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[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1046 Introduced in House (IH)]

110th CONGRESS
  1st Session
                                H. R. 1046

 To amend titles XI and XVIII of the Social Security Act to modernize 
          the quality improvement organization (QIO) program.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                           February 14, 2007

 Mr. Burgess introduced the following bill; which was referred to the 
 Committee on Energy and Commerce, and in addition to the Committee on 
   Ways and Means, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

 
 To amend titles XI and XVIII of the Social Security Act to modernize 
          the quality improvement organization (QIO) program.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare Quality 
Improvement Organization Modernization Act of 2007''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Quality improvement activities.
Sec. 3. Improved program administration.
Sec. 4. Data disclosure.
Sec. 5. Use of evaluation and competition.
Sec. 6. Quality improvement funding.
Sec. 7. Qualifications for QIOs.
Sec. 8. Coordination with medicaid.
Sec. 9. Conforming name to ``quality improvement organizations.''.

SEC. 2. QUALITY IMPROVEMENT ACTIVITIES.

    (a) Inclusion of Quality Improvement Functions.--Section 1154(a) of 
the Social Security Act (42 U.S.C. 1320c-3(a)) is amended by adding at 
the end the following new paragraph:
            ``(18) The organization shall offer quality improvement 
        assistance to providers, practitioners, Medicare Advantage 
        organizations offering Medicare Advantage plans under part C of 
        title XVIII, and prescription drug sponsors offering 
        prescription drug plans under part D of such title, including 
        the following:
                    ``(A) Education on quality improvement initiatives, 
                strategies, and techniques.
                    ``(B) Instruction on how to collect, submit, 
                aggregate, and interpret data on measures that may be 
                used for quality improvement, public reporting, and 
                payment.
                    ``(C) Instruction on how to conduct root-cause 
                analyses.
                    ``(D) Technical assistance for providers and 
                practitioners in beneficiary education to facilitate 
                patient self-management.
                    ``(E) Facilitating cooperation among various local 
                stakeholders in quality improvement.
                    ``(F) Facilitating adoption of procedures that 
                encourage timely candid feedback from patients and 
                their families concerning perceived problems.
                    ``(G) Guidance on redesigning clinical processes, 
                including the adoption and effective use of health 
                information technology, to improve the coordination, 
                effectiveness, and safety of care.
                    ``(H) Assistance in improving the quality of care 
                delivered in rural and frontier areas and reducing 
                health care disparities among racial and ethnic 
                minorities, as well as gender disparities, including 
                efforts to prevent or address any inconsistencies or 
                delays in the rate of adoption of health information 
                technology and in the effective use of such technology 
                among such entities that treat racial and ethnic 
                minorities or individuals dually eligible for benefits 
                under this title and title XVIII or that furnish such 
                services in rural areas.
                    ``(I) Assistance in improving coordination of care 
                as patients transition between providers and 
                practitioners, including developing the capacity to 
                securely exchange electronic health information and 
                helping providers and practitioners to effectively use 
                secure electronic health information to improve 
                quality.''.
    (b) Medicare Quality Accountability Program.--Paragraph (14) of 
section 1154(a) of such Act (42 U.S.C. 1320c-3(a)) is amended to read 
as follows:
            ``(14)(A) The organization shall conduct a review of all 
        written complaints about the quality of services (for which 
        payment may otherwise be made under title XVIII) not meeting 
        professionally recognized standards of health care, if the 
        complaint is filed with the organization by an individual 
        entitled to benefits for such services under such title (or a 
        person acting on the individual's behalf). Before the 
        organization concludes that the quality of services does not 
        meet professionally recognized standards of health care, the 
        organization must provide the practitioner or person concerned 
        with reasonable notice and opportunity for discussion.
            ``(B) The organization shall establish and operate a 
        Medicare quality accountability program consistent with the 
        following:
                    ``(i) The organization shall actively educate 
                Medicare beneficiaries of their right to bring quality 
                concerns to Quality Improvement Organizations.
                    ``(ii) The organization shall report findings of 
                its investigations to the beneficiary involved or a 
                representative of such beneficiary, regardless of 
                whether such findings involve a provider, physician or 
                other practitioner, or plan. Such report shall describe 
                whether the organization confirms the allegations in 
                the complaint and any actions taken by the provider, 
                practitioner, or plan, respectively, with respect to 
                such findings. Such findings may not be used in any 
                form in a medical malpractice action.
                    ``(iii) The organization shall assist providers, 
                practitioners, and plans in adopting best practices for 
                soliciting and welcoming feedback about patient 
                concerns, and assist providers, practitioners, and 
                plans in remedying patient-reported problems that are 
                confirmed by the organization and shall report findings 
                of patient reported problems to the provider, 
                practitioner, or plan involved before disclosing 
                investigation results to the patient or patient's 
                representative.
                    ``(iv) The organization shall determine whether the 
                complaint allegations about clinical quality of care 
                are confirmed and assist providers, practitioners, and 
                plans in remedying confirmed complaints.
                    ``(v) The organization shall assist providers, 
                practitioners, and plans in preventing recurrence of 
                quality problems caused by unsafe systems of care, and 
                refer to an appropriate regulatory body providers, 
                practitioners, or plans that are unwilling or unable to 
                improve.
                    ``(vi) The organization shall publish annual 
                quality reports in each State in which the organization 
                operates, including aggregate complaint data and 
                provider performance on standardized quality measures.
                    ``(vii) The organization shall promote beneficiary 
                awareness of standardized quality measures that may be 
                used for evaluating care and for choosing providers, 
                practitioners and plans.
            ``(C) The Secretary shall monitor and report to Congress, 
        regarding--
                    ``(i) the reliability of complaint determinations 
                by Quality Improvement Organizations;
                    ``(ii) the effect of disclosure of complaint 
                findings on the availability of primary- and specialty-
                care physician reviewers;
                    ``(iii) changes resulting from the systems change 
                process described in subparagraph (B)(v); and
                    ``(iv) trends in civil litigation filed by Medicare 
                beneficiaries or their representatives.''.

SEC. 3. IMPROVED PROGRAM ADMINISTRATION.

    Part B of title XI of the Social Security Act is amended by adding 
at the end the following new section:

                        ``program administration

    ``Sec. 1164.  (a) Improved Program Management.--
            ``(1) Report on management of the qio program.--The 
        Comptroller General of the United States shall submit to 
        Congress, no later than March 31, 2010, a report on the 
        implementation by the Secretary and the Director of the Office 
        of Management and Budget of this part and their overall 
        management of the program under this part.
            ``(2) Program management.--The report under paragraph (1) 
        shall include a review of all of the following:
                    ``(A) Implementation of the priorities, 
                recommendations, and strategies of the strategic 
                advisory committee under subsection (c)(1).
                    ``(B) Implementation of appropriate program and 
                contractor evaluation.
                    ``(C) Ensuring timely issuance of statements of 
                work.
                    ``(D) Ensuring timely and priority QIO access to 
                Medicare data for quality improvement purposes.
                    ``(E) Ensuring timely apportionment of funding.
                    ``(F) Ensuring funding levels are commensurate with 
                new work added to the QIO contract, as described in the 
                second sentence of section 1159(b)(1).
                    ``(G) The process of developing the apportionment 
                request and determining the funding allocation to QIOs.
                    ``(H) The identification of and progress towards 
                measures of effective management by the Secretary of 
                the QIO program.
                    ``(I) A review of the experience and qualifications 
                of staff of the Centers for Medicare & Medicaid 
                Services in overseeing the program.
            ``(3) Innovation.--The Secretary shall ensure that Quality 
        Improvement Organizations are provided maximum freedom in 
        designing and applying intervention strategies for local 
        quality improvement.
    ``(b) Assuring Data Access.--The Secretary shall ensure that 
Quality Improvement Organizations have timely, top priority access to 
Medicare data for all parts of Medicare pertinent to the contract 
activities, in a form allowing the data to be integrated and analyzed 
by such organizations according to the needs of partners and Medicare 
beneficiaries in each jurisdiction.
    ``(c) Setting Strategic Priorities.--
            ``(1) Appointment of strategic advisory committee.--The 
        Secretary shall appoint an independent strategic advisory 
        committee, composed of national quality measurement and 
        improvement experts, that includes at least three 
        representatives of organizations holding contracts under this 
        part and at least one appropriately qualified representative of 
        each of the following:
                    ``(A) Medicare beneficiaries.
                    ``(B) The Agency for Healthcare Research and 
                Quality.
                    ``(C) The Federal Employee Health Benefits Program.
                    ``(D) The Indian Health Service.
                    ``(E) The TRICARE program.
                    ``(F) The Veterans Health Affairs program.
                    ``(G) State Medicaid programs.
                    ``(H) Private purchasers.
                    ``(I) Health care providers.
                    ``(J) Physicians.
                    ``(K) Other health care practitioners.
            ``(2) Duties of committee.--Such committee shall set 
        national strategic priorities for improvement in the quality of 
        care, consistent with the Institute of Medicine's six aims for 
        health care improvement, including safety, effectiveness, 
        patient centeredness, timeliness, efficiency and equity, and 
        update these in time to permit preparation of a draft statement 
        of work and funding request for each program cycle under this 
        part.
            ``(3) Independent evaluation.--The committee should ensure 
        that the Quality Improvement Organization program is evaluated 
        by an independent entity using a study design, such as a 
        crossover design, to allow for an assessment of program 
        performance in a way that does not have an adverse impact on 
        providers, practitioners, and plans that may work with the 
        Organization.
            ``(4) Funding.--The Secretary shall allocate funds for the 
        strategic advisory committee from the portion of the funding 
        that does not directly fund the contracts with Quality 
        Improvement Organizations, as required under section 1159(b).
    ``(d) Taking Into Account Recommendations From Stakeholders in 
Statements of Work.--Each statement of work under this part for a 
contract period beginning on or after August 1, 2008, shall include a 
task for the contracting Quality Improvement Organization to convene 
stakeholders to identify high priority quality problems for work in the 
next contract period that are relevant to Medicare beneficiaries in the 
State. Each such organization shall propose, as part of such statement, 
one or more projects to the Secretary taking into consideration the 
recommendations of such stakeholders, along with suggested performance 
measures to evaluate progress on such item.
    ``(e) Allocation of Resources to Priority Areas.--The Secretary 
shall allocate at least 20 percent of the funding that directly funds 
contracts with Quality Improvement Organizations under section 1159(b) 
to promote improvement in one or more locally defined priority areas 
identified under subsection (d).
    ``(f) Quality Coordination.--Quality Improvement Organizations 
holding contracts under this part shall be an integral part of Federal 
performance improvement initiatives and each organization's activities 
shall be coordinated with initiatives developed by the Secretary and 
other Federal agencies.''.

SEC. 4. DATA DISCLOSURE.

    Section 1160 of the Social Security Act (42 U.S.C. 1320c-9) is 
amended--
            (1) in subsection (a)(3), by striking ``subsection (b)'' 
        and inserting ``subsections (b) and (f)''; and
            (2) by adding at the end the following new subsection:
    ``(f)(1) An organization with a contract with the Secretary under 
this part may share individual-specific data with a physician treating 
the individual, for quality improvement and patient safety purposes.
    ``(2) The Secretary shall promulgate, not later than 180 days after 
the date of the enactment of this subsection, a regulation that permits 
the sharing of data under paragraph (1).
    ``(3) Nothing in this subsection shall be construed to limit, 
alter, or affect the requirements imposed by the regulations 
promulgated under section 264(c) of the Health Insurance Portability 
and Accountability Act of 1996.''.

SEC. 5. USE OF EVALUATION AND COMPETITION.

    Section 1153 of the Social Security Act (42 U.S.C. 1320c-2) is 
amended--
            (1) by amending paragraph (3) of subsection (c) to read as 
        follows:
            ``(3) contract terms are consistent with subsection (j);'';
            (2) in subsection (c)(1), by inserting ``, at the sole 
        discretion of the organization,'' after ``or may subcontract'';
            (3) in subsection (e), by striking ``(1) Except as 
        provided'' and all that follows through ``(2)''; and
            (4) by adding at the end the following new subsections:
    ``(j)(1) Subject to the succeeding provisions of this subsection, 
each contract with an organization under this section shall be for an 
initial term of five years, beginning and ending on a common date for 
all contractors as required under this subsection and shall be 
renewable for 5 year terms thereafter.
    ``(2) If an incumbent organization achieves excellent performance 
as described in paragraph (3), then the Secretary may renew the 
contract with that organization without full and open competition, but 
in no case may an organization be permitted to hold a contract for more 
than 10 years without being subject to full and open competition.
    ``(3) Before publishing a request for proposal for a contract 
period, the Secretary shall, in consultation with the strategic 
advisory committee appointed under section 1164(c)(1), establish 
measurable goals for each task to be included in such proposal. The 
contract shall include performance thresholds by which an organization 
holding a contract under this section may demonstrate excellent 
performance. The Secretary may not establish such performance 
thresholds in such a way as to predetermine or limit either the number 
or percentage of organizations which may demonstrate excellent 
performance.
    ``(4) The Secretary shall publish the request for proposals no 
later than four months prior to the beginning of such contract period.
    ``(5) The Secretary shall utilize the strategic advisory committee 
appointed under section 1164(c)(1) to qualify the validity, 
reliability, and feasibility of measures to be used in evaluating the 
performance of organizations holding a contract under this section. 
Before any performance measure may be used for such purpose, it must 
have been designated by such committee to be valid, reliable, and 
feasible for use under similar circumstances, as demonstrated in at 
least one reliable and valid study.
    ``(6) In the case of an open competition for a contract under this 
section, if the incumbent organization bidding for the contract in the 
State in which it holds the contract demonstrates excellent performance 
in fulfilling the terms of such contract during the previous contract 
period, the Secretary shall award such organization a bonus equivalent 
to ten percent of the total possible score for the proposal.
    ``(7) The Secretary may not reduce the amount of a contract award 
below the amount proposed by the bidder prevailing in a competitive 
bidding process.
    ``(8) The Secretary shall design the process for performance 
evaluation of contracts under this section--
            ``(A) to avoid interfering with the work of contractors 
        with plans, providers, and practitioners;
            ``(B) to hold harmless and not penalize contractors when 
        performance is impaired or delayed by failures of the 
        Secretary, personnel of the Department of Health and Human 
        Services, or contractors of the Secretary, to provide timely 
        deliverables by other entities;
            ``(C) to use a continuous measurement strategy with 
        provision for frequent performance updates for evaluating 
        interim progress; and
            ``(D) to require that evaluation metrics be monitored and 
        permit their adjustment based on experience or evolving science 
        over the course of a contract cycle.
    ``(k)(1) The Secretary shall extend each contract under this 
section the contract period for which began on or after August 1, 2005, 
and before February 1, 2006, so that the subsequent contract period 
begins on October 1, 2009.
    ``(2) The Secretary shall apportion adequate funding so that 
organizations with contracts extended under this subsection can perform 
existing and new tasks, as determined by the Secretary, during the 
period of the contract extension.
    ``(3) There are authorized to be appropriated such sums as are 
necessary to respond to increased personnel requirements resulting from 
starting all contracts simultaneously, as provided under this 
subsection.''.

SEC. 6. QUALITY IMPROVEMENT FUNDING.

    Section 1159 of the Social Security Act (42 U.S.C. 1320c-8) is 
amended--
            (1) by inserting ``(a)'' before ``Expenses incurred''; and
            (2) by adding at the end the following new subsection:
    ``(b)(1) The aggregate annual funding for contracts under this part 
that begin after August 1, 2008, shall not be less than $421,666,000. 
In addition, there are authorized to be apportioned for contract 
periods in subsequent years such additional amounts as may be necessary 
to adequately fund any resource needs in excess of the amount provided 
under the previous sentence.
    ``(2) At least 80 percent of the funding under this part in a 
contract period shall be expended to directly fund the contracts held 
by organizations, as required under section 1153(b).
    ``(3) The Secretary shall determine the resource needs for a 
contract period in consultation with representatives from existing 
contractors. The determination shall take into account factors 
including any new work added via contract modification during the 
course of the contract period or added from one contract cycle to the 
next cycle. New work includes--
            ``(A) additional core contract tasks, requirements, 
        deliverables, and performance thresholds;
            ``(B) technical assistance for additional providers, 
        practitioners, and health plans and additional provider 
        settings;
            ``(C) increased outreach and communications to Medicare 
        beneficiaries, providers, practitioners, and plans; and
            ``(D) increased volume of medical reviews.
    ``(4) With respect to the apportionment of funds under this part 
for a contract period--
            ``(A) the Secretary shall submit a proposed apportionment 
        to the Director of the Office of Management and Budget no later 
        than 1 year before the first date of the contract period;
            ``(B) such Director shall approve an proposed apportionment 
        no later than 9 months before the first date of such contract 
        period;
            ``(C) for tasks the Secretary proposes to continue from the 
        previous contract period, if the apportionment is not 
        authorized by the deadline specified in subparagraph (B), 
        funding shall continue for the next contract period at a level 
        no less than the level for the previous contract period, 
        increased by the percentage increase in the consumer price 
        index for all urban consumers during the preceding 12-month 
        period.
    ``(5) Organizations with a contract under this part may enter into 
contracts with public or private entities including providers, 
practitioners, and payers other than the Secretary, to provide quality 
improvement or other services if there are arrangements made to avoid 
or mitigate potential conflicts of interest.
    ``(6) Such organizations shall have the ability to meet the terms 
of a contract by allocating funds to functions established by the 
Secretary at its discretion. The Secretary shall review whether the 
organization met the functions and goals set out for the organization, 
regardless of allocation of funds at the initial acceptance of the 
contract.
    ``(7) Organizations with a contract under this part may utilize 
funding allocated to such contracts to pay for food costs directly 
related to fulfilling contract requirements.''.

SEC. 7. QUALIFICATIONS FOR QIOS.

    (a) In General.--Subsection (b) of section 1153 of the Social 
Security Act (42 U.S.C. 1320c-2) is amended by adding at the end the 
following new paragraph:
    ``(4)(A) The Secretary shall not enter into or renew a contract 
under this section with an entity unless the entity has demonstrated 
success in facilitating clinical and administrative system redesign to 
improve the coordination, effectiveness, and safety of health care, and 
in facilitating cooperation among stakeholders in quality improvement.
    ``(B) The Secretary shall ensure that the entity complies with 
standards to ensure organizational integrity, including--
            ``(i) appropriate representation of consumers and other 
        stakeholders in the composition of the governing body;
            ``(ii) market-based compensation of board members and 
        executives;
            ``(iii) avoidance and mitigation of board member conflict 
        of interest; and
            ``(iv) safeguards to ensure appropriate travel expenses.
To the extent practicable, the Secretary shall utilize standards 
developed in the private sector for purposes of carrying out this 
subparagraph and shall conduct audits as necessary to ensure compliance 
with such standards.''.
    (b) Use of States for Geographic Areas.--Subsection (a) of such 
section is amended to read as follows:
    ``(a) The Secretary shall designate each State as a geographic area 
with respect to which contracts under this part will be made.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to contract periods beginning after the date of the enactment of 
this Act.

SEC. 8. COORDINATION WITH MEDICAID.

    (a) Permitting Alternative Quality Improvement Program.--Section 
1902(a)(30) of the Social Security Act (42 U.S.C. 1396a(a)(30)) is 
amended by striking ``and'' at the end of subparagraph (A), by adding 
``and'' and the end of subparagraph (B), and by adding at the end the 
following new subparagraph:
                    ``(C) provide, at the discretion of the State plan, 
                for a quality improvement program in place of the 
                program described in subparagraph (A), in whole or in 
                part, that--
                            ``(i) establishes priorities for achieving 
                        significant measurable improvement in the 
                        quality of health care services provided to 
                        individuals eligible under this title, and 
                        reviews such priorities at least every five 
                        years for the purpose of making appropriate 
                        revisions;
                            ``(ii) provides quality improvement 
                        assistance to providers and practitioners 
                        consistent with such priorities; and
                            ``(iii) provides for an annual report to 
                        the Secretary on quality performance under such 
                        plan of providers and practitioners using 
                        nationally standardized quality measures;''.
    (b) Role of QIOs.--Section 1902(d) of such Act (42 U.S.C. 1396a(d)) 
is amended--
            (1) by inserting ``(1)'' after ``(d)''; and
            (2) by adding at the end the following new paragraph:
    ``(2) If a State contracts with a Quality Improvement Organization 
having a contract with the Secretary under part B of title XI for the 
performance of quality improvement program activities required by 
subsection (a)(30)(C), such requirements shall be deemed to be met for 
those activities by delegation to such an Organization if the contract 
provides for the performance of activities not inconsistent with part B 
of title XI and provides for such assurances of satisfactory 
performance by such an entity or organization as the Secretary may 
prescribe.''.
    (c) Funding.--Section 1903(a)(3)(C) of such Act (42 U.S.C. 
1396b(a)(3)(C)) is amended--
            (1) in clause (i), by striking ``1902(d)'' and inserting 
        ``1902(d)(1)''; and
            (2) by adding at the end the following new clause:
                            ``(iii) 75 percent of the sums expended 
                        with respect to costs incurred during such 
                        quarter (as found necessary by the Secretary 
                        for the proper and efficient administration of 
                        the State plan) as are attributable to the 
                        performance of quality improvement program 
                        activities under a contract entered into under 
                        section 1902(d)(2) by an organization holding a 
                        contract under section 1153; and''.
    (d) Effective Date.--The amendments made by this section shall 
apply to contract periods beginning after the date of the enactment of 
this Act.

SEC. 9. CONFORMING NAME TO ``QUALITY IMPROVEMENT ORGANIZATIONS''.

    Part C of title XI of the Social Security Act is amended by 
striking ``utilization and quality control peer review'' (and ``peer 
review'') each place it appears before ``organization'' or 
``organizations'' and inserting ``quality improvement''.
                                 <all>
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