,i #aacth ,,congress #ast ,session ,h4 ,r4 #cgif ,,in ,,the ,,house ,,of ,,representatives ,december #ai1 #bjac,mrs4 ,black 7for herself and ,mr4 ,neal7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 for a period to be subsequently determined by the ,speaker1 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 hospitalization1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,comprehensive ,care ,payment ,innovation ,act4 #b4 ,permanent1 national voluntary payment bundling ,title ,,xviii of the ,social ,security ,act is amended by inserting after section #ahff;,e 7#db ,u4,s4,c4 #acie;cc-#e7 the following new section3 #ahff;,f4 ,national voluntary payment bundling 7a7 ,establishment and implementation 7#a7 ,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 hospitalization4 7#b7 ,deadline ,the ,secretary shall implement this section not later than ,january #a1 #bjae4 7#c7 ,applicable beneficiary defined ,in this section1 the term applicable beneficiary means an individual who is entitled to1 or enrolled for1 benefits under part ,a and enrolled for benefits under part ,b1 but not enrolled under part ,c or in a ,,pace program under section #ahid1 and who is admitted to a hospital for an applicable condition4 7b7 ,qualified entity and application process 7#a7 ,definitions ,in this section3 7,a7 ,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 section4 7,b7 ,qualified applicant ,the term qualified applicant means a corporation1 partnership1 or limited liability company1 that is authorized in writing by a group of providers of services and suppliers1 including at least a hospital1 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 section4 ,a qualified applicant may 7but is not required to7 be a provider of services or supplier that is otherwise participating under this title4 7#b7 ,application 7,a7 ,in general ,a qualified applicant may submit to the ,secretary an application to become a qualified entity to receive bundled payments under this section4 7,b7 ,contents ,an application under subparagraph 7,a7 with respect to a group of providers of services and suppliers-- 7i7 shall contain such information and assurances as the ,secretary may specify1 including with respect to the requirements under subsection 7c77#a72 and 7ii7 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 7g7 or 7h7 under which the group would be paid for such services4 7#c7 ,choice among applicable conditions ,a qualified entity may select one or more applicable conditions for bundled payments under this section4 ,nothing in this section shall be construed as requiring1 or authorizing the ,secretary to require1 a qualified entity to select any particular applicable condition under this section4 7#d7 ,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 #aaae;,a through the ,bundled ,payments for ,care ,improvement 7,,bpci7 ,initiative1 the ,secretary shall provide for an expedited application process under this subsection4 7c7 ,requirements for qualified entities 7#a7 ,requirements 7,a7 ,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 section4 7,b7 ,agreement period ,under such requirements1 a qualified entity shall agree to receive bundled payments for the furnishing of such services for a #e-year period 7each such year in such period referred to in this section as an agreement year74 7,c7 ,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 advance1 to the extent practicable1 of the beneficiary's inpatient admission for the applicable condition and episode of care involved4 ,such a notice shall include-- 7i7 appropriate notice of bundled payments for the applicable condition for the episode of care involved2 and 7ii7 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 care4 7,d7 ,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 7i71 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 arrangement4 7#b7 ,provision of data by ,secretary 7,a7 ,claims data ,the ,secretary shall furnish to a group of providers of services and suppliers interested in submitting an application under subsection 7b77#b7 claims data under parts ,a and ,b1 including complete claims files1 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 application4 ,such claims data shall also be furnished to a qualified entity monthly during the agreement period described in paragraph 7#a77;,b7 of any approved application with respect to an applicable condition4 7,b7 ,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 care4 7d7 ,applicable conditions 7#a7 ,initial conditions ,in this section1 the term applicable condition means any of the following procedures furnished as part of inpatient hospital services3 7,a7 ,hip_/,knee joint replacement4 7,b7 ,lumbar spine fusion4 7,c7 ,coronary artery bypass graft4 7,d7 ,heart valve replacement4 7,e7 ,percutaneous coronary intervention with stent4 7,f7 ,colon resection4 7#b7 ,discretion to add conditions ,such term also includes such additional procedures or conditions as the ,secretary may select4 ,in selecting such procedures or conditions1 the ,secretary may take into consideration the factors described in section #ahff;,d7a77#b77;,b74 7e7 ,applicable services2 episode of care ,in this section3 7#a7 ,applicable services ,the term applicable services means the following items and services3 7,a7 ,acute care inpatient services4 7,b7 ,physicians' services delivered in and outside of an acute care hospital setting4 7,c7 ,outpatient hospital services4 7,d7 ,post-acute care services1 including home health services1 skilled nursing services1 inpatient rehabilitation services1 and inpatient hospital services furnished by a long-term care hospital4 7,e7 ,other services the ,secretary determines appropriate4 7#b7 ,episode of care 7,a7 ,in general ,subject to subparagraph 7,b71 the term episode of care means1 with respect to an applicable condition and an applicable beneficiary1 the period consisting of-- 7i7 the #c days prior to the admission of the applicable beneficiary to a hospital with respect to the applicable condition2 7ii7 the duration of the applicable beneficiary's initial inpatient stay in such hospital for the applicable condition2 and 7iii7 the #ij days following the discharge of the applicable beneficiary from such hospital4 7,b7 ,establishment of period by the secretary ,the ,secretary1 as appropriate1 may establish a period 7other than the period described in subparagraph 7,a77 for an episode of care under this section based on data analyses4 7#c7 ,discharging hospital ,the term discharging hospital means1 with respect to applicable services in an episode of care1 the hospital referred to in paragraph 7#b77;,a74 7f7 ,bundled payment development 7#a7 ,in general ,subject to the succeeding provisions of this subsection1 the ,secretary shall develop bundled payments for qualified entities4 ,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 condition1 including readmissions related to the applicable condition but excluding unrelated readmissions1 under either a fee-for-service model with shared savings and losses 7under subsection 7g77 or under a prospective payment model for advanced qualified entities 7under subsection 7h774 ,bundled payments shall be based on the spending targets computed under paragraph 7#b74 7#b7 ,computation of spending targets 7,a7 ,in general ,the ,secretary shall compute under this paragraph1 for each qualified entity for each applicable condition for an episode of care beginning in an agreement year 7beginning with #bjae7 that is attributable to a discharging hospital1 a spending target equal to the updated amount computed under subparagraph 7,c7 for that entity1 episode1 and year4 7,b7 ,initial weighted average calculation for discharging hospitals 7i7 ,in general ,using fee-for-service claims data from the base period 7as defined in subparagraph 7,d771 subject to clause 7ii71 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 7with respect to such hospital73 7,i7 #fj percent of the standardized spending per episode in the most recent year in the base period4 7,,ii7 #cj percent of the standardized spending per episode in the previous year4 7,,iii7 #aj percent of the standardized spending per episode in the second previous year4 7ii7 ,exclusion of outliers and standardization ,in calculating the amount of the base average spending target for an applicable condition under clause 7i7 for a discharging hospital1 the ,secretary shall-- 7,i7 exclude from the calculation payments for episodes of care for the applicable condition that exceed the #ieth percentile of all such spending for such episodes of care and applicable condition1 as estimated by the ,secretary1 based on the most recent data available2 and 7,,ii7 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 7such as area wage indices7 and provider type 7such as indirect medical education adjustments and disproportionate share hospital adjustments74 7,c7 ,trending the spending targets based on national growth rates to agreement year2 periodic rebasing for new agreement periods 7i7 ,in general ,the ,secretary shall update the base average spending targets for all discharging hospitals under subparagraph 7,b7 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 involved4 ,such update shall not vary by discharging hospital4 7ii7 ,periodic rebasing for new agreement periods ,at the start of each new agreement period1 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 conditions1 including providing for adjustments by provider location and provider type of the type described in subparagraph 7,b77ii77,,ii74 7,d7 ,base period defined ,in this paragraph1 except as provided in subparagraph 7,c77ii71 the term base period means the most recent #c-year period for which complete data are available to carry out this subsection4 7g7 ,fee-for-,service bundled payment model with shared savings and shared losses 7#a7 ,fee-for-service-based payment ,if the payment model under this subsection is selected by a qualified entity1 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 7referred to in this subsection as fee-for-service payments74 7#b7 ,shared savings and losses 7,a7 ,computation of each qualified entity's actual standardized average spending per episode of care ,in applying this subsection1 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 year1 the ,secretary shall exclude outlier episodes of care described in subsection 7f77#b77;,b77ii77,i71 as estimated by the ,secretary1 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 7f77#b77;,b77ii77,,ii74 ,for the purpose of identifying outlier episodes of care for each applicable condition1 the percentile ranking of each episode of care and applicable condition and the #ieth percentile shall be based on payments standardized by adjustments for provider location and provider type of the type described in subsection 7f77#b77;,b77ii77,,ii74 7,b7 ,computation of gross shared savings and shared losses for each applicable condition for each discharging hospital ,for purposes of applying subparagraph 7,c71 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 hospital1 as calculated under subparagraph 7,a71 are-- 7i7 less than the applicable spending target under subsection 7f77#b77;,c7 for such condition1 year1 and hospital1 there shall be a gross shared savings for such applicable condition1 year1 and hospital equal to #fj percent of the difference between such actual average payments and the spending target for such condition1 year1 and hospital2 or 7ii7 greater than such applicable spending target1 there shall be a gross shared loss for such applicable condition1 year1 and hospital equal to #fj percent of such difference4 7,c7 ,retrospective reconciliation 7i7 ,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 entity1 for purposes of applying clauses 7ii7 and 7iii71 the ,secretary shall aggregate the gross shared savings and the gross shared losses under subparagraph 7,b7 of such entity for the year for all applicable conditions and for all discharging hospitals4 7ii7 ,payment to entity of net savings ,subject to clause 7iv7 and subsection 7j77#c7 7relating to quality performance thresholds71 if such aggregate gross shared savings exceeds such aggregate gross shared losses for a qualified entity for an agreement year1 the ,secretary shall pay to the qualified entity a lump sum amount equal to such excess for such year4 7iii7 ,collection from entity of net losses ,subject to clause 7iv71 if such aggregate gross shared losses exceeds such aggregate gross shared savings for a qualified entity for an agreement year1 the qualified entity shall pay to the ,secretary 7and the ,secretary shall collect from the entity7 a lump sum amount equal to such excess for such year4 7iv7 ,cap on payments ,in no case shall the payment under clause 7ii7 or 7iii7 with respect to a qualified entity for an agreement year exceed #aj percent of the aggregate spending target for that qualified entity for all applicable conditions and all discharging hospitals for that year4 7h7 ,prospective bundled payment model for advanced qualified entities 7#a7 ,in general ,subject to approval by the ,secretary1 if the payment model under this subsection is selected1 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 episode1 year1 and hospital under subsection 7f77#b7 and the provisions of subsection 7g7 do not apply4 ,such spending target shall be adjusted1 in the same manner described in subsection 7g77#b77;,b71 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 7f77#b77;,b77ii77,,ii74 7#b7 ,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 #ahii4 7#c7 ,relationship to ,,bpci ,the ,secretary may not terminate the ,bundled ,payments for ,care ,improvement initiative conducted pursuant to section #aaae;,a until the prospective bundled payment model is implemented under this subsection4 7i7 ,quality and efficiency arrangements 7#a7 ,in general ,subject to subsection 7c77#a77;,d7 7relating to application requirements for notice of quality and efficiency arrangements and their structure7 and subsection 7j77#c7 7relating to minimum quality performance thresholds71 qualified entities participating in either the fee-for-service bundled payment model under subsection 7g7 or the prospective bundled payment model under subsection 7h7 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 title4 7#b7 ,types of arrangements ,the arrangements under paragraph 7#a7 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 7or internal saving1 as the case may be7 realized under this section to qualifying providers and suppliers4 7j7 ,quality measures 7#a7 ,selection2 development 7,a7 ,selection ,for each applicable condition1 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 section4 ,in selecting quality measures1 to the extent appropriate and practicable1 the ,secretary shall choose measures that-- 7i7 are endorsed and validated by the entity with a contract under section #ahij2 7ii7 pertain to the ,national ,quality ,strategy's six priorities2 7iii7 are used by the ,secretary under other provisions of this title2 and 7iv7 minimize the incremental data extraction and reporting burden on providers and suppliers4 7,b7 ,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 care4 ,such measures shall be electronically specified for submittal through the use of qualified electronic health records 7as defined in section #cjjj7ac7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;jj7#ac7774 7#b7 ,reporting on quality measures 7,a7 ,in general ,a qualified entity shall submit data to the ,secretary on quality measures selected under paragraph 7#a7 for each agreement year in a form and manner specified by the ,secretary consistent with the succeeding provisions of this paragraph4 7,b7 ,submission of data through electronic health record ,to the extent practicable1 such data shall be submitted through the use of a qualified electronic health record 7as defined in section #cjjj7ac7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;jj7#ac7774 7,c7 ,submission of data used in other programs ,insofar as quality measures established under paragraph 7#a7 are the same as those measures used by the ,secretary under other provisions of this title1 such as those selected under section #ahhf7;b77#c77;,b77viii71 the ,secretary shall use existing processes for the submission of data for such measures under this paragraph4 7#c7 ,quality performance thresholds 7,a7 ,establishment ,for each applicable condition1 the ,secretary shall establish minimum quality performance thresholds for the measures established under paragraph 7#a74 ,in the case of a quality and efficiency arrangement1 such performance thresholds shall be developed using the quality measures identified by the qualified entity in its application under subsection 7c77#a77;,d7 if approved by the ,secretary4 7,b7 ,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 7,a7 for an agreement year-- 7i7 no payment may be made to the entity under subsection 7g77#b77;,c77ii7 with respect to that year2 and 7ii7 the entity may not implement any quality and efficiency arrangement under subsection 7i7 for that year4 7k7 ,waivers 7#a7 ,in general ,the ,secretary shall waive such provisions of this title and title ,,xi as may be necessary to carry out the program1 including the following3 7,a7 ,with respect to authorizing quality and efficiency arrangements between qualified entities and providers of services and suppliers1 section #ahgg7;a7 7relating to physician self-referral71 paragraphs 7#a7 and 7#b7 of sections #aabh;,a7b7 7relating to the gainsharing civil money penalties71 and paragraphs 7#a7 and 7#b7 of section #aabh;,b7b7 7relating to the anti-kickback statute74 7,b7 ,section #aabh;,a7a77#e7 of the ,act 7relating to the inducement civil money penalties74 7,c7 ,section #ahfa7;i7 7relating to the #c-;day acute hospitalization prerequisite before eligibility for post-hospital extended care services74 7,d7 ,with respect to home health services-- 7i7 sections #ahad7;a77#b77;,c7 and #ahce7;a77#b77;,a7 7relating to the requirement that an individual be confined to home in order to be eligible for benefits for home health services72 7ii7 limitations on the amount1 frequency1 and duration on home health services2 and 7iii7 prohibitions of free preoperative home safety assessments by home health agencies for patients scheduled to undergo surgery 7such as under ,advisory ,opinion ,no4 #jf-ja of the ,inspector ,general of the ,department of ,health and ,human ,services74 7#b7 ,authority to modify waivers under certain circumstances 7,a7 ,in general ,in the case of a qualified entity with respect to which one or more waivers under paragraph 7#a7 is in effect1 if upon a review of the performance or an audit of the entity the ,secretary finds a pattern of deficiencies or harm to applicable beneficiaries1 the ,secretary may modify or revoke any such waiver at any time as applied to that qualified entity4 7,b7 ,termination of certain waivers in the case of excess shared losses 7i7 ,in general ,subject to the process described in clause 7ii71 in the case of a qualified entity that has selected the payment model under subsection 7g7 and has gross shared losses exceeding the cap under subsection 7g77#b77;,c77iv7 with respect to an applicable condition1 the ,secretary shall terminate waivers described in paragraphs 7#a77;,c7 and 7#a77;,d7 with respect to such qualified entity and applicable condition4 7ii7 ,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 7i7 not later than #f months before the proposed effective date of the termination4 7l7 ,independent evaluation and reports on program 7#a7 ,independent evaluation ,the ,secretary shall conduct an independent evaluation of the impact of providing bundled payments to qualified entities under this section4 ,such evaluation shall include an examination of the extent to which the bundling of payments this section have resulted in-- 7,a7 improved health outcomes2 7,b7 improved access to care for applicable beneficiaries2 7,c7 reduced spending under this title2 and 7,d7 improvement in performance on quality measures selected under subsection 7j77#a77;,a74 7#b7 ,reports 7,a7 ,interim report ,not later than ,march #a1 #bjah1 the ,secretary shall submit to ,congress a report on the initial results of the independent evaluation conducted under paragraph 7#a74 7,b7 ,final report ,not later than ,march #a1 #bjbj1 the ,secretary shall submit to ,congress a report on the final results of the independent evaluation conducted under paragraph 7#a7 and may include recommendations for the expansion of bundled payment methodologies and applicable conditions under this section as the ,secretary determines to be appropriate4 4