II 

110TH CONGRESS 

1ST SESSION S. 691 

To amend title XVIII of the Social Security Act to improve the benefits 

under the Medicare program for beneficiaries with kidney disease, and 

for other purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 27, 2007 

Mr. CONRAD introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to improve 

the benefits under the Medicare program for beneficiaries 

with kidney disease, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Kidney Care Quality and Education Act of 2007’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—IMPROVING QUALITY THROUGH PATIENT EDUCATION, 

ACCESS, AND SAFETY INITIATIVES 


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Sec. 101. Support of public and patient education initiatives regarding kidney 

disease. 

Sec. 102. Medicare coverage of kidney disease patient education services. 

Sec. 103. Blood flow monitoring demonstration projects. 

Sec. 104. Institute of Medicine Evaluation and report on treatment modalities 

for patients with kidney failure. 

Sec. 105. Required training for patient care dialysis technicians. 

TITLE II—ASSURING QUALITY OF CARE FOR PROVIDERS, FACILITIES, AND PHYSICIANS THAT PROVIDE SERVICES TO INDIVIDUALS WITH END-STAGE RENAL DISEASE WHO ARE ENROLLED 

IN PART B 

Sec. 201. Establishment of the End-Stage Renal Disease (ESRD) Advisory 

Committee. 

Sec. 202. Update for the Medicare ESRD composite rate for 2008, 2009, and 

2010. 

Sec. 203. Continuous quality improvement initiative in the Medicare end-stage 

renal disease program. 

Sec. 204. Extension of Medicare secondary payer. 

1 TITLE I—IMPROVING QUALITY 

2 THROUGH PATIENT EDU3 CATION, ACCESS, AND SAFETY 

4 INITIATIVES 

5 SEC. 101. SUPPORT OF PUBLIC AND PATIENT EDUCATION 

6 INITIATIVES REGARDING KIDNEY DISEASE. 

7 (a) CHRONIC KIDNEY DISEASE DEMONSTRATION

8 PROJECTS.— 

9 (1) IN GENERAL.—The Secretary of Health and 

10 Human Services (in this section referred to as the 

11 ‘‘Secretary’’) shall establish demonstration projects 

12 to— 

13 (A) increase public awareness about the 

14 factors that lead to chronic kidney disease, how 

15 to prevent it, how to treat it, and how to avoid 

16 kidney failure; and 


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1 (B) enhance surveillance systems and ex2 pand research to better assess the prevalence 

3 and incidence of chronic kidney disease. 

4 (2) SCOPE AND DURATION.— 

5 (A) SCOPE.—The Secretary shall select at 

6 least 3 States in which to conduct demonstra7 tion projects under this subsection. In selecting 

8 the States under this subparagraph, the Sec9 retary shall take into account the size of the 

10 population of individuals with end-stage renal 

11 disease who are enrolled in part B of title 

12 XVIII of the Social Security Act and ensure the 

13 participation of individuals who reside in rural 

14 and urban areas. 

15 (B) DURATION.—The demonstration 

16 projects under this subsection shall be con17 ducted for a period that is not longer than 5 

18 years that begins on January 1, 2009. 

19 (3) EVALUATION AND REPORT.— 

20 (A) EVALUATION.—The Secretary shall 

21 conduct an evaluation of the demonstration 

22 projects conducted under this subsection. 

23 (B) REPORT.—Not later than 6 months 

24 after the date on which the demonstration 

25 projects under this subsection are completed, 


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1 the Secretary shall submit to Congress a report 

2 on the evaluation conducted under subpara3 graph (A) together with recommendations for 

4 such legislation and administrative action as the 

5 Secretary determines appropriate. 

6 (4) AUTHORIZATION OF APPROPRIATIONS.— 

7 There are authorized to be appropriated to carry out 

8 this subsection $2,000,000 for each of fiscal years 

9 2009 through 2013. 

10 (b) ESRD SELF-MANAGEMENT DEMONSTRATION

11 PROJECTS.— 

12 (1) IN GENERAL.—The Secretary shall establish 

13 demonstration projects to enable individuals with 

14 end-stage renal disease to develop self-management 

15 skills. 

16 (2) APPLICATION.—The provisions of para17 graph (2) (relating to scope and duration) and para18 graph (3) (relating to an evaluation and a report) of 

19 subsection (a) shall apply to the demonstration 

20 projects under this subsection in the same manner 

21 as such provisions apply to the demonstration 

22 projects under subsection (a). 

23 (3) AUTHORIZATION OF APPROPRIATIONS.— 

24 There are authorized to be appropriated to carry out 


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1 this subsection $2,000,000 for each of fiscal years 

2 2009 through 2013. 

3 SEC. 102. MEDICARE COVERAGE OF KIDNEY DISEASE PA4 TIENT EDUCATION SERVICES. 

5 (a) COVERAGE OF KIDNEY DISEASE EDUCATION

6 SERVICES.— 

7 (1) COVERAGE.—Section 1861(s)(2) of the So8 cial Security Act (42 U.S.C. 1395x(s)(2)) is amend9 ed— 

10 (A) in subparagraph (Z), by striking 

11 ‘‘and’’ after the semicolon at the end; 

12 (B) in subparagraph (AA), by adding 

13 ‘‘and’’ after the semicolon at the end; and 

14 (C) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(BB) kidney disease education services 

17 (as defined in subsection (ccc));’’. 

18 (2) SERVICES DESCRIBED.—Section 1861 of 

19 the Social Security Act (42 U.S.C. 1395x) is amend20 ed by adding at the end the following new sub21 section: 

22 ‘‘Kidney Disease Education Services 

23 ‘‘(ccc)(1) The term ‘kidney disease education serv24 ices’ means educational services that are— 


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1 ‘‘(A) furnished to an individual with kidney dis2 ease who, according to accepted clinical guidelines 

3 identified by the Secretary, will require dialysis or a 

4 kidney transplant; 

5 ‘‘(B) furnished, upon the referral of the physi6 cian managing the individual’s kidney condition, by 

7 a qualified person (as defined in paragraph (2)); and 

8 ‘‘(C) designed— 

9 ‘‘(i) to provide comprehensive information 

10 regarding— 

11 ‘‘(I) the management of comorbidities; 

12 ‘‘(II) the prevention of uremic com13 plications; and 

14 ‘‘(III) each option for renal replace15 ment therapy (including home and in-cen16 ter as well as vascular access options and 

17 transplantation); and 

18 ‘‘(ii) to ensure that the individual has the 

19 opportunity to actively participate in the choice 

20 of therapy. 

21 ‘‘(2) The term ‘qualified person’ means— 

22 ‘‘(A) a physician (as described in subsection 

23 (r)(1)); 

24 ‘‘(B) an individual who— 

25 ‘‘(i) is— 


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1 ‘‘(I) a registered nurse; 

2 ‘‘(II) a registered dietitian or nutri3 tion professional (as defined in subsection 

4 (vv)(2)); 

5 ‘‘(III) a clinical social worker (as de6 fined in subsection (hh)(1)); 

7 ‘‘(IV) a physician assistant, nurse 

8 practitioner, or clinical nurse specialist (as 

9 those terms are defined in subsection 

10 (aa)(5)); or 

11 ‘‘(V) a transplant coordinator; and 

12 ‘‘(ii) meets such requirements related to 

13 experience and other qualifications that the 

14 Secretary finds necessary and appropriate for 

15 furnishing the services described in paragraph 

16 (1); or 

17 ‘‘(C) a renal dialysis facility subject to the re18 quirements of section 1881(b)(1) with personnel 

19 who— 

20 ‘‘(i) provide the services described in para21 graph (1); and 

22 ‘‘(ii) meet the requirements of subpara23 graph (A) or (B). 

24 ‘‘(3) The Secretary shall develop the information to 

25 be provided under paragraph (1)(C)(i) and the requireVerDate Aug 31 2005 22:38 Feb 28, 2007 Jkt 059200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S691.IS S691

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1 ments under (2)(B)(ii) after consulting with physicians, 

2 health educators, professional organizations, accrediting 

3 organizations, kidney patient organizations, dialysis facili4 ties, transplant centers, network organizations described 

5 in section 1881(c)(2), and other knowledgeable persons. 

6 ‘‘(4) In promulgating regulations to carry out this 

7 subsection, the Secretary shall ensure that each bene8 ficiary who is entitled to kidney disease education services 

9 under this title receives such services in a timely manner 

10 to maximize the benefit of those services. 

11 ‘‘(5) The Secretary shall monitor the implementation 

12 of this subsection to ensure that beneficiaries who are eli13 gible for kidney disease education services receive such 

14 services in the manner described in paragraph (4). 

15 ‘‘(6) No individual shall be eligible to be provided 

16 more than 6 sessions of kidney disease education services 

17 under this title.’’. 

18 (3) PAYMENT UNDER THE PHYSICIAN FEE

19 SCHEDULE.—Section 1848(j)(3) of the Social Secu20 rity Act (42 U.S.C. 1395w–4(j)(3)) is amended by 

21 inserting ‘‘(2)(BB),’’ after ‘‘(2)(AA),’’. 

22 (4) PAYMENT TO RENAL DIALYSIS FACILI23 TIES.—Section 1881(b) of the Social Security Act 

24 (42 U.S.C. 1395rr(b)) is amended by adding at the 

25 end the following new paragraph: 


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1 ‘‘(14) For purposes of paragraph (12), the sin2 gle composite weighted formulas determined under 

3 such paragraph shall not take into account the 

4 amount of payment for kidney disease education 

5 services (as defined in section 1861(ccc)). Instead, 

6 payment for such services shall be made to the renal 

7 dialysis facility on an assignment-related basis under 

8 section 1848.’’. 

9 (5) LIMITATION ON NUMBER OF SESSIONS.— 

10 Section 1862(a)(1) of the Social Security Act (42 

11 U.S.C. 1395y(a)(1)) is amended— 

12 (A) in subparagraph (M), by striking 

13 ‘‘and’’ at the end; 

14 (B) in subparagraph (N), by striking the 

15 semicolon at the end and inserting ‘‘, and’’; and 

16 (C) by adding at the end the following new 

17 subparagraph: 

18 ‘‘(O) in the case of kidney disease edu19 cation services (as defined in section 

20 1861(ccc)), which are performed in excess of 

21 the number of sessions covered under such sec22 tion;’’. 

23 (6) ANNUAL REPORT TO CONGRESS.—Not later 

24 than April 1, 2009, and annually thereafter, the 

25 Secretary of Health and Human Services shall subVerDate Aug 31 2005 22:38 Feb 28, 2007 Jkt 059200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S691.IS S691

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1 mit a report to Congress on the number of Medicare 

2 beneficiaries who are entitled to kidney disease edu3 cation services (as defined in section 1861(ccc) of 

4 the Social Security Act, as added by paragraph (2)) 

5 under title XVIII of such Act and who receive such 

6 services, together with such recommendations for 

7 legislative and administrative action as the Secretary 

8 determines to be appropriate to fulfill the legislative 

9 intent that resulted in the enactment of that sub10 section. 

11 (b) EFFECTIVE DATE.—The amendments made by 

12 this section shall apply to services furnished on or after 

13 January 1, 2009. 

14 SEC. 103. BLOOD FLOW MONITORING DEMONSTRATION 

15 PROJECTS. 

16 (a) ESTABLISHMENT.—The Secretary of Health and 

17 Human Services (in this section referred to as the ‘‘Sec18 retary’’) shall establish demonstration projects to evaluate 

19 how blood flow monitoring affects the quality and cost of 

20 care for Medicare beneficiaries with end-stage renal dis21 ease. 

22 (b) DURATION.—The demonstration projects under 

23 this section shall be conducted for a period of not longer 

24 than 5 years that begins on January 1, 2009. 

25 (c) EVALUATION AND REPORT.— 


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1 (1) EVALUATION.—The Secretary shall conduct 

2 an evaluation of the demonstration projects con3 ducted under this section. 

4 (2) REPORT.—Not later than 6 months after 

5 the date on which the demonstration projects under 

6 this section are completed, the Secretary shall sub7 mit to Congress a report on the evaluation con8 ducted under paragraph (1) together with rec9 ommendations for such legislation and administra10 tive action as the Secretary determines appropriate. 

11 (d) WAIVER AUTHORITY.—The Secretary shall waive 

12 compliance with the requirements of title XVIII of the So13 cial Security Act (42 U.S.C. 1395 et seq.) to the extent, 

14 and for such period as, the Secretary determines is nec15 essary to conduct the demonstration projects. 

16 (e) AUTHORIZATION OF APPROPRIATIONS.— 

17 (1) IN GENERAL.—Payments for the costs of 

18 carrying out the demonstration projects under this 

19 section shall be made from the Federal Supple20 mentary Medical Insurance Trust Fund under sec21 tion 1841 of the Social Security Act (42 U.S.C. 

22 1395t). 

23 (2) AMOUNT.—There are authorized to be ap24 propriated from such Trust Fund $1,000,000 for 


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1 each of fiscal years 2009 through 2013 to carry out 

2 this section. 

3 SEC. 104. INSTITUTE OF MEDICINE EVALUATION AND RE4 PORT ON TREATMENT MODALITIES FOR PA5 TIENTS WITH KIDNEY FAILURE. 

6 (a) EVALUATION.— 

7 (1) IN GENERAL.—Not later than 2 months 

8 after the date of enactment of this Act, the Sec9 retary of Health and Human Services (in this sec10 tion referred to as the ‘‘Secretary’’) shall enter into 

11 an arrangement under which the Institute of Medi12 cine of the National Academy of Sciences (in this 

13 section referred to as the ‘‘Institute’’) shall conduct 

14 an evaluation of the barriers that exist to increasing 

15 the number of individuals with end-stage renal dis16 ease who elect to receive home dialysis services or 

17 other treatment modalities under the Medicare pro18 gram under title XVIII of the Social Security Act 

19 (42 U.S.C. 1395 et seq.). 

20 (2) SPECIFIC MATTERS EVALUATED.—In con21 ducting the evaluation under paragraph (1), the In22 stitute shall— 

23 (A) compare current Medicare home dialy24 sis costs and payments with current in-center 

25 and hospital dialysis costs and payments; 


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1 (B) catalogue and evaluate the incentives 

2 and disincentives in the current reimbursement 

3 system that influence whether patients receive 

4 home dialysis services or other treatment mo5 dalities; 

6 (C) evaluate patient education services and 

7 how such services impact the treatment choices 

8 made by patients; and 

9 (D) consider such other matters as the In10 stitute determines appropriate. 

11 (3) SCOPE OF REVIEW.—In conducting the 

12 evaluation under paragraph (1), the Institute shall 

13 consider a variety of perspectives, including the per14 spectives of physicians, other health care profes15 sionals, hospitals, dialysis facilities, health plans, 

16 purchasers, and patients. 

17 (b) REPORT.—Not later than 19 months after the 

18 date of enactment of this Act, the Institute shall submit 

19 to the Secretary and to Congress a report on the evalua20 tion conducted under subsection (a)(1). Such report shall 

21 contain a detailed description of the findings of such eval22 uation and recommendations for implementing incentives 

23 to encourage patients to elect to receive home dialysis 

24 services or other treatment modalities under the Medicare 

25 program. 


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1 (c) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated such sums as may be 

3 necessary for the purposes of conducting the evaluation 

4 and preparing the report required by this section. 

5 SEC. 105. REQUIRED TRAINING FOR PATIENT CARE DIALY6 SIS TECHNICIANS. 

7 (a) IN GENERAL.—Section 1881 of the Social Secu8 rity Act (42 U.S.C. 1395rr) is amended by adding the fol9 lowing new subsection: 

10 ‘‘(h)(1) Except as provided in paragraph (3), begin11 ning January 1, 2009, a provider of services or a renal 

12 dialysis facility may not use any individual as a patient 

13 care dialysis technician for more than 4 months unless the 

14 individual— 

15 ‘‘(A) has completed a training program in the 

16 care and treatment of an individual with chronic 

17 kidney failure who is undergoing dialysis treatment; 

18 ‘‘(B) has been certified by a nationally recog19 nized certification entity for dialysis technicians; and 

20 ‘‘(C) is competent to provide dialysis-related 

21 services. 

22 ‘‘(2) Beginning January 1, 2010, a provider of serv23 ices or a renal dialysis facility may not use on a tem24 porary, per diem, leased, or on any basis other than as 

25 a permanent employee, any individual as a patient care 


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1 dialysis technician unless the individual meets the require2 ments described in subparagraphs (A), (B), and (C) of 

3 paragraph (1). 

4 ‘‘(3) A provider of services or a renal dialysis facility 

5 may permit an individual enrolled in a training program 

6 described in paragraph (1)(A) to serve as a patient care 

7 dialysis technician while they are so enrolled. 

8 ‘‘(4) For purposes of paragraph (1), if, since the most 

9 recent completion by an individual of a training program 

10 described in paragraph (1)(A), there has been a period 

11 of 24 consecutive months during which the individual has 

12 not performed dialysis-related services for monetary com13 pensation, such individual shall be required to complete 

14 a new training program or become recertified as described 

15 in paragraph (1)(B). 

16 ‘‘(5) A provider of services or a renal dialysis facility 

17 shall provide such regular performance review and regular 

18 in-service education as assures that individuals serving as 

19 patient care dialysis technicians for the provider or facility 

20 are competent to perform dialysis-related services.’’. 


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1 TITLE II—ASSURING QUALITY 

2 OF CARE FOR PROVIDERS, 

3 FACILITIES, AND PHYSICIANS 

4 THAT PROVIDE SERVICES TO 

5 INDIVIDUALS WITH END6 STAGE RENAL DISEASE WHO 

7 ARE ENROLLED IN PART B 

8 SEC. 201. ESTABLISHMENT OF THE END-STAGE RENAL DIS9 EASE (ESRD) ADVISORY COMMITTEE. 

10 (a) IN GENERAL.—Pursuant to section 222 of the 

11 Public Health Service Act (42 U.S.C. 217a), the Secretary 

12 of Health and Human Services (in this section referred 

13 to as the ‘‘Secretary’’) shall establish within 1 year of the 

14 date of enactment of this Act an independent, multidisci15 plinary, nonpartisan End-Stage Renal Disease Advisory 

16 Committee (in this section referred to as the ‘‘Com17 mittee’’). 

18 (b) MEMBERSHIP.— 

19 (1) IN GENERAL.—The Committee shall consist 

20 of such members as the Secretary may appoint who 

21 shall serve for such term as the Secretary may speci22 fy. The Secretary shall ensure that a representative 

23 of the Centers for Medicare & Medicaid Services is 

24 included among the members of the Committee. 


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1 (2) CONSULTATION.—In appointing members of 

2 the Committee, the Secretary shall consult with pa3 tients, facilities and providers, physicians, nurses, a 

4 representative from the pediatric community, payers 

5 and insurers, manufacturers, and a representative of 

6 the Centers for Medicare & Medicaid Services who 

7 coordinates activities related to end-stage renal dis8 ease within the Centers. 

9 (c) PURPOSE OF THE COMMITTEE.— 

10 (1) DUTIES.—The Committee shall provide a 

11 forum for expert discussion and deliberation and the 

12 formulation of advice and recommendations to the 

13 Secretary regarding Medicare coverage for individ14 uals with end-stage renal disease, as described under 

15 section 1881 of the Social Security Act (42 U.S.C. 

16 1395rr). 

17 (2) RECOMMENDATIONS.— 

18 (A) ANNUAL RECOMMENDATIONS.—The 

19 Committee shall provide annual recommenda20 tions to the Secretary regarding— 

21 (i) selecting, modifying, and updating 

22 clinical and quality of life measures; 

23 (ii) modifying the payment structure; 


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1 (iii) determining hardship criteria to 

2 exempt certain facilities and providers 

3 from the program; and 

4 (iv) other issues related to implemen5 tation of a quality initiative by the Sec6 retary. 

7 (B) PERIODIC RECOMMENDATIONS.—The 

8 Committee shall provide periodic advice and 

9 recommendations to the Secretary regarding 

10 Medicare coverage for individuals with end11 stage renal disease, as described in such section 

12 1881. 

13 SEC. 202. UPDATE FOR THE MEDICARE ESRD COMPOSITE 

14 RATE FOR 2008, 2009, AND 2010. 

15 Section 1881(b)(12)(G) of the Social Security Act 

16 (42 U.S.C. 1395rr(b)(12)(G)), as amended by section 103 

17 of the Tax Relief and Health Care Act of 2006 (Public 

18 Law 109–432), is amended— 

19 (1) in clause (i), by striking ‘‘and’’ at the end; 

20 (2) in clause (ii)— 

21 (A) by inserting ‘‘and before January 1, 

22 2008,’’ after ‘‘April 1, 2007’’; and 

23 (B) by striking the period at the end and 

24 inserting a semicolon; and 


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1 (3) by adding at the end the following new 

2 clauses: 

3 ‘‘(iii) furnished during 2008, by the amount 

4 equal to the ESRD market basket (as developed 

5 pursuant to section 422(b) of the Medicare, Med6 icaid, and SCHIP Benefits Improvement and Pro7 tection Act of 2000 (Public Law 106–554), as en8 acted into law by section 1(a)(6) of Public Law 106- 

9 554) percentage increase for 2008 above the amount 

10 of such composite rate component for such services 

11 furnished on December 31, 2007; 

12 ‘‘(iv) furnished during 2009, by the amount 

13 equal to the ESRD market basket (as so developed) 

14 percentage increase for 2009 above the amount of 

15 such composite rate component for such services fur16 nished on December 31, 2008; and 

17 ‘‘(v) furnished on or after January 1, 2010, by 

18 the amount equal to the ESRD market basket (as 

19 so developed) percentage increase for 2010 above the 

20 amount of such composite rate component for such 

21 services furnished on December 31, 2009.’’. 


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1 SEC. 203. CONTINUOUS QUALITY IMPROVEMENT INITIA2 TIVE IN THE MEDICARE END-STAGE RENAL 

3 DISEASE PROGRAM. 

4 (a) ESTABLISHMENT OF THE PROGRAM.—Section 

5 1881 of the Social Security Act (42 U.S.C. 1395rr), as 

6 amended by section 105, is amended by adding at the end 

7 the following new subsection: 

8 ‘‘(i) CONTINUOUS QUALITY IMPROVEMENT INITIA9 TIVE IN THE END-STAGE RENAL DISEASE PROGRAM.— 

10 ‘‘(1) IN GENERAL.—Not later than January 1, 

11 2008, the Secretary shall establish a 3-year contin12 uous quality improvement initiative (in this section 

13 referred to as the ‘quality initiative’) under which 

14 quality payments are provided to renal dialysis facili15 ties, providers of services, and physicians that pro16 vide items and services to individuals with end-stage 

17 renal disease who are enrolled under part B and 

18 that meet quality benchmarks and demonstrate qual19 ity improvements. 

20 ‘‘(2) PARTICIPATION.— 

21 ‘‘(A) FACILITIES AND PROVIDERS.— 

22 ‘‘(i) IN GENERAL.—Except as pro23 vided in subparagraph (C)(i) and subject 

24 to clause (ii), all independent dialysis fa25 cilities and hospital-based dialysis pro26 viders that provide items and services to 


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1 individuals with end-stage renal disease 

2 who are enrolled in part B shall participate 

3 in the quality initiative. 

4 ‘‘(ii) POSITIVE UPDATE REQUIRED.— 

5 The quality initiative shall not apply to fa6 cilities and providers in a year unless the 

7 ESRD market basket percentage increase 

8 described in subsection (b)(12)(G) for such 

9 year is positive. 

10 ‘‘(B) PHYSICIANS.— 

11 ‘‘(i) IN GENERAL.—Except as pro12 vided in subparagraph (C)(i) and subject 

13 to clause (ii), all physicians who receive the 

14 monthly capitated payment under this title 

15 with respect to end-stage renal disease 

16 items and services shall participate in the 

17 quality initiative. 

18 ‘‘(ii) POSITIVE UPDATE REQUIRED.— 

19 The quality initiative shall not apply to 

20 physicians in a year unless the update to 

21 the conversion factor under section 

22 1848(d) for such year is positive. 

23 ‘‘(C) PEDIATRIC FACILITIES, PROVIDERS, 

24 AND PHYSICIANS.— 


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1 ‘‘(i) IN GENERAL.—Subject to clause 

2 (ii), a pediatric facility, provider, or physi3 cian who provides items and services to in4 dividuals with end-stage renal disease who 

5 are enrolled in part B and with at least 50 

6 percent of its patients being individuals 

7 under 18 years of age shall be required to 

8 report data for pediatric-specific measures 

9 under this subsection in order to receive 

10 the full market basket update during 2008, 

11 2009, and 2010 under subsection 

12 (b)(12)(G) or the full update under section 

13 1848(d). 

14 ‘‘(ii) POSITIVE UPDATE REQUIRED.— 

15 The reporting requirement under clause (i) 

16 shall not apply to— 

17 ‘‘(I) pediatric facilities and pro18 viders in a year unless the ESRD 

19 market basket percentage increase de20 scribed in subsection (b)(12)(G) for 

21 such year is positive; and 

22 ‘‘(II) to pediatric physicians in a 

23 year unless the update to the conver24 sion factor under section 1848(d) for 

25 such year is positive. 


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1 ‘‘(iii) EVALUATION.—The Secretary, 

2 in consultation with the End-Stage Renal 

3 Disease Advisory Committee established 

4 under section 201 of the Kidney Care 

5 Quality and Education Act of 2007 (in this 

6 subsection referred to as the ‘ESRD Advi7 sory Committee’), shall evaluate and make 

8 recommendations to Congress regarding 

9 the feasibility of incorporating pediatric fa10 cilities, providers, and physicians described 

11 in clause (i) fully into the quality initiative 

12 if the initiative were to extend beyond 

13 2010. 

14 ‘‘(3) DURATION.—The quality initiative shall be 

15 conducted during a period of 3 years beginning Jan16 uary 1, 2008. 

17 ‘‘(4) FUNDING.— 

18 ‘‘(A) BONUS POOL FOR PROVIDERS AND

19 FACILITIES.—During 2008, 2009, and 2010, 

the Secretary shall set aside at least 1 20 ⁄4, but no 

more than 1 21 ⁄2, of the ESRD market basket 

22 amount under subsection (b)(12)(G) for each 

23 year, respectively, to establish a bonus pool to 

24 be used to provide bonus payments for pro25 viders and facilities described in paragraph 


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1 (2)(A) that demonstrate improvements in qual2 ity or attainment of quality benchmarks. 

3 ‘‘(B) BONUS POOL FOR PHYSICIANS.— 

4 During 2008, 2009, and 2010, the Secretary 

shall set aside at least 1⁄4, but no more than 1 5 ⁄2, 

6 of the portion of the physician fee schedule up7 date under section 1848(d) that applies to phy8 sicians who receive the monthly capitated pay9 ment under this title with respect to end-stage 

10 renal disease items and services for each year 

11 respectively to establish a bonus pool to be used 

12 to provide bonus payments for physicians de13 scribed in paragraph (2)(B) that demonstrate 

14 improvements in quality or attainment of qual15 ity benchmarks. 

16 ‘‘(5) ESTABLISHMENT OF QUALITY INCENTIVE

17 PAYMENTS.— 

18 ‘‘(A) INCENTIVES FOR REPORTING IN

19 2008.— 

20 ‘‘(i) IN GENERAL.—During 2008, the 

21 Secretary shall make quality incentive pay22 ments from the bonus pool described in 

23 paragraph (4)(A) to facilities and providers 

24 and from the bonus pool described in para25 graph (4)(B) to physicians described in 


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1 subparagraphs (A) and (B) of paragraph 

2 (2) for reporting data about clinical and 

3 quality of life measures adopted by the 

4 Secretary in consultation with the ESRD 

5 Advisory Committee. 

6 ‘‘(ii) EXTENSION.—If the Secretary 

7 determines that there are problems associ8 ated with reporting that should be resolved 

9 before implementing the quality payment 

10 system under subparagraph (B), the Sec11 retary may extend the reporting period an 

12 additional year. 

13 ‘‘(iii) EXCEPTION TO REPORTING RE14 QUIREMENT.—The Secretary shall estab15 lish criteria for an application for a hard16 ship exception that would allow small or 

17 rural facilities and providers to receive the 

18 full update under subsection (b)(12)(G) 

19 even if they are not able to report data. 

20 ‘‘(B) QUALITY INCENTIVE PAYMENTS IN

21 2009 AND 2010.— 

22 ‘‘(i) IN GENERAL.—During 2009 and 

23 2010, the Secretary shall make quality in24 centive payments from their respective 

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1 ties, providers, and physicians described in 

2 subparagraphs (A) and (B) of paragraph 

3 (2) with respect to a year if the Secretary 

4 determines that the quality of care pro5 vided in that year by the facility, provider, 

6 or physician to individuals with end-stage 

7 renal disease who are enrolled under part 

8 B— 

9 ‘‘(I) has substantially improved 

10 (as determined by the Secretary in 

11 consultation with the ESRD Advisory 

12 Committee) over the prior year; or 

13 ‘‘(II) exceeds a threshold estab14 lished by the Secretary in consultation 

15 with the ESRD Advisory Committee. 

16 ‘‘(ii) REQUIREMENTS.—In deter17 mining which facilities, providers, or physi18 cians qualify for the quality incentive pay19 ments under clause (i), the Secretary shall 

20 do the following: 

21 ‘‘(I) Adopt clinical and quality of 

22 life measures in consultation with the 

23 ESRD Advisory Committee. 

24 ‘‘(II) For 2008, ensure that pay25 ments will be based on the reporting 


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1 of data regarding clinical and quality 

2 of life measures adopted by the Sec3 retary in consultation with the ESRD 

4 Advisory Committee. 

5 ‘‘(III) For 2009 and 2010, sub6 ject to subparagraph (C), ensure that 

7 payments will be based upon the com8 posite score awarded to the facilities, 

9 providers, and physicians. The com10 posite score will be based upon the 

11 submission of data about clinical and 

12 quality of life measures adopted by 

13 the Secretary in consultation with the 

14 ESRD Advisory Committee. 

15 ‘‘(C) DETERMINATION OF AMOUNT OF IN16 CENTIVE PAYMENT.— 

17 ‘‘(i) IN GENERAL.—Subject to clause 

18 (ii), the Secretary shall determine the 

19 amount of a quality incentive payment to 

20 a facility, provider, or physician based 

21 upon a quintile scale of a weighted com22 posite score of clinical and quality of life 

23 measures. 

24 ‘‘(ii) LIMITATION.—The Secretary 

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1 ments so that the total amount of such 

2 payments made in a year— 

3 ‘‘(I) to facilities and providers 

4 from the bonus pool under paragraph 

5 (4)(A) is equal to the total amount 

6 available for such payments for the 

7 year under such paragraph; and 

8 ‘‘(II) to physicians from the 

9 bonus pool under paragraph (4)(B) is 

10 equal to the total amount available for 

11 such payments for the year under 

12 such paragraph. 

13 ‘‘(D) REQUIREMENTS FOR ESTABLISH14 MENT OF THE COMPOSITE SCORE.—In estab15 lishing the composite score under this sub16 section, the Secretary shall— 

17 ‘‘(i) consult with the ESRD Advisory 

18 Committee to develop the clinical and qual19 ity of life measures and formula used to 

20 calculate the weighted composite score; 

21 ‘‘(ii) use a transparent process con22 sistent with the requirements of chapter 5 

23 of title 5, United States Code (commonly 

24 referred to as the ‘Administrative Proce25 dure Act’) to develop the measures and the 


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1 formula used to calculate the weighted 

2 composite score; and 

3 ‘‘(iii) assure that the payments reward 

4 facilities, providers, and physicians for— 

5 ‘‘(I) the attainment of minimum 

6 quality targets; and 

7 ‘‘(II) substantial improvement 

8 over the previous year, as dem9 onstrated by the movement of a facil10 ity, provider, or physician from 1 

11 quintile to another. 

12 ‘‘(6) REQUIREMENTS FOR INCENTIVE PAY13 MENTS.— 

14 ‘‘(A) IN GENERAL.—In order for a facility, 

15 provider, or physician to be eligible for quality 

16 incentive payments described in paragraph (5) 

17 for a year, the provider, facility, or physician 

18 must have provided for the submission of data 

19 in accordance with subparagraph (B) with re20 spect to that year. 

21 ‘‘(B) SUBMISSION OF DATA.—For 2008, 

22 2009, and 2010, each facility, provider, and 

23 physician described in subparagraphs (A) and 

24 (B) of paragraph (2) shall submit to the Sec25 retary such data that the Secretary determines 


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1 are appropriate for the measurement of health 

2 outcomes and other indices of quality, including 

3 data necessary for the operation of the contin4 uous quality improvement initiative under this 

5 subsection. Such data shall be submitted in a 

6 form and manner, and at a time, specified by 

7 the Secretary for purposes of this subsection. 

8 ‘‘(C) ATTESTATION REGARDING DATA.—In 

9 order for a facility, provider, or physician to be 

10 eligible for a quality incentive payment under 

11 this subsection for a year, the facility, provider, 

12 or physician must have provided the Secretary 

13 (under procedures established by the Secretary 

14 in consultation with the ESRD Advisory Com15 mittee) with an attestation that the data sub16 mitted under this subsection for the year are 

17 complete and accurate. 

18 ‘‘(7) PAYMENT METHODS AND TIMING OF PAY19 MENT.— 

20 ‘‘(A) IN GENERAL.—Subject to subpara21 graph (B), the payment of quality incentive 

22 payments shall be based on such method as the 

23 Secretary, in consultation with the ESRD Advi24 sory Committee, determines appropriate. 


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1 ‘‘(B) TIMING.—The Secretary shall ensure 

2 that quality incentive payments with respect to 

3 a year are made by no later than June 30 of 

4 the subsequent year. 

5 ‘‘(8) FEEDBACK.—The Secretary shall provide 

6 quality incentive payments and feedback to facilities, 

7 providers, and physicians as frequently as possible 

8 and as close to the date on which such facilities, pro9 viders, and physicians submitted quality data. 

10 ‘‘(9) TECHNICAL ASSISTANCE.—The Secretary 

11 shall identify or establish an appropriately skilled 

12 group or organization, such as the ESRD Networks, 

13 to provide technical assistance to consistently low14 performing facilities, providers, or physicians that 

15 are in the bottom quintile. 

16 ‘‘(10) STREAMLINE REPORTING.—The Sec17 retary shall— 

18 ‘‘(A) evaluate the current data systems 

19 used by facilities, providers, and physicians to 

20 submit data; and 

21 ‘‘(B) eliminate redundant reporting by con22 solidating all current data reporting into a new 

23 web-based system in order to minimize redun24 dancy and reduce regulatory and administrative 

25 demands. 


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1 ‘‘(11) PUBLIC REPORTING.— 

2 ‘‘(A) AVAILABILITY TO THE PUBLIC.—The 

3 Secretary shall establish procedures for making 

4 weighted composite scores calculated under this 

5 subsection available to the public in a clear and 

6 understandable form, including through its 

7 website and the Medicare.gov comparison tool. 

8 Such procedures shall ensure that a facility, 

9 provider, or physician has the opportunity to re10 view the data that is to be made public with re11 spect to the facility, provider, or physician prior 

12 to such data being made public. 

13 ‘‘(B) CERTIFICATES.—The Secretary shall 

14 provide certificates to facilities, providers, and 

15 physicians who provide services to individuals 

16 with end-stage renal disease under this title to 

17 display in patient areas. The certificate shall in18 dicate the weighted composite score obtained by 

19 the facility, provider, or physician under the 

20 quality initiative. 

21 ‘‘(C) WEB-BASED QUALITY LIST.—The 

22 Secretary shall establish a web-based quality 

23 list for facilities, providers, and physicians who 

24 provide items and services to individuals with 

25 end-stage renal disease who are enrolled under 


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1 part B that indicates whether measures were 

2 met or not. 

3 ‘‘(12) EVALUATIONS.— 

4 ‘‘(A) EVALUATION BY THE SECRETARY.— 

5 ‘‘(i) RECOGNIZING PART A SAVINGS

6 FROM CONTINUOUS QUALITY IMPROVE7 MENT INITIATIVE.—Not later than Janu8 ary 1, 2010, the Secretary shall evaluate 

9 and make recommendations to Congress 

10 regarding the feasibility of continuing the 

11 quality initiative by funding an annual in12 crease to the composite rate by the ESRD 

13 market basket amount under subsection 

14 (b)(12)(G) through reduced expenditures 

15 under the Federal Hospital Insurance 

16 Trust Fund as a result of the quality ini17 tiative. 

18 ‘‘(ii) RECOMMENDATIONS FOR AN AN19 NUAL UPDATE MECHANISM.—Not later 

20 than 12 months after the date of enact21 ment of this subsection, the Secretary, act22 ing through the Administrator of the Cen23 ters for Medicare & Medicaid Services, 

24 shall submit a report to Congress using the 

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1 tive to make recommendations about estab2 lishing a permanent update mechanism for 

3 the composite rate under this section. 

4 ‘‘(B) EVALUATION BY MEDPAC.— 

5 ‘‘(i) STUDY.—The Medicare Payment 

6 Advisory Commission shall conduct a study 

7 on the advisability and feasibility of mak8 ing the quality initiative permanent. 

9 ‘‘(ii) REPORT.—Not later than June 

10 1, 2009, the Commission shall submit a re11 port to Congress and the Secretary on the 

12 study conducted under clause (i) together 

13 with recommendations for such legislation 

14 and administrative actions as the Commis15 sion considers appropriate, including the 

16 need for establishing an annual update 

17 mechanism for the composite rate under 

18 this section. 

19 ‘‘(C) EVALUATION BY THE INSTITUTE OF

20 MEDICINE.— 

21 ‘‘(i) IN GENERAL.—Not later than 2 

22 years after the date of enactment of this 

23 subsection, the Secretary shall enter into 

24 an arrangement under which the Institute 

25 of Medicine of the National Academy of 


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1 Sciences (in this section referred to as the 

2 ‘Institute’) shall conduct an evaluation of 

3 the effectiveness of the quality initiative. 

4 ‘‘(ii) SCOPE OF REVIEW.—The Insti5 tute shall consider a variety of perspec6 tives, including the perspectives of facili7 ties, providers, physicians, nurses, other 

8 health care professionals, and patients. 

9 ‘‘(iii) REPORT.—Not later than 3 

10 years after the date of enactment of this 

11 subsection, the Institute shall submit to 

12 the Secretary and to Congress a report on 

13 the evaluation conducted under clause (i). 

14 Such report shall contain a detailed de15 scription of the findings of such evaluation 

16 and recommendations for implementing on 

17 an ongoing basis the quality initiative. 

18 ‘‘(iv) AUTHORIZATION OF APPROPRIA19 TIONS.—There are authorized to be appro20 priated such sums as may be necessary for 

21 the purpose of conducting the evaluation 

22 and preparing the report required by this 

23 subparagraph.’’. 

24 SEC. 204. EXTENSION OF MEDICARE SECONDARY PAYER. 

25 (a) EXTENSION.— 


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1 (1) IN GENERAL.—Section 1862(b)(1)(C) of the 

2 Social Security Act (42 U.S.C. 1395y(b)(1)(C)) is 

3 amended— 

4 (A) in the last sentence, by inserting ‘‘, 

5 and before January 1, 2008’’ after ‘‘prior to 

6 such date)’’; and 

7 (B) by adding at the end the following new 

8 sentence: ‘‘Effective for items and services fur9 nished on or after January 1, 2008 (with re10 spect to periods beginning on or after the date 

11 that is 42 months prior to such date), clauses 

12 (i) and (ii) shall be applied by substituting ‘42- 

13 month’ for ‘12-month’ each place it appears in 

14 the first sentence.’’. 

15 (2) EFFECTIVE DATE.—The amendments made 

16 by this subsection shall take effect on the date of en17 actment of this Act. For purposes of determining an 

18 individual’s status under section 1862(b)(1)(C) of 

19 the Social Security Act (42 U.S.C. 1395y(b)(1)(C)), 

20 as amended by paragraph (1), an individual who is 

21 within the coordinating period as of the date of en22 actment of this Act shall have that period extended 

23 to the full 42 months described in the last sentence 

24 of such section, as added by the amendment made 

25 by paragraph (1)(B). 


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1 (b) OIG STUDY AND REPORT.— 

2 (1) STUDY.—The Inspector General of the De3 partment of Health and Human Services shall con4 duct a study on— 

5 (A) the enforcement of the provisions of 

6 section 1862(b)(1)(C)(ii) of the Social Security 

7 Act (42 U.S.C. 1395y(b)(1)(C)(ii)); and 

8 (B) how effective such provisions are at 

9 protecting individuals on dialysis from receiving 

10 differential treatment by health plans once the 

11 individual is diagnosed with end stage renal dis12 ease. 

13 (2) REPORT.—Not later than 1 year after the 

14 date of enactment of this Act, the Inspector General 

15 of the Department of Health and Human Services 

16 shall submit to Congress a report on the study con17 ducted under paragraph (1), together with such rec18 ommendations as the Inspector General determines 

19 appropriate. 

Æ 


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