,,ii #aadth ,,congress #ast ,session ,s4 #acif ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,may #bj1 #bjae ,mr4 ,thune 7for himself and ,ms4 ,stabenow7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish a demonstration program requiring the utilization of ,value-,based ,insurance ,design in order to demonstrate that reducing the copayments or coinsurance charged to ,medicare beneficiaries for selected high-value prescription medications and clinical services can increase their utilization and ultimately improve clinical outcomes1 enhance beneficiary satisfaction1 and lower health care expenditures4 #a4 ,short title ,this ,act may be cited as the ,value-,based ,insurance ,design ,seniors ,copayment ,reduction ,act of #bjae4 #b4 ,findings ,congress makes the following findings3 7#a7 ,a growing body of evidence demonstrates that increases in patient-level financial barriers 7including deductibles1 copayments1 and coinsurance7 for high-value medical services 7such as prescription medications1 clinician visits1 diagnostic tests1 and procedures7 systematically reduces the use of such services4 ,savings attributable to cost-related1 decreased utilization of specific services may lead to an increase in total medical expenditures due to increased use of other related clinical services1 such as hospitalizations and emergency room visits4 7#b7 ,empirical research studies demonstrate that reductions in beneficiary out-of-pocket expenses for high-value prescription medications and clinical services can mitigate the adverse health and financial consequences attributable to cost-related decreased utilization of high-value services4 7#c7 ,financial barriers to prescription medications and clinical services that are deemed to be high-value should be reduced or eliminated to increase their use4 7#d7 ,value-,based ,insurance ,design is a methodology that adjusts patient out-of-pocket costs for prescription medications and clinical services according to the clinical value1 not exclusively the cost4 ,value-,based ,insurance ,design is based on the concept of clinical nuance that recognizes-- 7,a7 prescription medications and clinical services differ in the clinical benefit provided2 and 7,b7 the clinical benefit derived from a specific prescription medication or clinical service depends on the clinical situation1 the provider1 and where the care is delivered4 7#e7 ,the current one-size-fits-all copayment or coinsurance design for prescription medications and clinical services provided under the ,medicare program does not recognize the well-established value differences in health outcomes produced by various medical interventions4 7#f7 ,the establishment by ,medicare of copayment and coinsurance requirements using ,value-,based ,insurance ,design methodologies will improve patient-centered health outcomes1 enhance personal responsibility1 and afford a more efficient use of taxpayer dollars4 #c4 ,demonstration program 7a7 ,in general ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall establish a demonstration program to test ,value-,based ,insurance ,design methodologies in ,medicare ,advantage plans under part ,c of title ,,xviii of the ,social ,security ,act for beneficiaries with chronic clinical conditions4 7b7 ,demonstration program design 7#a7 ,in general ,the ,secretary shall select not less than #b ,medicare ,advantage plans to participate in the demonstration program under this section4 7#b7 ,requirements ,a ,medicare ,advantage plan selected to participate in the demonstration program under paragraph 7#a7 shall meet the following requirements3 7,a7 ,the plan offers a coordinated ,medicare ,part ,d drug benefit4 7,b7 ,the plan and the ,medicare ,advantage organization offering the plan meet such other criteria as the ,secretary determines appropriate4 7c7 ,expansion of demonstration program ,the ,secretary shall expand the demonstration program by issuing regulations to implement1 on a permanent basis1 the components of the demonstration program that are beneficial to ,medicare beneficiaries and the ,medicare program1 unless the report under subsection 7e7 or 7f77#c7 contains an evaluation that the demonstration program under this section-- 7#a7 increases ,medicare program expenditures for beneficiaries participating in the demonstration program2 or 7#b7 decreases the quality of health care services provided to ,medicare beneficiaries participating in the demonstration program4 7d7 ,value-,based ,insurance ,design methodology 7#a7 ,value-,based ,insurance ,design ,for purposes of this section1 ,value-,based ,insurance ,design is a methodology for identifying specific prescription medications and clinical services for which copayments or coinsurance should be reduced or eliminated due to the high-value and effectiveness of such medications and services for specific clinical conditions4 7#b7 ,reduction of copayments and coinsurance ,under the demonstration program1 a ,medicare ,advantage organization1 using ,value-,based ,insurance ,design methodologies1 shall identify each prescription medication and clinical service for which the amount of the copayment or coinsurance payable should be reduced or eliminated4 7#c7 ,reduction of copayments and coinsurance to encourage use of specific clinical services ,under the demonstration program1 the ,medicare ,advantage organization1 using ,value-,based ,insurance ,design1 may lower cost-sharing under the plan for the purpose of encouraging enrollees to use prescription medications and clinical services 7such as preventive care1 primary care1 specialty visits1 diagnostic tests1 procedures1 and durable medical equipment7 that such organization has identified as high-value for the management of specified clinical conditions in paragraph 7#e74 ,any such variation on copayment or coinsurance by a ,medicare ,advantage organization must occur on an annual basis and be evidence-based4 7#d7 ,reduction of copayments and coinsurance to encourage use of specific high-performing providers ,under the demonstration program1 the ,medicare ,advantage organization1 using ,value-,based ,insurance ,design1 may lower cost-sharing under the plan for the purpose of encouraging enrollees to use providers that such organization has identified as high-performing based on quality metrics4 ,any such variation on copayment or coinsurance by a ,medicare ,advantage organization must occur on an annual basis4 7#e7 ,specific clinical conditions ,in identifying clinical conditions for purposes of paragraph 7#c71 the ,medicare ,advantage organization shall1 at a minimum1 consider the services utilized across the spectrum of care in the management of the following clinical conditions3 7,a7 ,asthma4 7,b7 ,atrial fibrillation4 7,c7 ,deep venous thrombosis4 7,d7 ,cancer4 7,e7 ,chronic obstructive pulmonary disease4 7,f7 ,chronic renal failure_/,end stage renal disease4 7,g7 ,congestive heart failure4 7,h7 ,ischemic heart disease_/,myocardial infarction4 7,i7 ,depression4 7,j7 ,diabetes mellitus4 7,k7 ,hyperlipidemia4 7,l7 ,hypertension4 7,m7 ,osteoporosis4 7,n7 ,stroke4 7,o7 ,tobacco abuse disorder4 7#f7 ,prohibition of increases of copayments and coinsurance ,a ,medicare ,advantage plan selected to participate in the demonstration program under paragraph 7#a7 may not raise cost-sharing on any item or service to discourage its use4 7e7 ,report on implementation 7#a7 ,in general ,not later than #a year after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report on the implementation by the ,secretary of the demonstration program under this section4 7#b7 ,elements ,the report required by paragraph 7#a7 shall include the following3 7,a7 ,a statement setting forth each medication and clinical service identified pursuant to subsection 7d77#c74 7,b7 ,for each such medication or clinical service identified pursuant to subsection 7d77#c71 a statement of the amount of the copayment or coinsurance required to be paid for such service and the amount of the reduction from previous cost-sharing levels4 7,c7 ,for each such high-performing provider identified pursuant to subsection 7d77#d71 a statement of the amount of the copayment or coinsurance required to be paid for such clinician visit and the amount of the reduction from previous cost-sharing levels4 7f7 ,review and assessment of utilization of value-,based insurance design methodologies 7#a7 ,in general ,the ,secretary shall enter into a contract or agreement with an independent1 nonbiased entity having expertise in ,value-,based ,insurance ,design to review and assess the implementation of the demonstration program under this section4 ,the review and assessment shall include the following3 7,a7 ,an assessment of the utilization of ,value-,based ,insurance ,design methodologies referred to in subsection 7d74 7,b7 ,an analysis of whether reducing or eliminating the copayment or coinsurance for each medication and clinical service identified pursuant to subsection 7d77#c7 resulted in increased adherence to medication regimens1 increased service utilization1 improvement in quality metrics1 better health outcomes1 or enhanced beneficiary experience4 7,c7 ,an analysis of the cost-savings resulting from reducing or eliminating the copayment or coinsurance for each medication or clinical service so identified4 7,d7 ,an analysis of whether reducing or eliminating the copayment or coinsurance for each high-performing provider identified pursuant to subsection 7d77#d7 resulted in improvement in quality metrics1 better health outcomes1 or enhanced beneficiary experience4 7,e7 ,an analysis of the cost-savings resulting from reducing or eliminating the copayment or coinsurance for each high-performing provider so identified4 7,f7 ,such other matters as the ,secretary considers appropriate4 7#b7 ,report ,the contract or agreement entered into under paragraph 7#a7 shall require the entity concerned to submit to the ,secretary a report on the review and assessment conducted by the entity under that paragraph in time for the inclusion of the results of such report in the report required by paragraph 7#c74 7#c7 ,report to ,congress ,not later than #c years after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report on the review and assessment conducted under this subsection4 ,the report shall include the following3 7,a7 ,a description of the results of the review and assessment4 7,b7 ,such recommendations as the ,secretary considers appropriate for enhancing the utilization of the methodologies referred to in subsection 7d77#a7 so as to reduce copayments and coinsurance paid by ,medicare beneficiaries for high-value prescription medications and clinical services furnished under the ,medicare program and to otherwise improve the quality of health care provided under such ,medicare program4 7g7 ,waiver ,the ,secretary may waive such provisions of titles ,,xi and ,,xviii of the ,social ,security ,act as may be necessary to carry out the demonstration program under this section4 7h7 ,implementation funding ,for purposes of carrying out the demonstration program under this section1 the ,secretary shall provide for the transfer from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 and the ,federal ,supplementary ,insurance ,trust ,fund under section #ahda of the ,social ,security ,act 7#db ,u4,s4,c4 #aciet71 including the ,medicare ,prescription ,drug ,account in such ,trust ,fund1 in such proportion as determined appropriate by the ,secretary1 of such sums as may be necessary4