,,ii #aahth ,,congress #b;d ,session ,s4 #dcch ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,may #ae1 #bjbd,mr4 ,whitehouse 7for himself and ,mr4 ,cassidy7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to provide for the establishment of hybrid primary care payments under the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,pay ,p,c,ps ,act of #bjbd4 #b4 ,findings ,congress makes the following findings3 7#a7 ,transformation of primary care practices serves as an essential foundation for improving health and life outcomes for ,medicare beneficiaries1 particularly for those with multiple chronic conditions and complex needs1 mental health challenges1 or living in rural and other socioeconomically challenged communities4 7#b7 ,research has shown that #be percent or more of primary care activities are not recognized for payment under most fee schedules1 including the ,medicare physician fee schedule1 largely because these activities reflect a wide range of high frequency1 brief activities that cannot efficiently be paid fee-for-service and because the billing costs for submitting claims for such services would usually exceed the value of payment4 7#c7 ,fee-for-service is ill-suited to support many elements of practice transformation to produce effective primary care1 such as developing and maintaining multi-disciplinary team-based care strategies that leverage clinicians such as nurse practitioners1 physician assistants1 nutritionists1 and pharmacists1 and coordinating care with other clinicians and social service providers4 7#d7 ,research has shown that primary care represents a much smaller percentage of total health care spending by payers1 regardless of type of insurance coverage1 in the ,united ,states than in other wealthy nations1 and that higher percentage of total spending that is devoted to primary care services is associated with lower overall health care spending1 and in the ,medicare ,shared ,savings ,program1 with higher savings performance by accountable care organizations led by physician groups4 7#e7 ,a composite1 prospective payment would provide primary care practices with more predictable and flexible revenues to support such elements of effective primary care and help appropriately value services and activities performed by primary care providers and critical services not currently paid for4 7#f7 ,payments for some physician services under the ,medicare program1 including many that produce substantial spending under the ,medicare program1 have major distortions4 7#g7 ,determination of payments for physician services under the ,medicare program currently begins with subjective survey-based estimates of clinician time and effort per discrete service4 ,this approach to valuing physician services is inconsistent with the comprehensive and continuous nature of primary care4 7#h7 ,studies have found that payment levels in the ,medicare physician fee schedule reflect estimates of clinician time per service for a variety of services that are particularly inaccurate4 7#i7 ,the extreme complexity of having more than #h1jjj billing codes in the ,medicare physician fee schedule risks inaccuracy in estimations of relative values for closely related procedures and obscures distortions in pricing that grow over time for specific services4 #c4 ,establishing hybrid primary care payment in medicare 7a7 ,establishment ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 may establish within the ,medicare physician fee schedule established under section #ahdh7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;b771 hybrid payments only to be available to primary care providers1 as defined in the shared savings program under section #ahii of such ,act 7#db ,u4,s4,c4 #acie;jjj74 7b7 ,hybrid payments 7#a7 ,in general ,such hybrid payments may be comprised of the sum of-- 7,a7 prospective1 per-member-per-month payments2 and 7,b7 fee-for-service payments4 7#b7 ,determination of amount of prospective1 per-member-per-month payment 7,a7 ,in general ,subject to the preceding provisions of this subsection1 the total prospective1 per-member-per-month payment-- 7i7 may represent between #dj and #gj percent of expected annual total allowed charges derived from the ,medicare physician fee schedule for primary care providers of services and suppliers2 7ii7 should be at least actuarially equivalent to the applicable physician fee schedule amounts for the services included within the total prospective1 per-member-per-month payment2 and 7iii7 should be calculated based on historic ,medicare payments for those services which would be included as part of the prospective1 per-member-per-month payment4 7,b7 ,application of certain factors ,the ,secretary may consider applying percentages different from those specified in subparagraph 7,a7 for different types of primary care providers based on factors such as historical fee-for-service revenue patterns or quality performance of the provider4 7,c7 ,risk adjustment ,the ,secretary may assess the need to risk adjust the prospective1 per-member-per-month payment and develop appropriate risk adjustment methodologies1 taking into consideration only those factors that predict levels of primary care service utilization4 ,risk adjustment methodologies may incorporate clinical diagnoses1 demographic factors1 and other relevant information such as social determinants of health4 7c7 ,categorization of services 7#a7 ,in general ,for such hybrid payments1 the ,secretary may create categories of different services that are wholly reimbursed under the ,medicare physician fee schedule1 but may not include services for which reimbursement occurs partly through other payment schedules under the ,medicare program4 7#b7 ,services included in prospective1 per-member-per-month payment ,the ,secretary may include the following types of services in the prospective1 per-member-per-month payment under this section3 7,a7 ,care management services4 7,b7 ,communications such as emails1 phone calls1 and patient portals with patients and their caregivers4 7,c7 ,behavioral health integration services4 7,d7 ,office-based evaluation and management visits1 regardless of modality1 for new and established patients4 7#c7 ,clarification regarding fee-for-service payment for other services ,for such hybrid payments1 the ,secretary may continue to pay through reduced fee-for-service payments for all other services not specified in paragraph 7#b7 under the ,medicare physician fee schedule1 including screenings1 preventive services1 annual wellness visits 7as defined in section #ahfa7;hhh7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7hhh7771 vaccinations1 and initial preventive physical examinations 7as defined in section #ahfa7ww7 of such ,act 7#db ,u4,s4,c4 #aciex7ww7774 7d7 ,identification of quality measures ,the ,secretary may identify quality measures with respect to primary care providers that receive hybrid payment under this section to safeguard health outcomes for ,medicare beneficiaries1 and reward high quality performance through mechanisms such as annual bonus payments4 ,quality measures may be identified using existing mechanisms such as those approved for use in the ,accountable ,care ,organization_/,patient-,centered ,medical ,home_/,primary ,care ,core ,set agreed to by members of the ,core ,quality ,measure ,collaborative4 ,measurement may address areas such as-- 7#a7 patient experience2 7#b7 clinical quality measures2 7#c7 service utilization1 including measures of rates of emergency department visits and hospitalizations2 and 7#d7 efficiency in referrals1 which may include measures of the comprehensiveness of services that the primary care provider furnishes4 7e7 ,attribution ,the ,secretary shall establish procedures under which a beneficiary is attributed to a primary care provider using historical claims data and the beneficiary affirms that the provider is their primary care provider4 7f7 ,exclusion from ,,mips ,section #ahdh7q77#a77;,c77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#a77;c77ii77 is amended-- 7#a7 in subclause 7,,ii71 by striking or at the end2 7#b7 in subclause 7,,iii71 by striking the period at the end and inserting 2 or2 and 7#c7 by adding at the end the following new subclause3 7,,iv7 is a primary care provider that receives hybrid payments pursuant to section #c of the ,pay ,p,c,ps ,act of #bjbd4 4 #d4 ,reducing beneficiary cost sharing for primary care services 7a7 ,in general ,notwithstanding any other provision of law1 the ,secretary of ,health and ,human ,services 7in this section referred to as the 8,secretary07 may reduce by #ej percent any beneficiary cost sharing otherwise applicable under part ,b of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq47 for primary care services that may be reimbursed through the newly established prospective1 per-member-per-month payment established under section #c1 provided that the beneficiary designates a primary care provider as their usual source of care and informs the ,secretary of who that provider is pursuant to the procedures established under section #c7;e74 7b7 ,report to ,congress ,not later than #ahj days after the date on which subsection 7a7 is first implemented1 and annually thereafter1 the ,secretary shall submit to ,congress a report on the implementation of such subsection1 including an analysis of-- 7#a7 whether the reduction of beneficiary cost-sharing under such subsection has impacted beneficiary utilization of primary care services that may be reimbursed through the newly established per-member-per-month payment2 and 7#b7 whether the ,secretary has observed any instances of fraud or abuse associated with the reduction of such cost-sharing1 and whether the ,secretary has taken steps to minimize any such fraud or abuse4 #e4 ,establishing a new technical advisory committee on relative value updates and revisions ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended by adding at the end the following new subparagraph3 7,p7 ,establishment of technical advisory committee on relative value updates and revisions 7i7 ,in general ,the ,secretary shall establish a technical advisory committee 7in this section referred to as the committee7 within the ,centers for ,medicare ,medicaid ,services to provide the ,secretary with technical input regarding the accurate determination of relative value units under this paragraph4 7ii7 ,membership 7,i7 ,in general ,the committee shall be composed of #ac members appointed by the ,secretary from among individuals-- 7aa7 reflecting diverse experiences in provider payment1 including providers billing the ,medicare program under this title1 providers providing care under the laws administered by the ,secretary of ,veterans ,affairs or the ,secretary of ,defense1 and providers in primary care or family medicine 7as defined for purposes of the shared savings program under section #ahii72 and 7bb7 with technical expertise in ,medicare payment policies4 7,,ii7 ,chair #a of the members appointed under subclause 7,i7 shall be a representative of personnel of the ,centers for ,medicare ,medicaid ,services1 and that member shall serve as chair of the committee4 7iii7 ,staff ,the committee shall be staffed by personnel of the ,centers for ,medicare ,medicaid ,services4 7iv7 ,duties ,the committee shall advise the ,secretary on an ongoing basis regarding the determination of relative value units under the physician fee schedule through duties such as the following3 7,i7 ,designing new valuation methodologies the ,secretary may use to determine the time and resource use by health professionals associated with furnishing services or other new approaches to determining relative resources for each ,,hcpcs code4 ,the committee may prioritize furnished services that are most common or represent the services with the highest allowed charges4 7,,ii7 ,advising on research and development relevant to the determination of relative value units for individual ,,hcpcs codes4 7,,iii7 ,providing recommendations with respect to changes in valuations of current ,,hcpcs codes based upon any newly developed valuation methodologies4 7,,iv7 ,evaluating whether existing ,,hcpcs codes within the same family of services should be collapsed to result in fewer payment codes4 7,v7 ,identifying opportunities for bundling or unbundling services for payment purposes4 7,,vi7 ,assessing the operational burden of new approaches on physicians and other suppliers and beneficiaries while also considering the vulnerabilities of new approaches on overt fraud and abuse4 7,,vii7 ,assessing the impacts of these new approaches and potential adoption on beneficiary access1 financial liabilities1 quality of care1 and health disparities4 7v7 ,funding 7,i7 ,implementation ,the ,secretary may provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 such amounts as are necessary to carry out this subsection 7other than research and development under clause 7iv77,,ii77 7not to exceed #e1jjj1jjj7 for each of fiscal years #bjbe through #bjbi4 ,any amounts transferred under the preceding sentence for a fiscal year shall remain available until expended4 7,,ii7 ,research and development ,the ,secretary may provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 such amounts as are necessary to carry out research and development under clause 7iv77,,ii7 7not to exceed #aj1jjj1jjj7 for each of fiscal years #bjbe through #bjbi4 ,any amounts transferred under the preceding sentence for a fiscal year shall remain available until expended4 7vi7 ,duration ,the ,commission shall terminate not later than the expiration of the #e-year period beginning on the date of its establishment4 4