,i #aaeth ,,congress #ast ,session ,h4 ,r4 #cghj ,,in ,,the ,,house ,,of ,,representatives ,september #ad1 #bjag,mr4 ,hudson 7for himself1 ,mr4 ,kennedy1 ,ms4 ,jenkins of ,kansas1 and ,mr4 ,kind7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 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 under the ,medicare program for conditions of participation1 reporting requirements1 and a quality program with respect to air ambulance services4 #a4 ,short title ,this ,act may be cited as the ,air ,ambulance ,quality and ,accountability ,act4 #b4 ,findings ,congress finds as follows3 7#a7 ,patient access to high quality and essential air ambulance services can mean the difference between life and death and quality of survival for patients4 7#b7 ,medicare should assure beneficiaries of high quality air ambulance services and patient safety4 7#c7 ,medicare has no requirements related to quality measurement and reporting1 adherence to relevant standards as a condition of participating in ,medicare1 and robust cost reporting4 7#d7 ,medicare currently reimburses all suppliers and providers of air ambulance services the same1 regardless of clinical capability or investment in aviation safety that exceeds requirements of the ,federal ,aviation ,administration4 7#e7 ,a subset of patients requiring air transport are so critically ill or injured as to require an advanced level of clinical capability to address unstable and life-threatening medical conditions that may develop or deteriorate during transport4 ,the costs of providing care to such patients should be reported to enable the ,congress to assess the sufficiency and appropriateness of reimbursement for these most vulnerable patients4 7#f7 ,there remain many geographic areas of the nation with limited access to air ambulance services due to low volume of patients in geographically isolated and very rural areas4 7#g7 ,medicare and ,medicaid payment should be adequate to protect and promote access to air ambulance services that are capable of meeting the clinical needs of the most critically ill and injured patients1 allow necessary investments in transport safety1 and enable transport to the appropriate medical center to receive them4 7#h7 ,an evaluation of ,medicare payment policy is warranted to assess and secure recommendations about payment adequacy for air ambulance providers and suppliers and the realistic costs of providing this life-saving transport services4 7#i7 ,mandatory cost reporting is necessary for air ambulance services providers receiving ,medicare reimbursement to ensure fair and adequate reimbursement and allow appropriate access4 7#aj7 ,such reporting should also capture essential data with regard to access1 cost1 utilization1 quality and variation of such services to enable more specifically narrowly tailoring payments commensurate with higher costs actually incurred such as those treating the most critically ill and injured1 investing in higher cost aviation safety and airframes1 and serving patients in the most geographically isolated areas4 #c4 ,standards for air ambulance providers and suppliers 7a7 ,minimum standards ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77 is amended by adding at the end the following new paragraph3 7#ag7 ,minimum standards for air ambulance providers and suppliers 7,a7 ,in general ,not later than #b years after the date of the enactment of this paragraph1 the ,secretary shall1 in consultation with relevant stakeholders1 establish minimum standards which air ambulance suppliers and providers would be required to satisfy as a condition of participation under this title4 7,b7 ,air ambulance minimum standards ,in establishing the minimum standards under subparagraph 7,a71 the ,secretary shall include at least minimum standards with respect to the following3 7i7 ,scope of practice1 training and clinical capability of medical personnel relevant to medical condition of patients transported4 7ii7 ,medical equipment 7such as patient monitoring1 respiratory and hemodynamic and other relevant patient support equipment71 devices1 technology and formularies4 7iii7 ,vehicle attributes to support needed care1 including configuration and conditions of medical environment1 electrical supply in air ambulance and other related equipment4 7iv7 ,documentation standards1 such as patient care records1 timeline of care and transport1 history of present illness and assessments1 and documentation specific to diagnostic and therapeutic procedures4 7v7 ,medical direction and physician medical oversight1 such as credentials of such physicians4 7vi7 ,reporting of always events1 such as care coordination and transition1 pain management1 preventing ventilator acquired pneumonia or invasive line or wound infections4 7vii7 ,reporting of never events1 such as loss of oxygen1 delivery of a baby during transport1 patient death or disability due to vehicle failure or crash1 transport to unintended destination1 dropping a patient or allowing a fall during movement of patient1 failure to communicate time of arrival1 hypoglycemia1 and medication errors4 7viii7 ,patient safety and infection control4 7ix7 ,physician directed clinical quality management and clinical performance improvement programs including quality assurance1 utilization review1 outcomes1 proficiency measures and patient safety4 7x7 ,standards relevant to particular populations1 such as those on balloon pumps or ,,ecmo4 7,c7 ,deemed status ,air ambulance providers and suppliers that are accredited by an accreditation organization approved by the ,secretary as having standards that meet or exceed the ,secretary's standards for such providers shall be deemed to be in compliance with the minimum requirements required pursuant to this paragraph4 4 #d4 ,air ambulance cost reporting program ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l771 as amended by section #c1 is further amended by adding at the end the following new paragraph3 7#ah7 ,air ambulance cost reporting program 7,a7 ,in general ,for the first year beginning at least #ab months after the date of the enactment of this paragraph and each subsequent year1 an air ambulance provider or supplier of air ambulance services shall submit to the ,secretary 7in a form and manner and at such time as specified by the ,secretary7 data described in subparagraph 7,b7 for the reporting period 7as specified by the ,secretary7 for such year4 7,b7 ,cost data ,for purposes of reporting data under this for air ambulance services furnished with respect to a year1 the data described in this subparagraph are cost data specified by the ,secretary relating to the following3 7i7 ,geographic location factors1 including mileage and number of providers in the service area4 7ii7 ,capital and operational costs1 such as the type of aircraft1 including fixed wing aircraft1 rotary wing aircraft--single or twin engine1 instrumented flight or visual flight4 7iii7 ,maintenance of aircraft1 including avionics1 communications equipment1 fuel1 and general repairs4 7iv7 ,maintenance of equipment1 including specialty clinical equipment4 7v7 ,medical supplies4 7vi7 ,employee expenses1 including salaries and insurance 7life1 health1 and liability74 7vii7 ,building expenses1 including rent and maintenance4 7viii7 ,any other costs as specified by the ,secretary1 in consultation with the ,secretary of ,transportation1 as needed to be included under this subparagraph for purposes of informing the report and evaluation under section #f of the ,air ,ambulance ,quality and ,accountability ,act or for purposes of enabling ,congress to make appropriate determinations about payment under this section to air ambulance providers and suppliers4 ,the ,secretary1 in consultation with providers and suppliers of air ambulance services1 shall periodically update1 as determined necessary by the ,secretary1 the cost data specified pursuant to this subparagraph4 7,c7 ,suspension of payment for failure to report 7i7 ,in general ,with respect to air ambulance services furnished by a supplier or provider of air ambulance services during the second year beginning at least #ab months after the date of the enactment of this paragraph or any subsequent year1 in the case that the supplier or provider does not submit data to the ,secretary in accordance with subparagraph 7,a7 for the reporting period applicable to such year 7which shall be during the previous year71 the ,secretary shall suspend payments under the fee schedule under this subsection for air ambulance services furnished by such supplier or provider during such year until such supplier or provider submits such data in accordance with such subparagraph4 7ii7 ,treatment of new ,medicare suppliers and providers of air ambulance services ,in the case of a supplier or provider of air ambulance services that first becomes a ,medicare enrolled supplier or provider of air ambulance services during the reporting period applicable to a year with respect to which clause 7i7 applies 7and had not previously submitted claims under this title such as a person or entity or under a different billing number or tax identifier71 such supplier or provider shall not be subject to clause 7i7 until the subsequent year and with respect to data required to be submitted for the reporting period applicable to such subsequent year4 4 #e4 ,air ambulance quality reporting program ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l771 as amended by sections #c and #d1 is further amended by adding at the end the following new paragraph3 7#ai7 ,air ambulance quality reporting program 7,a7 ,payment based on performance 7i7 ,in general ,the ,secretary shall establish an air ambulance quality reporting and performance program under which-- 7,i7 with respect to air ambulance services furnished by a supplier or provider of air ambulance services during the first consequence year1 second consequence year1 or third consequence year1 in the case that the supplier or provider does not submit a report1 with respect to the performance period for such year1 in accordance with subparagraph 7,c71 after determining the percentage increase under paragraph 7#c77;,b71 and after application of paragraphs 7#c77;,c7 and 7#ah71 the ,secretary shall reduce such percentage increase for payments under the fee schedule under this subsection during such year by #b percentage points2 and 7,,ii7 with respect to air ambulance services furnished by a supplier or provider of air ambulance services during a consequence year after the third consequence year1 the ,secretary applies a percentage point adjustment to the percentage increase determined under paragraph 7#c77;,b71 after application of paragraphs 7#c77;,c7 and 7#ah71 in a manner that provides for differential payment to a supplier or provider of air ambulance services based upon the quality of care furnished 7as determined under subparagraph 7,b77 during a performance period with respect to such consequence year 7with such percentage point adjustment ranging from an increase of #e percentage points for such services furnished in a consequence year by such a provider or supplier with the highest demonstrated performance in the performance period for such year to a decrease of #e percentage points for such services furnished in the consequence year by such a provider or supplier with the lowest demonstrated performance for the performance period for such year74 7ii7 ,special rule ,the application of this subparagraph may result in such percentage increase being less than #j4j for a year1 and may result in payment rates under the fee schedule under this subsection for a year being less than such payment rates for the preceding year4 7iii7 ,noncumulative application ,any adjustment under this subparagraph shall apply only with respect to the year involved and the ,secretary shall not take into account such adjustment in computing the payment amount under the fee schedule under this subsection for a subsequent year4 7iv7 ,treatment of new ,medicare suppliers and providers of air ambulance services ,in the case of a supplier or provider of air ambulance services that first becomes a ,medicare enrolled supplier or provider of air ambulance services during the performance period for a consequence year 7and had not previously submitted claims under this title such as a person or entity or under a different billing number or tax identifier71 the adjustment under clause 7i7 shall not apply to such supplier or provider until the subsequent consequence year and performance period for such subsequent consequence year4 7,b7 ,determining performance 7i7 ,in general ,under the air ambulance quality reporting and performance program1 the performance of a provider or supplier of air ambulance services with respect to a performance period with respect to a consequence year after the third consequence year shall be determined as specified by the ,secretary based on data required under subparagraph 7,c7 to be submitted 7in a form and manner and at such time as specified by the ,secretary7 by the provider or supplier for such performance period for the consequence year4 7ii7 ,treatment of non-reporters ,under the air ambulance quality reporting and performance program1 for purposes of subparagraph 7,a71 any provider or supplier of air ambulance services who does not submit data required under subparagraph 7,c7 to submitted for a performance period with respect to a consequence year after the third consequence year1 shall be treated as if such provider or supplier had the lowest demonstrated performance for the performance period for such year4 7,c7 ,reporting 7i7 ,in general ,for purposes of this paragraph for years beginning with the first consequence year1 an air ambulance provider or supplier shall submit to the ,secretary a report1 with respect to the performance period for such year1 on-- 7,i7 the measures described in subparagraph 7,d77i72 7,,ii7 in the case of a consequence year before the fourth consequence year-- 7aa7 at least #b of the measures described in subparagraph 7,d77ii77,i72 and 7bb7 at least #b of the measures established under subparagraph 7,d77iii77,i72 and 7,,iii7 in the case of a consequence year beginning with the fourth consequence year-- 7aa7 at least #d of the measures described in subparagraph 7,d77ii77,,ii72 and 7bb7 at least #d of the measures established under subparagraph 7,d77iii77,,ii74 7ii7 ,availability of data ,the ,secretary shall establish procedures for making data submitted under clause 7i7 available to the public4 ,such procedures shall ensure that-- 7,i7 data submitted under clause 7i7 for the first consequence year shall not be made public2 and 7,,ii7 an air ambulance provider or supplier has the opportunity to review the data that is to be made public with respect to the air ambulance provider or supplier prior to such data being made public4 7,d7 ,measures ,in establishing the quality program under subparagraph 7,a71 the following shall apply3 7i7 ,over-triage ,the ,secretary shall provide for the application of a measure with respect to over-triage in mode of transportation4 7ii7 ,patient safety measures ,the ,secretary shall1 in consultation with providers and suppliers of air ambulance services1 establish-- 7,i7 with respect to a performance period with respect to a consequence year before the fourth consequence year1 at least #c patient safety measures for providers and suppliers of air ambulance services2 and 7,,ii7 with respect to a performance period with respect to a consequence year beginning with the fourth consequence year1 at least #f patient safety measures for providers and suppliers of air ambulance services4 7iii7 ,clinical quality measures ,the ,secretary shall1 in consultation with providers and suppliers of air ambulance services1 establish-- 7,i7 with respect to a performance period with respect to a consequence year before the fourth consequence year1 at least #c clinical quality measures for providers and suppliers of air ambulance services2 and 7,,ii7 with respect to a performance period with respect to a consequence year beginning with the fourth consequence year1 at least #f clinical quality measures for providers and suppliers of air ambulance services4 7iv7 ,updates ,the ,secretary1 in consultation with providers and suppliers of air ambulance services1 shall periodically update1 as determined necessary by the ,secretary1 the measures to be applied pursuant to this subparagraph4 7,e7 ,definitions ,for purposes of this paragraph3 7i7 ,the term consequence year means a year beginning with the #eth year starting at least #ab months after the date of the enactment of this paragraph4 ,the terms first consequence year1 second consequence year1 and third consequence year mean such #eth year starting at least #ab months after such date of enactment1 the #fth year starting at least #ab months after such date of enactment1 and the #gth year starting at least #ab months after such date of enactment1 respectively4 7ii7 ,the term performance period means1 with respect to a consequence year1 such period as specified by the ,secretary4 4 #f4 ,med,p,a,c study on access1 quality1 costs1 and reimbursement 7a7 ,evaluation ,not later than three years after ,december #ca of the first year to which paragraph 7#ah7 of section #ahcd7l7 of the ,social ,security ,act1 as added by section #d1 applies1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report containing an evaluation of the costs of air providers and suppliers4 ,such evaluation shall-- 7#a7 be derived from the cost and other data submitted under such paragraph 7#ah7 of such section #ahcd7l72 and 7#b7 differentiate as appropriate to recognize variation or higher costs related to-- 7,a7 aviation instrument flight control2 7,b7 provision of care to critically ill or injured patients2 7,c7 the provision of services in geographically isolated areas2 and 7,d7 the provision of care to uninsured individuals4 7b7 ,recommendations ,as part of the report submitted under subsection 7a71 the ,medicare ,payment ,advisory ,commission shall provide recommendations on whether changes should be made with regard to reimbursement of air ambulance providers and suppliers under title ,,xviii of the ,social ,security ,act based upon the data submitted under paragraph 7#ah7 of section #ahcd7l7 of the ,social ,security ,act1 as added by section #d1 taking into consideration variables affecting payment adequacy under such title for and its impact on ,medicare beneficiaries1 including-- 7#a7 whether payment under such title is sufficient to ensure access to air ambulance services or should be altered1 including whether payment should be higher for air ambulance providers and suppliers-- 7,a7 with higher levels of clinical capability to serve the most critically ill and injured patients2 and 7,b7 that utilize advanced and expense avionics such as ,instrument ,flight ,rules2 7#b7 whether uncompensated care borne by air ambulance providers and suppliers impedes access2 7#c7 the degree to which there is variation in the utilization of air ambulance services on a per capita and per transport basis1 including whether the undersupply or oversupply of helicopters or fixed wing aircraft in a geographic region affects access and the volume and adequacy of payments under such title with regard to such utilization2 7#d7 the degree to which membership programs are utilized by air ambulance providers and suppliers to sustain their operations1 and if revenue from membership programs is used to reduce their costs or provide capital funding1 and whether such programs are beneficial to ,medicare beneficiaries2 7#e7 the degree of subsidization that occurs from private insurers or hospitals sponsoring air ambulance providers or suppliers to cover inadequate payments under title ,,xviii or ,,xix of the ,social ,security ,act and enable reasonable profitability2 7#f7 the ratio of charges to ,medicare reimbursement and the impact on beneficiary cost sharing of cost1 utilization1 and variation in air ambulance services2 7#g7 appropriate financial or other incentives for the utilization of ground critical care transport where medically appropriate2 7#h7 the degree to which a quality reporting and performance program based upon patient safety measures and clinical quality measures should be used in determining a value based payment model for suppliers and providers of air ambulance service2 and 7#i7 any other information deemed relevant and appropriate by the ,medicare ,payment ,advisory ,commission for the purposes of providing such recommendations4