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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1114 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1114

 To establish a demonstration project to provide for patient-centered 
medical homes to improve the effectiveness and efficiency in providing 
    medical assistance under the Medicaid program and child health 
    assistance under the State Children's Health Insurance Program.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                              May 20, 2009

 Mr. Durbin (for himself and Mr. Burr) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
 To establish a demonstration project to provide for patient-centered 
medical homes to improve the effectiveness and efficiency in providing 
    medical assistance under the Medicaid program and child health 
    assistance under the State Children's Health Insurance Program.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medical Homes Act of 2009''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Medical homes provide patient-centered care, leading to 
        better health outcomes and greater patient satisfaction. A 
        growing body of research supports the need to involve patients 
        and their families in their own health care decisions, to 
        better inform them of their treatment options, and to improve 
        their access to information.
            (2) Medical homes help patients better manage chronic 
        diseases and maintain basic preventive care, resulting in 
        better health outcomes than those who lack medical homes. An 
        investigation of the Chronic Care Model discovered that the 
        medical home reduced the risk of cardiovascular disease in 
        diabetes patients, helped congestive heart failure patients 
        become more knowledgeable and stay on recommended therapy, and 
        increased the likelihood that asthma and diabetes patients 
        would receive appropriate therapy.
            (3) Medical homes also reduce disparities in access to 
        care. A survey conducted by the Commonwealth Fund found that 74 
        percent of adults with a medical home have reliable access to 
        the care they need, compared with only 52 percent of adults 
        with a regular provider that is not a medical home and 38 
        percent of adults without any regular source of care or 
        provider.
            (4) Medical homes reduce racial and ethnic differences in 
        access to medical care. Three-fourths of Caucasians, African 
        Americans, and Hispanics with medical homes report getting care 
        when they need it.
            (5) Medical homes reduce duplicative health services and 
        inappropriate emergency room use. In 1998, North Carolina 
        launched the Community Care of North Carolina (CCNC) program, 
        which employs the medical home concept. Presently, CCNC has 
        developed 14 regional networks that include all of the 
        Federally qualified health centers in the State and cover 
        740,000 recipients. An analysis conducted by Mercer Human 
        Resources Consulting Group found that CCNC resulted in 
        $244,000,000 in savings to the Medicaid program in 2004, with 
        similar results in 2005 and 2006.
            (6) Health information technology is a crucial foundation 
        for medical homes. While many doctors' offices use electronic 
        health records for billing or other administrative functions, 
        few practices utilize health information technology 
        systematically to measure and improve the quality of care they 
        provide. For example, electronic health records can generate 
        reports to ensure that all patients with chronic conditions 
        receive recommended tests and are on target to meet their 
        treatment goals. Computerized ordering systems, particularly 
        with decision-support tools, can prevent medical and medication 
        errors, while e-mail and interactive Internet websites can 
        facilitate communication between patients and providers and 
        improve patient education.

SEC. 3. MEDICAID AND CHIP DEMONSTRATION PROJECT TO SUPPORT PATIENT-
              CENTERED PRIMARY CARE.

    (a) Definitions.--In this section:
            (1) Care management model.--The term ``care management 
        model'' means a model that--
                    (A) uses health information technology and other 
                innovations such as the chronic care model, to improve 
                the management and coordination of care provided to 
                patients;
                    (B) is centered on the relationship between a 
                patient and their personal primary care provider;
                    (C) seeks guidance from--
                            (i) a steering committee; and
                            (ii) a medical management committee; and
                    (D) has established, where practicable, effective 
                referral relationships between the primary care 
                provider and the major medical specialties and 
                ancillary services in the region.
            (2) Health center.--The term ``health center'' has the 
        meaning given that term in section 330(a) of the Public Health 
        Service Act (42 U.S.C. 254b(a)).
            (3) Medicaid.--The term ``Medicaid'' means the program for 
        medical assistance established under title XIX of the Social 
        Security Act (42 U.S.C. 1396 et seq.).
            (4) Medical management committee.--The term ``medical 
        management committee'' means a group of practitioners that--
                    (A) provides services in the community in which the 
                practice or health center is located;
                    (B) reviews evidence-based practice guidelines;
                    (C) selects targeted disease and care processes 
                that address health conditions in the community (as 
                identified in the National or State health assessment 
                or as outlined in ``Healthy People 2010'', or any 
                subsequent similar report (as determined by the 
                Secretary));
                    (D) defines programs to target disease and care 
                processes;
                    (E) establishes standards and measures for patient-
                centered medical homes, taking into account nationally-
                developed standards and measures; and
                    (F) makes the determination described in 
                subparagraph (A)(iii) of paragraph (5), taking into 
                account the considerations under subparagraph (B) of 
                such paragraph.
            (5) Patient-centered medical home.--
                    (A) In general.--The term ``patient-centered 
                medical home'' means a physician-directed practice or a 
                health center that--
                            (i) incorporates the attributes of the care 
                        management model described in paragraph (1);
                            (ii) voluntarily participates in an 
                        independent evaluation process whereby primary 
                        care providers submit information to the 
                        medical management committee of the relevant 
                        network;
                            (iii) the medical management committee 
                        determines has the capability to achieve 
                        improvements in the management and coordination 
                        of care for targeted beneficiaries (as defined 
                        by statewide quality improvement standards and 
                        outcomes); and
                            (iv) meets the requirements imposed on a 
                        covered entity for purposes of applying part C 
                        of title XI of the Social Security Act (42 
                        U.S.C. 1320d et seq.) and all regulatory 
                        provisions promulgated thereunder, including 
                        regulations (relating to privacy) adopted 
                        pursuant to the authority of the Secretary 
                        under section 264(c) of the Health Insurance 
                        Portability and Accountability Act of 1996 (42 
                        U.S.C. 1320d-2 note).
                    (B) Considerations.--In making the determination 
                under subparagraph (A)(iii), the medical management 
                committee shall consider the following:
                            (i) Access and communication with 
                        patients.--Whether the practice or health 
                        center applies both standards for access to 
                        care for, and standards for communication with, 
                        targeted beneficiaries who receive care through 
                        the practice or health center.
                            (ii) Managing patient information and using 
                        information management to support patient 
                        care.--Whether the practice or health center 
                        has readily accessible, clinically useful 
                        information on such beneficiaries that enables 
                        the practice or health center to provide 
                        comprehensive and systematic treatment.
                            (iii) Managing and coordinating care 
                        according to individual needs.--Whether the 
                        practice or health center--
                                    (I) maintains continuous 
                                relationships with such beneficiaries 
                                by implementing evidence-based 
                                guidelines and applying such guidelines 
                                to the identified needs of individual 
                                beneficiaries over time and with the 
                                intensity needed by such beneficiaries;
                                    (II) assists in the early 
                                identification of health care needs;
                                    (III) provides ongoing primary 
                                care;
                                    (IV) coordinates with a broad range 
                                of other specialty, ancillary, and 
                                related services; and
                                    (V) provides health care services 
                                and consultations in a culturally and 
                                linguistically appropriate manner, as 
                                well as at a time and location that is 
                                convenient to the patient.
                            (iv) Providing ongoing assistance and 
                        encouragement in patient self-management.--
                        Whether the practice or health center--
                                    (I) collaborates with targeted 
                                beneficiaries who receive care through 
                                the practice or health center to pursue 
                                their goals for optimal achievable 
                                health;
                                    (II) assesses patient-specific 
                                barriers; and
                                    (III) conducts activities to 
                                support patient self-management.
                            (v) Resources to manage care.--Whether the 
                        practice or health center has in place the 
                        resources and processes necessary to achieve 
                        improvements in the management and coordination 
                        of care for targeted beneficiaries who receive 
                        care through the practice or health center.
                            (vi) Monitoring performance.--Whether the 
                        practice or health center--
                                    (I) monitors its clinical process 
                                and performance (including process and 
                                outcome measures) in meeting the 
                                applicable standards under paragraph 
                                (4)(E); and
                                    (II) provides information in a form 
                                and manner specified by the steering 
                                committee and medical management 
                                committee with respect to such process 
                                and performance.
            (6) Personal primary care provider.--The term ``personal 
        primary care provider'' means--
                    (A) a physician, nurse practitioner, or other 
                qualified health care provider (as determined by the 
                Secretary), who--
                            (i) practices in a patient-centered medical 
                        home; and
                            (ii) has been trained to provide first 
                        contact, continuous, and comprehensive care for 
                        the whole person, not limited to a specific 
                        disease condition or organ system, including 
                        care for all types of health conditions (such 
                        as acute care, chronic care, and preventive 
                        services); or
                    (B) a health center that--
                            (i) is a patient-centered medical home; and
                            (ii) has providers on staff that have 
                        received the training described in subparagraph 
                        (A)(ii).
            (7) Primary care case management services; primary care 
        case manager.--The terms ``primary care case management 
        services'' and ``primary care case manager'' have the meaning 
        given those terms in section 1905(t) of the Social Security Act 
        (42 U.S.C. 1396d(t)).
            (8) Project.--The term ``project'' means the demonstration 
        project established under this section.
            (9) CHIP.--The term ``CHIP'' means the State Children's 
        Health Insurance Program established under title XXI of the 
        Social Security Act (42 U.S.C. 1396aa et seq.).
            (10) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (11) Steering committee.--The term ``steering committee'' 
        means a local management group comprised of collaborating local 
        health care practitioners or a local not-for-profit network of 
        health care practitioners--
                    (A) that implements State-level initiatives;
                    (B) that develops local improvement initiatives;
                    (C) whose mission is to--
                            (i) investigate questions related to 
                        community-based practice; and
                            (ii) improve the quality of primary care; 
                        and
                    (D) whose membership--
                            (i) represents the health care delivery 
                        system of the community it serves; and
                            (ii) includes physicians (with an emphasis 
                        on primary care physicians) and at least 1 
                        representative from each part of the 
                        collaborative or network (such as a 
                        representative from a health center, a 
                        representative from the health department, a 
                        representative from social services, and a 
                        representative from each public and private 
                        hospital in the collaborative or the network).
            (12) Targeted beneficiary.--
                    (A) In general.--The term ``targeted beneficiary'' 
                means an individual who is eligible for benefits under 
                a State plan under Medicaid or a State child health 
                plan under CHIP.
                    (B) Participation in patient-centered medical 
                home.--Individuals who are eligible for benefits under 
                Medicaid or CHIP in a State that has been selected to 
                participate in the project shall receive care through a 
                patient-centered medical home when available.
                    (C) Ensuring choice.--In the case of such an 
                individual who receives care through a patient-centered 
                medical home, the individual shall receive guidance 
                from their personal primary care provider on 
                appropriate referrals to other health care 
                professionals in the context of shared decision-making.
    (b) Establishment.--The Secretary shall establish a demonstration 
project under Medicaid and CHIP for the implementation of a patient-
centered medical home program that meets the requirements of subsection 
(d) to improve the effectiveness and efficiency in providing medical 
assistance under Medicaid and CHIP to an estimated 500,000 to 1,000,000 
targeted beneficiaries.
    (c) Project Design.--
            (1) Duration.--The project shall be conducted for a 3-year 
        period, beginning not later than [October 1, 2011].
            (2) Sites.--
                    (A) In general.--The project shall be conducted in 
                8 States--
                            (i) four of which already provide medical 
                        assistance under Medicaid for primary care case 
                        management services as of the date of enactment 
                        of this Act; and
                            (ii) four of which do not provide such 
                        medical assistance.
                    (B) Application.--A State seeking to participate in 
                the project shall submit an application to the 
                Secretary at such time, in such manner, and containing 
                such information as the Secretary may require.
                    (C) Selection.--In selecting States to participate 
                in the project, the Secretary shall ensure that urban, 
                rural, and underserved areas are served by the project.
            (3) Grants and payments.--
                    (A) Development grants.--
                            (i) First year development grants.--The 
                        Secretary shall award development grants to 
                        States participating in the project during the 
                        first year the project is conducted. Grants 
                        awarded under this clause shall be used by a 
                        participating State to--
                                    (I) assist with the development of 
                                steering committees, medical management 
                                committees, and local networks of 
                                health care providers; and
                                    (II) facilitate coordination with 
                                local communities to be better prepared 
                                and positioned to understand and meet 
                                the needs of the communities served by 
                                patient-centered medical homes.
                            (ii) Second year funding.--The Secretary 
                        shall award additional grant funds to States 
                        that received a development grant under clause 
                        (i) during the second year the project is 
                        conducted if the Secretary determines such 
                        funds are necessary to ensure continued 
                        participation in the project by the State. 
                        Grant funds awarded under this clause shall be 
                        used by a participating State to assist in 
                        making the payments described in paragraph (B). 
                        To the extent a State uses such grant funds for 
                        such purpose, no matching payment may be made 
                        to the State for the payments made with such 
                        funds under section 1903(a) or 2105(a) of the 
                        Social Security Act (42 U.S.C. 1396b(a); 
                        1397ee(a)).
                    (B) Additional payments to personal primary care 
                providers and steering committees.--
                            (i) Payments to personal primary care 
                        providers.--
                                    (I) In general.--Subject to 
                                subsection (d)(6)(B), a State 
                                participating in the project shall pay 
                                a personal primary care provider not 
                                less than $2.50 per month per targeted 
                                beneficiary assigned to the personal 
                                primary care provider, regardless of 
                                whether the provider saw the targeted 
                                beneficiary that month.
                                    (II) Federal matching payment.--
                                Subject to subparagraph (A)(ii), 
                                amounts paid to a personal primary care 
                                provider under subclause (I) shall be 
                                considered medical assistance or child 
                                health assistance for purposes of 
                                section 1903(a) or 2105(a), 
                                respectively, of the Social Security 
                                Act (42 U.S.C. 1396b(a); 1397ee(a)).
                                    (III) Patient population.--In 
                                determining the amount of payment to a 
                                personal primary care provider per 
                                month with respect to targeted 
                                beneficiaries under this clause, a 
                                State participating in the project 
                                shall take into account the care needs 
                                of such targeted beneficiaries.
                            (ii) Payments to steering committees.--
                                    (I) In general.--Subject to 
                                subsection (d)(6)(B), a State 
                                participating in the project shall pay 
                                a steering committee not less than 
                                $2.50 per targeted beneficiary per 
                                month.
                                    (II) Federal matching payment.--
                                Subject to subparagraph (A)(ii), 
                                amounts paid to a steering committee 
                                under subclause (I) shall be considered 
                                medical assistance or child health 
                                assistance for purposes of section 
                                1903(a) or 2105(a), respectively, of 
                                the Social Security Act (42 U.S.C. 
                                1396b(a); 1397ee(a)).
                                    (III) Use of funds.--Amounts paid 
                                to a steering committee under subclause 
                                (I) shall be used (in accordance with 
                                any applicable Medicaid requirements) 
                                to purchase health information 
                                technology, pay primary care case 
                                managers, support network initiatives, 
                                and for such other uses as the steering 
                                committee determines appropriate.
            (4) Technical assistance.--The Secretary shall make 
        available technical assistance to States, physician practices, 
        and health centers participating in the project during the 
        duration of the project.
            (5) Best practices information.--The Secretary shall 
        collect and make available to States participating in the 
        project information on best practices for patient-centered 
        medical homes.
    (d) Patient-Centered Medical Home Program.--
            (1) In general.--For purposes of this section, a patient-
        centered medical home program meets the requirements of this 
        subsection if, under such program, targeted beneficiaries have 
        access to a personal primary care provider in a patient-
        centered medical home as their source of first contact, 
        comprehensive, and coordinated care for the whole person.
            (2) Elements.--
                    (A) Mandatory elements.--
                            (i) In general.--Such program shall include 
                        the following elements:
                                    (I) A steering committee.
                                    (II) A medical management 
                                committee.
                                    (III) A network of physician 
                                practices and health centers that have 
                                volunteered to participate as patient-
                                centered medical homes to provide high-
                                quality care, focusing on preventive 
                                care, at the appropriate time and place 
                                and in a cost-effective manner.
                                    (IV) Hospitals and local public 
                                health departments that will work in 
                                cooperation with the network of 
                                patient-centered medical homes to 
                                coordinate and provide health care.
                                    (V) Primary care case managers to 
                                assist with care coordination.
                                    (VI) Health information technology 
                                to facilitate the provision and 
                                coordination of health care by network 
                                participants.
                            (ii) Multiple locations in the state.--In 
                        the case where a State operates a patient-
                        centered medical home program in 2 or more 
                        areas in the State, the program in each of 
                        those areas shall include the elements 
                        described in clause (i).
                    (B) Optional elements.--Such program may include a 
                non-profit organization that--
                            (i) includes a steering committee and a 
                        medical management committee; and
                            (ii) manages the payments to steering 
                        committees described in subsection 
                        (c)(3)(B)(ii).
            (3) Goals.--Such program shall be designed--
                    (A) to increase--
                            (i) cost efficiencies of health care 
                        delivery;
                            (ii) access to appropriate health care 
                        services, especially wellness and prevention 
                        care, at times convenient for patients;
                            (iii) patient satisfaction;
                            (iv) communication among primary care 
                        providers, hospitals, and other health care 
                        providers;
                            (v) school attendance; and
                            (vi) the quality of health care services 
                        (as determined by the relevant steering 
                        committee and medical management committee, 
                        taking into account nationally developed 
                        standards and measures); and
                    (B) to decrease--
                            (i) inappropriate emergency room 
                        utilization, which can be accomplished through 
                        initiatives, such as expanded hours of care 
                        throughout the program network;
                            (ii) avoidable hospitalizations; and
                            (iii) duplication of health care services 
                        provided.
            (4) Payment.--Under the program, payment shall be provided 
        to personal primary care providers and steering committees (in 
        accordance with subsection (c)(3)(B)).
            (5) Notification.--The State shall notify individuals 
        enrolled in Medicaid or CHIP about--
                    (A) the patient-centered medical home program;
                    (B) the providers participating in such program; 
                and
                    (C) the benefits of such program.
            (6) Treatment of states with a managed care contract.--
                    (A) In general.--In the case where a State 
                contracts with a private entity to manage parts of the 
                State Medicaid program, the State shall--
                            (i) ensure that the private entity follows 
                        the care management model; and
                            (ii) establish a medical management 
                        committee and a steering committee in the 
                        community.
                    (B) Adjustment of payment amounts.--The State may 
                adjust the amount of payments made under (c)(3)(B), 
                taking into consideration the management role carried 
                out by the private entity described in subparagraph (A) 
                and the cost effectiveness provided by such entity in 
                certain areas, such as health information technology.
    (e) Evaluation and Project Report.--
            (1) In general.--
                    (A) Evaluation.--The Secretary, in consultation 
                with appropriate health care professional associations, 
                shall evaluate the project in order to determine the 
                effectiveness of patient-centered medical homes in 
                terms of quality improvement, patient and provider 
                satisfaction, and the improvement of health outcomes.
                    (B) Project report.--Not later than 12 months after 
                completion of the project, the Secretary shall submit 
                to Congress a report on the project containing the 
                results of the evaluation conducted under subparagraph 
                (A). Such report shall include--
                            (i) an assessment of the differences, if 
                        any, between the quality of the care provided 
                        through the patient-centered medical home 
                        program conducted under the project in the 
                        States that provided medical assistance for 
                        primary care case management services and those 
                        that did not;
                            (ii) an assessment of quality improvements 
                        and clinical outcomes as a result of such 
                        program;
                            (iii) estimates of cost savings resulting 
                        from such program; and
                            (iv) recommendations for such legislation 
                        and administrative action as the Secretary 
                        determines to be appropriate.
            (2) Sense of the senate.--It is the sense of the Senate 
        that titles XIX and XXI of the Social Security Act (42 U.S.C. 
        1396 et seq.; 1397aa et seq.) should be amended, based on the 
        results of the evaluation and report under paragraph (1), to 
        establish a patient-centered medical home program under such 
        titles on a permanent basis.
    (f) Waiver.--
            (1) In general.--Subject to paragraph (2), the Secretary 
        shall waive compliance with such requirements of titles XI, 
        XIX, and XXI of the Social Security Act (42 U.S.C. 1301 et 
        seq.; 1396 et seq.; 1397aa et seq.) to the extent and for the 
        period the Secretary finds necessary to conduct the project.
            (2) Limitation.--In no case shall the Secretary waive 
        compliance with the requirements of subsections (a)(10)(A), 
        (a)(15), and (bb) of section 1902 of the Social Security Act 
        (42 U.S.C. 1396a) under paragraph (1), to the extent that such 
        requirements require the provision of and reimbursement for 
        services described in section 1905(a)(2)(C) of such Act (42 
        U.S.C. 1396d(a)(2)(C)).
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