,,ii #aafth ,,congress #ast ,session ,s4 #abjb ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,april #aa1 #bjai,mr4 ,markey 7for himself and ,mr4 ,portman7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide for a permanent ,independence at ,home medical practice program under the ,medicare program4 #a4 ,short title ,this ,act may be cited as the ,independence at ,home ,act of #bjai4 #b4 ,independence at home medical practice program 7a7 ,program ,title ,,xviii of the ,social ,security ,act is amended by inserting after section #ahff;,f the following new section3 #ahff;,g4 ,independence at home medical practice program 7a7 ,establishment 7#a7 ,in general ,not later than ,january #a1 #bjba1 the ,secretary shall establish and implement a national independence at home medical practice program 7in this section referred to as the ,program7 that utilizes primary care teams that-- 7,a7 are directed by physicians1 nurse practitioners1 or physician assistants2 and 7,b7 emphasize home-based care that is designed to reduce expenditures and improve health outcomes in the provision of items and services under this title to applicable beneficiaries4 7#b7 ,goals ,under the ,program1 an independence at home medical practice shall be accountable for providing comprehensive1 coordinated1 continuous1 and accessible care to applicable beneficiaries at home and coordinating health care across all treatment settings1 resulting in-- 7,a7 reducing preventable hospitalizations2 7,b7 preventing hospital readmissions2 7,c7 reducing emergency room visits2 7,d7 improving health outcomes commensurate with each applicable beneficiary's stage of chronic illness2 7,e7 improving the efficiency of care1 such as by reducing duplicative diagnostic and laboratory tests2 7,f7 reducing the cost of items and services covered under this title2 and 7,g7 achieving applicable beneficiary and family caregiver satisfaction4 7b7 ,independence at home medical practice 7#a7 ,independence at home medical practice defined ,in this section3 7,a7 ,in general ,the term independence at home medical practice means a legal entity that meets each of the following requirements3 7i7 ,the entity is comprised of an individual physician1 nurse practitioner1 or physician assistant or group of such practitioners that furnishes care as part of a team that may include physicians1 nurse practitioners1 nurses1 physician assistants1 pharmacists1 licensed mental health practitioners1 social workers1 and other health and social services staff1 as appropriate4 7ii7 ,the entity is organized1 at least in part1 for the purpose of furnishing physicians' services4 7iii7 ,the entity-- 7,i7 has experience in furnishing home-based primary care services to applicable beneficiaries1 as determined appropriate by the ,secretary2 7,,ii7 makes in-home visits2 and 7,,iii7 is available #bd hours per day1 seven days per week1 to carry out plans of care that are tailored to an applicable beneficiary's chronic conditions and designed to achieve the goals described in subparagraphs 7,a7 through 7,g7 of subsection 7a77#b74 7iv7 ,the entity enters into an agreement with the ,secretary4 7v7 ,the entity furnishes services to at least #bjj applicable beneficiaries during each year covered under the agreement unless the ,secretary determines that a lower minimum number of applicable beneficiaries is necessary for the goals of the ,program to be achieved4 7vi7 ,the entity uses certified electronic health record technology and may use remote monitoring1 mobile diagnostic technology1 telehealth1 and other communications-based technology services1 as determined appropriate by the ,secretary4 7vii7 ,the entity meets such other criteria as the ,secretary determines to be appropriate to participate in the ,program4 7,b7 ,physician ,the term physician means a physician described in section #ahfa7r77#a7 who has the medical training or experience to fulfill the physician's role described in subparagraph 7,a77i74 7#b7 ,inclusion of affiliated providers and practitioners ,nothing in this subsection shall prevent an independence at home medical practice from including providers of services1 practitioners described in section #ahdb7;b77#ah77;,c71 or other practitioners1 including pharmacists1 in an arrangement with the practice to share in any savings under the ,program4 7c7 ,quality measures and performance standards 7#a7 ,quality measures 7,a7 ,in general ,the ,secretary shall solicit stakeholder input and1 taking into consideration such input1 determine appropriate quality measures to assess the quality of care furnished by independence at home medical practices4 ,to the extent possible1 such measures shall include outcome measures and experience of care measures4 7,b7 ,reporting requirements ,under the ,program1 an independence at home medical practice shall submit data in a form and manner and at a frequency specified by the ,secretary4 7#b7 ,quality performance standards ,the ,secretary shall establish quality performance standards that independence at home medical practices must meet in order to be eligible to receive incentive payments under subsection 7d77#b74 7#c7 ,data ,sharing ,not less frequently than on a quarterly basis1 the ,secretary shall provide independence at home medical practices with regular practice-level feedback reports on cost and utilization data in a clear and actionable manner4 ,these reports shall include1 to the extent practicable1 information on fee-for-service cost and utilization1 as well as beneficiary-level lists of emergency department visits1 hospitalizations1 hierarchical condition category risk scores1 quality performance data1 claims line feed1 and other high-cost services used in the previous quarter1 together with other data that may be useful for practices1 as determined by the ,secretary4 7d7 ,incentive payment methodology 7#a7 ,establishment of target spending level ,the ,secretary shall establish an estimated annual spending target based on the amount the ,secretary estimates would have been spent in the absence of the ,program1 for items and services covered under parts ,a and ,b furnished to applicable beneficiaries or comparable beneficiaries1 as determined by the ,secretary1 for each independence at home medical practice under this section4 ,such spending targets shall be determined on a per capita basis4 ,such spending targets shall include a risk corridor that takes into account normal variation in expenditures for items and services covered under parts ,a and ,b furnished to such beneficiaries with the size of the corridor being related to the number of applicable beneficiaries furnished services by each independence at home medical practice4 ,the spending targets may also be adjusted for applicable beneficiary risk characteristics1 factors relevant to characterize random variation among practices1 and other factors as the ,secretary determines appropriate4 7#b7 ,incentive payments ,subject to meeting the quality performance standards under subsection 7c77#b71 an independence at home medical practice is eligible to receive an incentive payment under the ,program if actual expenditures for a year for the applicable beneficiaries who are attributed to the practice are less than the estimated spending target established under paragraph 7#a7 for such year4 ,an incentive payment for such year shall be equal to a portion 7as determined by the ,secretary but in no case greater than #hj percent7 of the amount by which actual expenditures 7including incentive payments under this paragraph7 for applicable beneficiaries under parts ,a and ,b for such year are estimated to be less than #e percent less than the estimated spending target for such year1 as determined under paragraph 7#a74 7e7 ,applicable beneficiary 7#a7 ,in general ,in this section1 the term applicable beneficiary1 with respect to an independence at home medical practice1 is an individual who is attributed to such practice as a newly-assigned beneficiary or a continuously-assigned beneficiary 7as such terms are defined in paragraphs 7#b7 and 7#c71 respectively74 7#b7 ,newly-assigned beneficiary defined ,for purposes of paragraph 7#a71 the term newly-assigned beneficiary means an individual whom the independence at home medical practice has determined-- 7,a7 is entitled to benefits under part ,a and enrolled for benefits under part ,b2 7,b7 is not-- 7i7 enrolled in a ,medicare ,advantage plan under part ,c or a ,,pace program under section #ahid2 7ii7 attributed under-- 7,i7 another shared savings program1 under this title1 such as under section #ahii2 or 7,,ii7 a model tested or expanded under section #aaae;,a that involves shared savings under this title1 or any other demonstration that involves such shared savings2 or 7iii7 determined to have end stage renal disease as provided in section #bbf;,a or receiving dialysis at home2 7,c7 has two or more chronic illnesses1 as determined by the ,secretary1 such as congestive heart failure1 diabetes1 chronic obstructive pulmonary disease1 ischemic heart disease1 stroke1 ,alzheimer's ,disease and neurodegenerative diseases1 other dementias designated by the ,secretary1 and other diseases and conditions which result in high costs under this title2 7,d7 subject to paragraph 7#d71 during the #ab-month period immediately preceding the individual's attribution to an independence at home medical practice-- 7i7 had a nonelective hospital admission2 and 7ii7 received-- 7,i7 skilled nursing care or rehabilitation services in a skilled nursing facility paid under section #ahhh7;e72 7,,ii7 rehabilitation services in an inpatient rehabilitation facility2 or 7,,iii7 part-time or intermittent nursing care 7as described in section #ahfa7m77#a77 through a home health agency or physical or occupational therapy or speech-language pathology services 7as described in section #ahfa7m77#b77 through a home health agency2 7,e7 has not been assigned to an independence at home medical practice in a previous participation year during an agreement period2 and 7,f7 meets such other criteria as the ,secretary determines appropriate4 7#c7 ,continuously-assigned beneficiary defined ,for purposes of paragraph 7#a71 the term continuously-assigned beneficiary means an individual whom the independence at home medical practice has determined-- 7,a7 meets the criteria described in subparagraphs 7,a7 through 7,c7 and subparagraph 7,f7 of paragraph 7#b72 and 7,b7 has two or more functional dependencies requiring the assistance of another person 7such as bathing1 dressing1 toileting1 walking1 or feeding74 7#d7 ,waiver of certain requirements when beneficiary changes plans ,the requirements under paragraph 7#b77;,d7 shall not apply when an individual is attributed to an independence at home medical practice under this section subsequent to the first time an individual is attributed to such a practice under this section4 7#e7 ,patient election to participate ,the ,secretary shall adopt an appropriate method to determine that applicable beneficiaries have agreed to enroll in an independence at home medical practice4 ,enrollment in an independence at home medical practice shall be voluntary4 7#f7 ,beneficiary access to services ,nothing in this section shall be construed as-- 7,a7 encouraging physicians1 nurse practitioners1 physician assistants1 or other team members to limit applicable beneficiary access to services covered under this title2 or 7,b7 requiring applicable beneficiaries to relinquish access to any benefit under this title as a condition of receiving services from an independence at home medical practice4 7f7 ,agreements 7#a7 ,in general ,subject to paragraph 7#b71 an agreement with an independence at home medical practice under the ,program shall be for a period determined appropriate by the ,secretary but in no case less than #c years4 7#b7 ,renewals ,subject to subsection 7j71 the ,secretary may renew an agreement with an independence at home medical practice under the ,program4 7g7 ,permitting practices ,to furnish supplemental benefits at own expense ,under the ,program1 independence at home medical practices may furnish applicable beneficiaries with items and services for which payment is not made under parts ,a and ,b1 as determined by the ,secretary4 ,no payment for such items and services shall be made under this title4 7h7 ,waiver authority 7#a7 ,in general ,subject to paragraph 7#b71 the ,secretary may waive such provisions of this title and title ,,xi as the ,secretary determines necessary in order to implement the ,program4 7#b7 ,limitation ,the ,secretary may only waive the collection of coinsurance that is payable by individuals under section #ahcc7;a77#a7 if the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services certifies that such a waiver would reduce 7or would not result in any increase in7 net program spending under this title4 7i7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to this section4 7j7 ,termination and re-,entry 7#a7 ,mandatory termination ,the ,secretary shall terminate an agreement with an independence at home medical practice if-- 7,a7 the ,secretary determines that the practice did not achieve savings for the third of #c consecutive years under the ,program2 or 7,b7 such practice fails to meet at least a minimum number of quality performance standards established under subsection 7c77#b7 during any year of the agreement period4 7#b7 ,permissive termination ,the ,secretary may terminate an agreement with an independence at home medical practice for such other reasons determined appropriate by the ,secretary4 7#c7 ,re-entry ,in the case where an independence at home medical practice voluntarily elects to exit the ,program during the demonstration phase under section #ahff;,e or the transition under subsection 7k77#a71 the ,secretary may re-enter into an agreement with such practice under this section if the ,secretary determines that the practice would have otherwise met the requirements to remain in the ,program under this section4 7k7 ,practice transitions 7#a7 ,practice making transition from demonstration ,the ,secretary shall provide for an appropriate transition from the demonstration program under section #ahff;,e to the ,program under this section4 ,such transition shall include a process that ensures that independence at home medical practices and applicable beneficiaries participating in such demonstration are automatically included in the ,program under this section at the time of the implementation of the ,program4 7#b7 ,practices ,newly ,enrolling in the ,program ,the ,secretary shall also provide for the participation of new medical practices in the ,program under this section1 defined as practices that have not participated in the demonstration program under section #ahff;,e previously1 as well as practices with previous experience participating in such demonstration program but who may not be participating at the time of the implementation of the ,program under this section4 7#c7 ,special rule for individuals participating in similar programs ,in the case of an individual who has regularly received home-based primary care services1 as determined by the ,secretary1 during the #ab-month period immediately preceding the individual's attribution to an independence at home medical practice for the first time1 the ,secretary may1 as determined appropriate1 apply clause 7i7 of subsection 7e77#b77;,d7 7relating to a prior nonelective hospital admission7 by increasing the #ab-month period described in such subsection as it relates to such clause to a period of up to #bd months4 7l7 ,limitation on review ,there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise of-- 7#a7 the attribution of applicable beneficiaries to an independence at home medical practice2 7#b7 the determination of the estimated annual spending target for an independence at home medical practice under subsection 7d77#a72 7#c7 the assessment of the quality of care furnished by an independence at home medical practice and the establishment of quality performance standards under subsection 7c72 7#d7 the determination of whether an independence at home medical practice is eligible for incentive payments under subsection 7d77#b71 and the amount of such incentive payments2 and 7#e7 the termination of an independence at home medical practice under subsection 7j74 4 7b7 ,,gao study and report 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study on the independence at home medical practice program under section #ahff;,g of the ,social ,security ,act1 as added by subsection 7a74 ,such study shall include an analysis of-- 7,a7 whether independence at home medical practices are meeting the requirements under such program2 7,b7 whether such program is reducing expenditures under this title2 7,c7 the care that beneficiaries are receiving under such program2 and 7,d7 other areas determined appropriate by the ,comptroller ,general4 7#b7 ,report ,not later than #e years after the date of the implementation of such independence at home medical practice program1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on the study conducted under paragraph 7#a71 together with such recommendations as the ,comptroller ,general determines to be appropriate4 7c7 ,revisions to existing demonstration program 7#a7 ,extension through the implementation of the new program ,section #ahff;,e7e77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc-#e7;e77#a77 is amended by inserting plus the period beginning at the end of such #g-year period and ending on the date of the implementation of the ,program under section #ahff;,g after #g-year period4 7#b7 ,permitting existing practices to see more beneficiaries ,section #ahff;,e7e77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc-#e7;e77#a77 is amended-- 7,a7 in the second sentence1 by inserting the following before the period3 plus for the period beginning at the end of such seventh year and ending on the date of the implementation of the ,program under section #ahff;,g2 and 7,b7 by adding at the end the following new sentence3 ,beginning on the date of the enactment of this sentence1 the limitation on the number of beneficiaries that may participate in the demonstration program pursuant to the first sentence shall not apply with respect to independence at home medical practices participating in the demonstration program as of such date of enactment44