

‘‘(i) the reasonable costs of providing

5

such services for discharges occurring in

6

the first cost reporting period beginning on

7

or after the first day of the 5-year exten-

8

sion period, for

9

‘‘(ii) the reasonable costs of providing

10

such services for discharges occurring in

11

the first cost reporting period beginning on

12

or after the implementation of the dem-

13

onstration program.’’.

14

(b) CONFORMING AMENDMENTS.—Subsection (a)(5)

15 of section 410A of the Medicare Prescription Drug, Im16 provement, and Modernization Act of 2003 (Public Law 17 108–173; 117 Stat. 2272), as amended by section 3123(b) 18 of this Act, is amended by striking ‘‘1-year extension’’ and 19 inserting ‘‘5-year extension’’. 20

PART II—PROMOTING TRANSPARENCY AND

21

COMPETITION

22 23 24

SEC.

3621.

DEVELOPING

METHODOLOGY

TO

ASSESS

HEALTH PLAN VALUE.

(a) DEVELOPMENT.—The Secretary of Health and

25 Human Services (referred to in this section as the ‘‘Sec-

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31 1 retary’’), in consultation with relevant stakeholders includ2 ing health insurance issuers, health care consumers, em3 ployers, health care providers, and other entities deter4 mined appropriate by the Secretary, shall develop a meth5 odology to measure health plan value. Such methodology 6 shall take into consideration, where applicable— 7

(1) the overall cost to enrollees under the plan;

8

(2) the quality of the care provided for under

9

the plan;

10

(3) the efficiency of the plan in providing care;

11

(4) the relative risk of the plan’s enrollees as

12

compared to other plans;

13

(5) the actuarial value or other comparative

14

measure of the benefits covered under the plan; and

15

(6) other factors determined relevant by the

16

Secretary.

17

(b) REPORT.—Not later than 18 months after the

18 date of enactment of this Act, the Secretary shall submit 19 to Congress a report concerning the methodology devel20 oped under subsection (a). 21 22

SEC. 3622. DATA COLLECTION; PUBLIC REPORTING.

Section 399II(a) of the Public Health Service Act,

23 as added by section 3015, is amended to read as follows: 24

‘‘(a) IN GENERAL.—

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32 1

‘‘(1) ESTABLISHMENT

OF STRATEGIC FRAME-

2

WORK.—The

3

ment an overall strategic framework to carry out the

4

public reporting of performance information, as de-

5

scribed in section 399JJ. Such strategic framework

6

may include methods and related timelines for im-

7

plementing nationally consistent data collection, data

8

aggregation, and analysis methods.

9

‘‘(2)

Secretary shall establish and imple-

COLLECTION

AND

AGGREGATION

OF

10

DATA.—The

11

consistent data on quality and resource use meas-

12

ures from information systems used to support

13

health care delivery, and may award grants or con-

14

tracts for this purpose. The Secretary shall align

15

such collection and aggregation efforts with the re-

16

quirements and assistance regarding the expansion

17

of health information technology systems, the inter-

18

operability of such technology systems, and related

19

standards that are in effect on the date of enact-

20

ment of the Patient Protection and Affordable Care

21

Act.

Secretary shall collect and aggregate

22

‘‘(3) SCOPE.—The Secretary shall ensure that

23

the data collection, data aggregation, and analysis

24

systems described in paragraph (1) involve an in-

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33 1

creasingly broad range of patient populations, pro-

2

viders, and geographic areas over time.’’.

3

SEC. 3623. MODERNIZING COMPUTER AND DATA SYSTEMS

4

OF THE CENTERS FOR MEDICARE & MED-

5

ICAID

6

MENTS IN CARE DELIVERY.

7

SERVICES

TO

SUPPORT

IMPROVE-

(a) IN GENERAL.—The Secretary of Health and

8 Human Services (in this section referred to as the ‘‘Sec9 retary’’) shall develop a plan (and detailed budget for the 10 resources needed to implement such plan) to modernize 11 the computer and data systems of the Centers for Medi12 care & Medicaid Services (in this section referred to as 13 ‘‘CMS’’). 14

(b) CONSIDERATIONS.—In developing the plan, the

15 Secretary shall consider how such modernized computer 16 system could— 17

(1) in accordance with the regulations promul-

18

gated under section 264(c) of the Health Insurance

19

Portability and Accountability Act of 1996, make

20

available data in a reliable and timely manner to

21

providers of services and suppliers to support their

22

efforts to better manage and coordinate care fur-

23

nished to beneficiaries of CMS programs; and

24

(2) support consistent evaluations of payment

25

and delivery system reforms under CMS programs.

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34 1

(c) POSTING

OF

PLAN.—By not later than 9 months

2 after the date of the enactment of this Act, the Secretary 3 shall post on the website of the Centers for Medicare & 4 Medicaid Services the plan described in subsection (a). 5 6 7

SEC. 3624. EXPANSION OF THE SCOPE OF THE INDEPENDENT MEDICARE ADVISORY BOARD.

(a) ANNUAL PUBLIC REPORT.—

8

(1) REPORT.—Section 1899A of the Social Se-

9

curity Act, as added by section 3403, is amended by

10

adding at the end the following new subsection:

11

‘‘(n) ANNUAL PUBLIC REPORT.—

12

‘‘(1) IN

GENERAL.—Not

later than July 1,

13

2014, and annually thereafter, the Board shall

14

produce a public report containing standardized in-

15

formation on system-wide health care costs, patient

16

access to care, utilization, and quality-of-care that

17

allows for comparison by region, types of services,

18

types of providers, and both private payers and the

19

program under this title.

20

‘‘(2) REQUIREMENTS.—Each report produced

21

pursuant to paragraph (1) shall include information

22

with respect to the following areas:

23

‘‘(A) The quality and costs of care for the

24

population at the most local level determined

25

practical by the Board (with quality and costs

GOE09B95

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35 1

compared to national benchmarks and reflecting

2

rates of change, taking into account quality

3

measures described in section 1890(b)(7)(B)).

4

‘‘(B) Beneficiary and consumer access to

5

care, patient and caregiver experience of care,

6

and the cost-sharing or out-of-pocket burden on

7

patients.

8 9

‘‘(C) Epidemiological shifts and demographic changes.

10

‘‘(D) The proliferation, effectiveness, and

11

utilization of health care technologies, including

12

variation in provider practice patterns and

13

costs.

14

‘‘(E) Any other areas that the Board de-

15

termines affect overall spending and quality of

16

care in the private sector.’’.

17

(2) ALIGNMENT

WITH MEDICARE PROPOSALS.—

18

Section 1899A(c)(2)(B) of the Social Security Act,

19

as added by section 3403, is amended—

20 21 22 23 24 25

(A) in clause (v), by striking ‘‘and’’ at the end; (B) in clause (vi), by striking the period at the end and inserting ‘‘; and’’; and (C) by adding at the end the following new clause:

GOE09B95

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36 1

‘‘(vii) take into account the data and

2

findings contained in the annual reports

3

under subsection (n) in order to develop

4

proposals that can most effectively promote

5

the delivery of efficient, high quality care

6

to Medicare beneficiaries.’’.

7 8

(b) ADVISORY RECOMMENDATIONS ERAL

FOR

NON-FED-

HEALTH CARE PROGRAMS.—Section 1899A of the

9 Social Security Act, as added by section 3403 and as 10 amended by subsection (a)(1), is amended by adding at 11 the end the following new subsection: 12 13 14

‘‘(o) ADVISORY RECOMMENDATIONS ERAL

FOR

NON-FED-

HEALTH CARE PROGRAMS.— ‘‘(1) IN

GENERAL.—Not

later than January 15,

15

2015, and at least once every two years thereafter,

16

the Board shall submit to Congress and the Presi-

17

dent recommendations to slow the growth in na-

18

tional health expenditures (excluding expenditures

19

under this title and in other Federal health care pro-

20

grams) while preserving or enhancing quality of

21

care, such as recommendations—

22 23

‘‘(A) that the Secretary or other Federal agencies can implement administratively;

24

‘‘(B) that may require legislation to be en-

25

acted by Congress in order to be implemented;

GOE09B95

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37 1

‘‘(C) that may require legislation to be en-

2

acted by State or local governments in order to

3

be implemented;

4 5

‘‘(D) that private sector entities can voluntarily implement; and

6

‘‘(E) with respect to other areas deter-

7

mined appropriate by the Board.

8

‘‘(2) COORDINATION.—In making recommenda-

9

tions under paragraph (1), the Board shall coordi-

10

nate such recommendations with recommendations

11

contained in proposals and advisory reports pro-

12

duced by the Board under subsection (c).

13

‘‘(3) AVAILABLE

TO PUBLIC.—The

Board shall

14

make recommendations submitted to Congress and

15

the President under this subsection available to the

16

public.’’.

17

(c) RULE

OF

CONSTRUCTION.—Nothing in the

18 amendments made by this section shall preclude the Inde19 pendent Medicare Advisory Board, as established under 20 section 1899A of the Social Security Act (as added by sec21 tion 3403), from solely using data from public or private 22 sources to carry out the amendments made by subsections 23 (a)(1) and (b).

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38 1 2 3

SEC. 3625. ADDITIONAL PRIORITY FOR THE NATIONAL HEALTH CARE WORKFORCE COMMISSION.

Section 5101(d)(4)(A) of this Act is amended by add-

4 ing at the end the following new clause: 5

‘‘(v) An analysis of, and recommenda-

6

tions for, eliminating the barriers to enter-

7

ing and staying in primary care, including

8

provider compensation.’’.

9

PART III—PROMOTING ACCOUNTABILITY AND

10

RESPONSIBILITY

11 12

SEC. 3631. HEALTH CARE FRAUD ENFORCEMENT.

(a) FRAUD SENTENCING GUIDELINES.—

13

(1) DEFINITION.—In this subsection, the term

14

‘‘Federal health care offense’’ has the meaning given

15

that term in section 24 of title 18, United States

16

Code, as amended by this Act.

17

(2) REVIEW

AND AMENDMENTS.—Pursuant

to

18

the authority under section 994 of title 28, United

19

States Code, and in accordance with this subsection,

20

the United States Sentencing Commission shall—

21

(A) review the Federal Sentencing Guide-

22

lines and policy statements applicable to per-

23

sons convicted of Federal health care offenses;

24

(B) amend the Federal Sentencing Guide-

25

lines and policy statements applicable to per-

26

sons convicted of Federal health care offenses

GOE09B95

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39 1

involving Government health care programs to

2

provide that the aggregate dollar amount of

3

fraudulent bills submitted to the Government

4

health care program shall constitute prima facie

5

evidence of the amount of the intended loss by

6

the defendant; and

7 8

(C) amend the Federal Sentencing Guidelines to provide—

9

(i) a 2-level increase in the offense

10

level for any defendant convicted of a Fed-

11

eral health care offense relating to a Gov-

12

ernment health care program which in-

13

volves a loss of not less than $1,000,000

14

and less than $7,000,000;

15

(ii) a 3-level increase in the offense

16

level for any defendant convicted of a Fed-

17

eral health care offense relating to a Gov-

18

ernment health care program which in-

19

volves a loss of not less than $7,000,000

20

and less than $20,000,000;

21

(iii) a 4-level increase in the offense

22

level for any defendant convicted of a Fed-

23

eral health care offense relating to a Gov-

24

ernment health care program which in-

GOE09B95

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40 1

volves a loss of not less than $20,000,000;

2

and

3

(iv) if appropriate, otherwise amend

4

the Federal Sentencing Guidelines and pol-

5

icy statements applicable to persons con-

6

victed of Federal health care offenses in-

7

volving Government health care programs.

8

(3) REQUIREMENTS.—In carrying this sub-

9

section, the United States Sentencing Commission

10 11 12

shall— (A) ensure that the Federal Sentencing Guidelines and policy statements—

13

(i) reflect the serious harms associ-

14

ated with health care fraud and the need

15

for aggressive and appropriate law enforce-

16

ment action to prevent such fraud; and

17

(ii) provide increased penalties for

18

persons convicted of health care fraud of-

19

fenses in appropriate circumstances;

20

(B) consult with individuals or groups rep-

21

resenting health care fraud victims, law enforce-

22

ment officials, the health care industry, and the

23

Federal judiciary as part of the review de-

24

scribed in paragraph (2);

GOE09B95

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41 1

(C) ensure reasonable consistency with

2

other relevant directives and with other guide-

3

lines under the Federal Sentencing Guidelines;

4

(D) account for any aggravating or miti-

5

gating circumstances that might justify excep-

6

tions, including circumstances for which the

7

Federal Sentencing Guidelines, as in effect on

8

the date of enactment of this Act, provide sen-

9

tencing enhancements;

10

(E)

make

any

necessary

conforming

11

changes to the Federal Sentencing Guidelines;

12

and

13

(F) ensure that the Federal Sentencing

14

Guidelines adequately meet the purposes of sen-

15

tencing.

16

(b) INTENT REQUIREMENT

FOR

HEALTH CARE

17 FRAUD.—Section 1347 of title 18, United States Code, 18 is amended— 19 20 21 22

(1) by inserting ‘‘(a)’’ before ‘‘Whoever knowingly’’; and (2) by adding at the end the following: ‘‘(b) With respect to violations of this section, a per-

23 son need not have actual knowledge of this section or spe24 cific intent to commit a violation of this section.’’.

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42 1

(c) HEALTH CARE FRAUD OFFENSE.—Section 24(a)

2 of title 18, United States Code, is amended— 3

(1) in paragraph (1), by striking the semicolon

4

and inserting ‘‘or section 1128B of the Social Secu-

5

rity Act (42 U.S.C. 1320a–7b); or’’; and

6

(2) in paragraph (2)—

7

(A) by inserting ‘‘1349,’’ after ‘‘1343,’’;

8

and

9

(B) by inserting ‘‘section 301 of the Fed-

10

eral Food, Drug, and Cosmetic Act (21 U.S.C.

11

331), or section 501 of the Employee Retire-

12

ment Income Security Act of 1974 (29 U.S.C.

13

1131),’’ after ‘‘title,’’.

14

(d) SUBPOENA AUTHORITY RELATING

TO

HEALTH

15 CARE.— 16

(1) SUBPOENAS

UNDER THE HEALTH INSUR-

17

ANCE PORTABILITY AND ACCOUNTABILITY ACT OF

18

1996.—Section

19

Code, is amended—

20 21 22

1510(b) of title 18, United States

(A) in paragraph (1), by striking ‘‘to the grand jury’’; and (B) in paragraph (2)—

23

(i) in subparagraph (A), by striking

24

‘‘grand jury subpoena’’ and inserting ‘‘sub-

25

poena for records’’; and

GOE09B95

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43 1

(ii) in the matter following subpara-

2

graph (B), by striking ‘‘to the grand jury’’.

3

(2) SUBPOENAS

UNDER THE CIVIL RIGHTS OF

4

INSTITUTIONALIZED

5

Rights of Institutionalized Persons Act (42 U.S.C.

6

1997 et seq.) is amended by inserting after section

7

3 the following:

8 9

PERSONS

ACT.—The

Civil

‘‘SEC. 3A. SUBPOENA AUTHORITY.

‘‘(a) AUTHORITY.—The Attorney General, or at the

10 direction of the Attorney General, any officer or employee 11 of the Department of Justice may require by subpoena 12 access to any institution that is the subject of an investiga13 tion under this Act and to any document, record, material, 14 file, report, memorandum, policy, procedure, investigation, 15 video or audio recording, or quality assurance report relat16 ing to any institution that is the subject of an investiga17 tion under this Act to determine whether there are condi18 tions which deprive persons residing in or confined to the 19 institution of any rights, privileges, or immunities secured 20 or protected by the Constitution or laws of the United 21 States. 22 23 24 25

‘‘(b) ISSUANCE

AND

ENFORCEMENT

OF

SUB-

POENAS.—

‘‘(1) ISSUANCE.—Subpoenas issued under this section—

GOE09B95

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44 1

‘‘(A) shall bear the signature of the Attor-

2

ney General or any officer or employee of the

3

Department of Justice as designated by the At-

4

torney General; and

5

‘‘(B) shall be served by any person or class

6

of persons designated by the Attorney General

7

or a designated officer or employee for that

8

purpose.

9

‘‘(2) ENFORCEMENT.—In the case of contu-

10

macy or failure to obey a subpoena issued under this

11

section, the United States district court for the judi-

12

cial district in which the institution is located may

13

issue an order requiring compliance. Any failure to

14

obey the order of the court may be punished by the

15

court as a contempt that court.

16

‘‘(c) PROTECTION

OF

SUBPOENAED RECORDS

AND

17 INFORMATION.—Any document, record, material, file, re18 port, memorandum, policy, procedure, investigation, video 19 or audio recording, or quality assurance report or other 20 information obtained under a subpoena issued under this 21 section— 22

‘‘(1) may not be used for any purpose other

23

than to protect the rights, privileges, or immunities

24

secured or protected by the Constitution or laws of

GOE09B95

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45 1

the United States of persons who reside, have re-

2

sided, or will reside in an institution;

3

‘‘(2) may not be transmitted by or within the

4

Department of Justice for any purpose other than to

5

protect the rights, privileges, or immunities secured

6

or protected by the Constitution or laws of the

7

United States of persons who reside, have resided,

8

or will reside in an institution; and

9

‘‘(3) shall be redacted, obscured, or otherwise

10

altered if used in any publicly available manner so

11

as to prevent the disclosure of any personally identi-

12

fiable information.’’.

13

SEC. 3632. DEVELOPMENT OF STANDARDS FOR FINANCIAL

14 15 16 17

AND ADMINISTRATIVE TRANSACTIONS.

(a) ADDITIONAL TRANSACTION STANDARDS ERATING

AND

OP -

RULES.— (1) DEVELOPMENT

OF

ADDITIONAL

TRANS-

18

ACTION STANDARDS AND OPERATING RULES.—Sec-

19

tion 1173(a) of the Social Security Act (42 U.S.C.

20

1320d–2(a)), as amended by section 1104(b)(2), is

21

amended—

22

(A) in paragraph (1)(B), by inserting be-

23

fore the period the following: ‘‘, and subject to

24

the requirements under paragraph (5)’’; and

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(B) by adding at the end the following new

2

paragraph:

3

‘‘(5) CONSIDERATION

4

ACTIVITIES AND ITEMS.—

5

‘‘(A) IN

OF STANDARDIZATION OF

GENERAL.—For

purposes of car-

6

rying out paragraph (1)(B), the Secretary shall

7

solicit, not later than January 1, 2012, and not

8

less than every 3 years thereafter, input from

9

entities described in subparagraph (B) on—

10

‘‘(i) whether there could be greater

11

uniformity in financial and administrative

12

activities and items, as determined appro-

13

priate by the Secretary; and

14

‘‘(ii) whether such activities should be

15

considered financial and administrative

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transactions (as described in paragraph

17

(1)(B)) for which the adoption of stand-

18

ards and operating rules would improve

19

the operation of the health care system

20

and reduce administrative costs.

21

‘‘(B) SOLICITATION

OF INPUT.—For

pur-

22

poses of subparagraph (A), the Secretary shall

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seek input from—

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‘‘(i) the National Committee on Vital

25

and Health Statistics, the Health Informa-

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tion Technology Policy Committee, and the

2

Health Information Technology Standards

3

Committee; and

4

‘‘(ii) standard setting organizations

5

and stakeholders, as determined appro-

6

priate by the Secretary.’’.

7 8

(b) ACTIVITIES ATION.—For

AND

ITEMS

FOR

INITIAL CONSIDER-

purposes of section 1173(a)(5) of the Social

9 Security Act, as added by subsection (a), the Secretary 10 of Health and Human Services (in this section referred 11 to as the ‘‘Secretary’’) shall, not later than January 1, 12 2012, seek input on activities and items relating to the 13 following areas: 14

(1) Whether the application process, including

15

the use of a uniform application form, for enrollment

16

of health care providers by health plans could be

17

made electronic and standardized.

18

(2) Whether standards and operating rules de-

19

scribed in section 1173 of the Social Security Act

20

should apply to the health care transactions of auto-

21

mobile insurance, worker’s compensation, and other

22

programs or persons not described in section

23

1172(a) of such Act (42 U.S.C. 1320d–1(a)).

24

(3) Whether standardized forms could apply to

25

financial audits required by health plans, Federal

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and State agencies (including State auditors, the Of-

2

fice of the Inspector General of the Department of

3

Health and Human Services, and the Centers for

4

Medicare & Medicaid Services), and other relevant

5

entities as determined appropriate by the Secretary.

6

(4) Whether there could be greater trans-

7

parency and consistency of methodologies and proc-

8

esses used to establish claim edits used by health

9

plans (as described in section 1171(5) of the Social

10 11

Security Act (42 U.S.C. 1320d(5))). (5) Whether health plans should be required to

12

publish their timeliness of payment rules.

13

(c) ICD CODING CROSSWALKS.—

14

(1) ICD-9

TO ICD-10 CROSSWALK.—The

Sec-

15

retary shall task the ICD-9-CM Coordination and

16

Maintenance Committee to convene a meeting, not

17

later than January 1, 2011, to receive input from

18

appropriate stakeholders (including health plans,

19

health care providers, and clinicians) regarding the

20

crosswalk between the Ninth and Tenth Revisions of

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the International Classification of Diseases (ICD-9

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and ICD-10, respectively) that is posted on the

23

website of the Centers for Medicare & Medicaid

24

Services, and make recommendations about appro-

25

priate revisions to such crosswalk.

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(2) REVISION

OF CROSSWALK.—For

purposes

2

of the crosswalk described in paragraph (1), the Sec-

3

retary shall make appropriate revisions and post any

4

such revised crosswalk on the website of the Centers

5

for Medicare & Medicaid Services.

6

(3) USE

OF REVISED CROSSWALK.—For

pur-

7

poses of paragraph (2), any revised crosswalk shall

8

be treated as a code set for which a standard has

9

been adopted by the Secretary for purposes of sec-

10

tion 1173(c)(1)(B) of the Social Security Act (42

11

U.S.C. 1320d–2(c)(1)(B)).

12

(4) SUBSEQUENT

CROSSWALKS.—For

subse-

13

quent revisions of the International Classification of

14

Diseases that are adopted by the Secretary as a

15

standard code set under section 1173(c) of the So-

16

cial Security Act (42 U.S.C. 1320d–2(c)), the Sec-

17

retary shall, after consultation with the appropriate

18

stakeholders, post on the website of the Centers for

19

Medicare & Medicaid Services a crosswalk between

20

the previous and subsequent version of the Inter-

21

national Classification of Diseases not later than the

22

date of implementation of such subsequent revision.