42 USC 1395cc-4 - National pilot program on payment bundling

U.S Code last checked for updates: May 02, 2024

§ 1395cc–4.

National pilot program on payment bundling

(a)

Implementation

(1)

In general

(2)

Definitions

In this section:

(A)

Applicable beneficiary

The term “applicable beneficiary” means an individual who—

(i)

is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B of such subchapter, but not enrolled under part C or a PACE program under section 1395eee of this title; and

(ii)

is admitted to a hospital for an applicable condition.

(B)

Applicable condition

The term “applicable condition” means 1 or more of 10 conditions selected by the Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors:

(i)

Whether the conditions selected include a mix of chronic and acute conditions.

(ii)

Whether the conditions selected include a mix of surgical and medical conditions.

(iii)

Whether a condition is one for which there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished while reducing total expenditures under this subchapter.

(iv)

Whether a condition has significant variation in—

(I)

the number of readmissions; and

(II)

the amount of expenditures for post-acute care spending under this subchapter.

(v)

Whether a condition is high-volume and has high post-acute care expenditures under this subchapter.

(vi)

Which conditions the Secretary determines are most amenable to bundling across the spectrum of care given practice patterns under this subchapter.

(C)

Applicable services

The term “applicable services” means the following:

(i)

Acute care inpatient services.

(ii)

Physicians’ services delivered in and outside of an acute care hospital setting.

(iii)

Outpatient hospital services, including emergency department services.

(iv)

Post-acute care services, including home health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a long-term care hospital.

(v)

Other services the Secretary determines appropriate.

(D)

Episode of care

(i)

In general

Subject to clause (ii), the term “episode of care” means, with respect to an applicable condition and an applicable beneficiary, the period that includes—

(I)

the 3 days prior to the admission of the applicable beneficiary to a hospital for the applicable condition;

(II)

the length of stay of the applicable beneficiary in such hospital; and

(III)

the 30 days following the discharge of the applicable beneficiary from such hospital.

(ii)

Establishment of period by the Secretary

(E)

Physicians’ services

(F)

Pilot program

(G)

Provider of services

(H)

Readmission

(I)

Supplier

(3)

Deadline for implementation

(b)

Developmental phase

(1)

Determination of patient assessment instrument

(2)

Development of quality measures for an episode of care and for post-acute care

(A)

In general

The Secretary, in consultation with the Agency for Healthcare Research and Quality and the entity with a contract under section 1395aaa(a) of this title, shall develop quality measures for use in the pilot program—

(i)

for episodes of care; and

(ii)

for post-acute care.

(B)

Site-neutral post-acute care quality measures

(C)

Coordination with quality measure development and endorsement procedures

(c)

Details

(1)

Duration

(A)

In general

(B)

Expansion

The Secretary may, at any point after January 1, 2016, expand the duration and scope of the pilot program, to the extent determined appropriate by the Secretary, if—

(i)

the Secretary determines that such expansion is expected to—

(I)

reduce spending under this subchapter without reducing the quality of care; or

(II)

improve the quality of care and reduce spending;

(ii)

the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under this subchapter; and

(iii)

the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under this subchapter for individuals.

(2)

Participating providers of services and suppliers

(A)

In general

(B)

Requirements

(3)

Payment methodology

(A)

In general

(i)

Establishment of payment methods

(ii)

No additional program expenditures

(B)

Inclusion of certain services

(C)

Bundled payments

(i)

In general

A bundled payment under the pilot program shall—

(I)

be comprehensive, covering the costs of applicable services and other appropriate services furnished to an individual during an episode of care (as determined by the Secretary); and

(II)

be made to the entity which is participating in the pilot program.

(ii)

Requirement for provision of applicable services and other appropriate services

(D)

Payment for post-acute care services after the episode of care

(4)

Quality measures

(A)

In general

The Secretary shall establish quality measures (including quality measures of process, outcome, and structure) related to care provided by entities participating in the pilot program. Quality measures established under the preceding sentence shall include measures of the following:

(i)

Functional status improvement.

(ii)

Reducing rates of avoidable hospital readmissions.

(iii)

Rates of discharge to the community.

(iv)

Rates of admission to an emergency room after a hospitalization.

(v)

Incidence of health care acquired infections.

(vi)

Efficiency measures.

(vii)

Measures of patient-centeredness of care.

(viii)

Measures of patient perception of care.

(ix)

Other measures, including measures of patient outcomes, determined appropriate by the Secretary.

(B)

Reporting on quality measures

(i)

In general

(ii)

Submission of data through electronic health record

(d)

Waiver

(e)

Independent evaluation and reports on pilot program

(1)

Independent evaluation

The Secretary shall conduct an independent evaluation of the pilot program, including the extent to which the pilot program has—

(A)

improved quality measures established under subsection (c)(4)(A);

(B)

improved health outcomes;

(C)

improved applicable beneficiary access to care; and

(D)

reduced spending under this subchapter.

(2)

Reports

(A)

Interim report

(B)

Final report

(f)

Consultation

(g)

Application of pilot program to continuing care hospitals

(1)

In general

(2)

Special rules

In pilot testing the continuing care hospital model under paragraph (1), the following rules shall apply:

(A)

Such model shall be tested without the limitation to the conditions selected under subsection (a)(2)(B).

(B)

Notwithstanding subsection (a)(2)(D), an episode of care shall be defined as the full period that a patient stays in the continuing care hospital plus the first 30 days following discharge from such hospital.

(3)

Continuing care hospital defined

(h)

Administration

(Aug. 14, 1935, ch. 531, title XVIII, § 1866D, as added and amended

cite as: 42 USC 1395cc-4