Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015

To amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities, and for other purposes. 1. Short title This Act may be cited as the Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 2. Establishing beneficiary equity in the Medicare hospital readmission program (a) Transitional adjustment for dual eligible population and socioeconomic status Section 1886(q)(4)(C) of the Social Security Act ( 42 U.S.C. 1395ww(q)(4)(C) (iii) Transitional adjustment for dual eligibles and socioeconomic status (I) In general In determining a hospital’s excess readmission ratio under clause (i) for purposes of making payments for discharges occurring during fiscal years 2016 and 2017, and before the initial application of clause (iv), and in order to ensure that hospitals that treat the most vulnerable populations are not unfairly penalized by the program under this subsection, the Secretary shall provide for such risk adjustment as will take into account both a hospital's proportion of inpatients who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)) and the socioeconomic status of the patients served by the hospital. (II) Quantitative method For purposes of applying subclause (I)(bb), the Secretary, to the maximum extent practicable, shall utilize the most recent data available from the Bureau of the Census in order to develop a quantitative method to adjust for socioeconomic status. In developing such quantitative method, the Secretary— (aa) shall, to the maximum extent practicable, use inputs that address at least income, education level, or poverty rate; and (bb) may include inputs that address other socioeconomic and sociodemographic factors determined appropriate by the Secretary. (III) Patients served by the hospital For purposes of subclause (I)(bb), the Secretary shall, to the maximum extent practicable, measure the socioeconomic status for all patients served by each hospital. The Secretary may supplement incomplete or inaccessible patient-level data with data related to the geographic region of the patients served by the hospital. (IV) Minimizing reporting burden on hospitals In carrying out this clause, the Secretary shall not impose any additional reporting requirements on hospitals. . (b) Subsequent adjustments based on IMPACT and MedPAC reports Section 1886(q)(4)(C) of the Social Security Act ( 42 U.S.C. 1395ww(q)(4)(C) (iv) Risk adjustments under readmission program based on IMPACT and MedPAC reports In making recommendations under subparagraph (D) of section 2(d)(1) of the IMPACT Act of 2014 ( Public Law 113–185 42 U.S.C. 1395lll . (c) MedPAC study on 30-Day readmission threshold The Medicare Payment Advisory Commission shall conduct a study on the appropriateness of using a threshold of 30 days for readmissions under section 1886(q)(5)(E) of the Social Security Act ( 42 U.S.C. 1395ww(q)(5)(E) (d) Addressing issue of noncompliant patients Section 1886(q)(4)(C) of the Social Security Act ( 42 U.S.C. 1395ww(q)(4)(C) (v) Consideration of exclusion of noncompliant patient cases based on V or other appropriate codes In promulgating regulations to carry out this subsection for the applicable period with respect to fiscal year 2017, the Secretary shall consider the use of V or other ICD-related codes for potential exclusions of cases in order to address the issue of noncompliant patients. . (e) Excluding certain clinical conditions (1) Study (A) In general The Secretary of Health and Human Services shall conduct a study, consistent with this paragraph, that assesses and makes recommendations with respect to excluding patients whose clinical conditions or diagnoses may require frequent hospitalizations, from the calculation of excess readmissions under section 1886(q)(5)(E) of the Social Security Act ( 42 U.S.C. 1395ww(q)(5)(E) (B) Use of a technical expert panel The Secretary shall convene a multi-stakeholder technical expert panel comprised of individuals knowledgeable about clinical care of hospitalized patients and quality measurement, to provide input and recommendations on the study conducted under this paragraph. (C) Clinical conditions to be considered In conducting the study, the Secretary shall consider exclusions for patients with transplants, burns, psychosis, and substance abuse disorders. The Secretary may include additional clinical conditions where appropriate care may require frequent hospitalizations. (D) Transparency The Secretary shall make a draft of report on such study available for public comment for a period of not less than 30 days. The final study and recommendations shall address the Secretary’s response to public comments. (E) Deadline The Secretary shall submit a final report on the study to Congress no later than Oct. 1, 2016. Such final report shall include recommendations regarding the relevant clinical conditions that should be excluded from the calculation of excess readmissions described in subparagraph (A). (2) Application to calculation of excess readmissions Beginning with fiscal year 2018, the Secretary shall exclude any relevant clinical conditions identified in the recommendations made in the final report under paragraph (1)(E) in determining a hospital’s publicly reported readmission rate and excess readmissions ratio under section 1886(q)(4)(C) of the Social Security Act ( 42 U.S.C. 1395ww(q)(4)(C) (f) Budget neutral implementation The Secretary of Health and Human Services shall make such payment adjustment to subsection (d) hospitals under the inpatient prospective payment system under section 1886 of the Social Security Act ( 42 U.S.C. 1395ww

Summary: Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015 This bill amends title XVIII (Medicare) of the Social Security Act (SSAct) with respect to the hospital readmissions reduction program under the inpatient (hospital) prospective payment system (IPPS). The Secretary of Health and Human Services, in determining a hospital's excess readmission ratio for purposes of making payments for discharges occurring during FY2016-FY2017, is required to make a risk adjustment to the ratio that takes into account both: (1) a hospital's proportion of inpatients who are full-benefit dual eligible individuals (eligible for both Medicare and Medicaid under SSAct title XIX), and (2) the socioeconomic status of patients served by the hospital. The Secretary must base the risk adjustment under the readmission program for subsequent fiscal years on specified reports required by the Improving Medicare Post Acute Care Transformation Act of 2014 as well as a report the Medicare Payment Advisory Commission shall submit on the appropriateness of using a threshold of 30 days for readmissions under the program. The Administrator of the Centers for Medicare & Medicaid Services must then incorporate report recommendations in carrying out risk adjustments for discharges occurring in such fiscal years in order to ensure that the most vulnerable populations are not unfairly penalized by the program. The Secretary shall consider the use of V or other International Classification of Diseases-related codes for potential exclusion of noncompliant patient cases when promulgating related regulations for FY2017. The Secretary must: (1) assess whether to exclude from the calculation of excess readmissions any patients whose clinical conditions or diagnoses may require frequent hospitalizations; then (2) exclude, starting in FY2018, any relevant clinical conditions identified in the assessment recommendations when determining a hospital's publicly reported readmission rate and excess readmissions ratio. The Secretary is directed to make a payment adjustment to subsection (d) hospitals necessary to ensure that the implementation of this Act does not result in any increase in aggregate expenditures under the IPPS. (Generally, a subsection (d) hospital is an acute care hospital, particularly one that receives payment under the IPPS when providing covered inpatient services to eligible beneficiaries.)