the number of sessions covered under such sec-
tion;’’. 
(6) ANNUAL REPORT TO CONGRESS.—Not later 
than April 1, 2009, and annually thereafter, the 
Secretary of Health and Human Services shall sub-
mit a report to Congress on the number of Medicare 
beneficiaries who are entitled to kidney disease edu-
cation services (as defined in section 1861(ccc) of 
the Social Security Act, as added by paragraph (2)) 
under title XVIII of such Act and who receive such 
services, together with such recommendations for 
legislative and administrative action as the Secretary 
determines to be appropriate to fulfill the legislative 
intent that resulted in the enactment of that sub-
section. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2009. 
SEC. 103. BLOOD FLOW MONITORING DEMONSTRATION 
PROJECTS. 
(a) ESTABLISHMENT.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall establish demonstration projects to evaluate 
how blood flow monitoring affects the quality and cost of 
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care for Medicare beneficiaries with end-stage renal dis-
ease. 
(b) DURATION.—The demonstration projects under 
this section shall be conducted for a period of not longer 
than 5 years that begins on January 1, 2009. 
(c) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Secretary shall conduct 
an evaluation of the demonstration projects con-
ducted under this section. 
(2) REPORT.—Not later than 6 months after 
the date on which the demonstration projects under 
this section are completed, the Secretary shall sub-
mit to Congress a report on the evaluation con-
ducted under paragraph (1) together with rec-
ommendations for such legislation and administra-
tive action as the Secretary determines appropriate. 
(d) WAIVER AUTHORITY.—The Secretary shall waive 
compliance with the requirements of title XVIII of the So-
cial Security Act (42 U.S.C. 1395 et seq.) to the extent, 
and for such period as, the Secretary determines is nec-
essary to conduct the demonstration projects. 
(e) AUTHORIZATION OF APPROPRIATIONS.— 
(1) IN GENERAL.—Payments for the costs of 
carrying out the demonstration projects under this 
section shall be made from the Federal Supple-
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mentary Medical Insurance Trust Fund under sec-
tion 1841 of the Social Security Act (42 U.S.C. 
1395t). 
(2) AMOUNT.—There are authorized to be ap-
propriated from such Trust Fund $1,000,000 for 
each of fiscal years 2009 through 2013 to carry out 
this section. 
SEC. 104. INSTITUTE OF MEDICINE EVALUATION AND RE-
PORT ON TREATMENT MODALITIES FOR PA-
TIENTS WITH KIDNEY FAILURE. 
(a) EVALUATION.— 
(1) IN
GENERAL.—Not later than 2 months 
after the date of enactment of this Act, the Sec-
retary of Health and Human Services (in this sec-
tion referred to as the ‘‘Secretary’’) shall enter into 
an arrangement under which the Institute of Medi-
cine of the National Academy of Sciences (in this 
section referred to as the ‘‘Institute’’) shall conduct 
an evaluation of the barriers that exist to increasing 
the number of individuals with end-stage renal dis-
ease who elect to receive home dialysis services or 
other treatment modalities under the Medicare pro-
gram under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.). 
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(2) SPECIFIC MATTERS EVALUATED.—In con-
ducting the evaluation under paragraph (1), the In-
stitute shall— 
(A) compare current Medicare home dialy-
sis costs and payments with current in-center 
and hospital dialysis costs and payments; 
(B) catalogue and evaluate the incentives 
and disincentives in the current reimbursement 
system that influence whether patients receive 
home dialysis services or other treatment mo-
dalities; 
(C) evaluate patient education services and 
how such services impact the treatment choices 
made by patients; and 
(D) consider such other matters as the In-
stitute determines appropriate. 
(3) SCOPE
OF
REVIEW.—In conducting the 
evaluation under paragraph (1), the Institute shall 
consider a variety of perspectives, including the per-
spectives of physicians, other health care profes-
sionals, hospitals, dialysis facilities, health plans, 
purchasers, and patients. 
(b) REPORT.—Not later than 19 months after the 
date of enactment of this Act, the Institute shall submit 
to the Secretary and to Congress a report on the evalua-
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tion conducted under subsection (a)(1). Such report shall 
contain a detailed description of the findings of such eval-
uation and recommendations for implementing incentives 
to encourage patients to elect to receive home dialysis 
services or other treatment modalities under the Medicare 
program. 
(c) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary for the purposes of conducting the evaluation 
and preparing the report required by this section. 
SEC. 105. REQUIRED TRAINING FOR PATIENT CARE DIALY-
SIS TECHNICIANS. 
(a) IN GENERAL.—Section 1881 of the Social Secu-
rity Act (42 U.S.C. 1395rr) is amended by adding the fol-
lowing new subsection: 
‘‘(h)(1) Except as provided in paragraph (3), begin-
ning January 1, 2009, a provider of services or a renal 
dialysis facility may not use any individual as a patient 
care dialysis technician for more than 4 months unless the 
individual— 
‘‘(A) has completed a training program in the 
care and treatment of an individual with chronic 
kidney failure who is undergoing dialysis treatment; 
‘‘(B) has been certified by a nationally recog-
nized certification entity for dialysis technicians; and 
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‘‘(C) is competent to provide dialysis-related 
services. 
‘‘(2) Beginning January 1, 2010, a provider of serv-
ices or a renal dialysis facility may not use on a tem-
porary, per diem, leased, or on any basis other than as 
a permanent employee, any individual as a patient care 
dialysis technician unless the individual meets the require-
ments described in subparagraphs (A), (B), and (C) of 
paragraph (1). 
‘‘(3) A provider of services or a renal dialysis facility 
may permit an individual enrolled in a training program 
described in paragraph (1)(A) to serve as a patient care 
dialysis technician while they are so enrolled. 
‘‘(4) For purposes of paragraph (1), if, since the most 
recent completion by an individual of a training program 
described in paragraph (1)(A), there has been a period 
of 24 consecutive months during which the individual has 
not performed dialysis-related services for monetary com-
pensation, such individual shall be required to complete 
a new training program or become recertified as described 
in paragraph (1)(B). 
‘‘(5) A provider of services or a renal dialysis facility 
shall provide such regular performance review and regular 
in-service education as assures that individuals serving as 
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patient care dialysis technicians for the provider or facility 
are competent to perform dialysis-related services.’’. 
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 DIS-
EASE (ESRD) ADVISORY COMMITTEE. 
(a) IN GENERAL.—Pursuant to section 222 of the 
Public Health Service Act (42 U.S.C. 217a), the Secretary 
of Health and Human Services (in this section referred 
to as the ‘‘Secretary’’) shall establish within 1 year of the 
date of enactment of this Act an independent, multidisci-
plinary, nonpartisan End-Stage Renal Disease Advisory 
Committee (in this section referred to as the ‘‘Com-
mittee’’). 
(b) MEMBERSHIP.— 
(1) IN GENERAL.—The Committee shall consist 
of such members as the Secretary may appoint who 
shall serve for such term as the Secretary may speci-
fy. The Secretary shall ensure that a representative 
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of the Centers for Medicare & Medicaid Services is 
included among the members of the Committee. 
(2) CONSULTATION.—In appointing members of 
the Committee, the Secretary shall consult with pa-
tients, facilities and providers, physicians, nurses, a 
representative from the pediatric community, payers 
and insurers, manufacturers, and a representative of 
the Centers for Medicare & Medicaid Services who 
coordinates activities related to end-stage renal dis-
ease within the Centers. 
(c) PURPOSE OF THE COMMITTEE.— 
(1) DUTIES.—The Committee shall provide a 
forum for expert discussion and deliberation and the 
formulation of advice and recommendations to the 
Secretary regarding Medicare coverage for individ-
uals with end-stage renal disease, as described under 
section 1881 of the Social Security Act (42 U.S.C. 
1395rr). 
(2) RECOMMENDATIONS.— 
(A) ANNUAL
RECOMMENDATIONS.—The 
Committee shall provide annual recommenda-
tions to the Secretary regarding— 
(i) selecting, modifying, and updating 
clinical and quality of life measures; 
(ii) modifying the payment structure; 
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(iii) determining hardship criteria to 
exempt certain facilities and providers 
from the program; and 
(iv) other issues related to implemen-
tation of a quality initiative by the Sec-
retary. 
(B) PERIODIC
RECOMMENDATIONS.—The 
Committee shall provide periodic advice and 
recommendations to the Secretary regarding 
Medicare coverage for individuals with end- 
stage renal disease, as described in such section 
1881. 
SEC. 202. UPDATE FOR THE MEDICARE ESRD COMPOSITE 
RATE FOR 2008, 2009, AND 2010. 
Section 1881(b)(12)(G) of the Social Security Act 
(42 U.S.C. 1395rr(b)(12)(G)), as amended by section 103 
of the Tax Relief and Health Care Act of 2006 (Public 
Law 109–432), is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by inserting ‘‘and before January 1, 
2008,’’ after ‘‘April 1, 2007’’; and 
(B) by striking the period at the end and 
inserting a semicolon; and 
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(3) by adding at the end the following new 
clauses: 
‘‘(iii) furnished during 2008, by the amount 
equal to the ESRD market basket (as developed 
pursuant to section 422(b) of the Medicare, Med-
icaid, and SCHIP Benefits Improvement and Pro-
tection Act of 2000 (Public Law 106–554), as en-
acted into law by section 1(a)(6) of Public Law 106- 
554) percentage increase for 2008 above the amount 
of such composite rate component for such services 
furnished on December 31, 2007; 
‘‘(iv) furnished during 2009, by the amount 
equal to the ESRD market basket (as so developed) 
percentage increase for 2009 above the amount of 
such composite rate component for such services fur-
nished on December 31, 2008; and 
‘‘(v) furnished on or after January 1, 2010, by 
the amount equal to the ESRD market basket (as 
so developed) percentage increase for 2010 above the 
amount of such composite rate component for such 
services furnished on December 31, 2009.’’. 
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SEC. 203. CONTINUOUS QUALITY IMPROVEMENT INITIA-
TIVE IN THE MEDICARE END-STAGE RENAL 
DISEASE PROGRAM. 
(a) ESTABLISHMENT
OF
THE PROGRAM.—Section 
1881 of the Social Security Act (42 U.S.C. 1395rr), as 
amended by section 105, is amended by adding at the end 
the following new subsection: 
‘‘(i) CONTINUOUS QUALITY IMPROVEMENT INITIA-
TIVE IN THE END-STAGE RENAL DISEASE PROGRAM.— 
‘‘(1) IN GENERAL.—Not later than January 1, 
2008, the Secretary shall establish a 3-year contin-
uous quality improvement initiative (in this section 
referred to as the ‘quality initiative’) under which 
quality payments are provided to renal dialysis facili-
ties, providers of services, and physicians that pro-
vide items and services to individuals with end-stage 
renal disease who are enrolled under part B and 
that meet quality benchmarks and demonstrate qual-
ity improvements. 
‘‘(2) PARTICIPATION.— 
‘‘(A) FACILITIES AND PROVIDERS.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in subparagraph (C)(i) and subject 
to clause (ii), all independent dialysis fa-
cilities and hospital-based dialysis pro-
viders that provide items and services to 
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individuals with end-stage renal disease 
who are enrolled in part B shall participate 
in the quality initiative. 
‘‘(ii) POSITIVE UPDATE REQUIRED.— 
The quality initiative shall not apply to fa-
cilities and providers in a year unless the 
ESRD market basket percentage increase 
described in subsection (b)(12)(G) for such 
year is positive. 
‘‘(B) PHYSICIANS.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in subparagraph (C)(i) and subject 
to clause (ii), all physicians who receive the 
monthly capitated payment under this title 
with respect to end-stage renal disease 
items and services shall participate in the 
quality initiative. 
‘‘(ii) POSITIVE UPDATE REQUIRED.— 
The quality initiative shall not apply to 
physicians in a year unless the update to 
the 
conversion 
factor 
under 
section 
1848(d) for such year is positive. 
‘‘(C) PEDIATRIC
FACILITIES, PROVIDERS, 
AND PHYSICIANS.— 
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‘‘(i) IN GENERAL.—Subject to clause 
(ii), a pediatric facility, provider, or physi-
cian who provides items and services to in-
dividuals with end-stage renal disease who 
are enrolled in part B and with at least 50 
percent of its patients being individuals 
under 18 years of age shall be required to 
report data for pediatric-specific measures 
under this subsection in order to receive 
the full market basket update during 2008, 
2009, 
and 
2010 
under 
subsection 
(b)(12)(G) or the full update under section 
1848(d). 
‘‘(ii) POSITIVE UPDATE REQUIRED.— 
The reporting requirement under clause (i) 
shall not apply to— 
‘‘(I) pediatric facilities and pro-
viders in a year unless the ESRD 
market basket percentage increase de-
scribed in subsection (b)(12)(G) for 
such year is positive; and 
‘‘(II) to pediatric physicians in a 
year unless the update to the conver-
sion factor under section 1848(d) for 
such year is positive. 
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‘‘(iii) EVALUATION.—The Secretary, 
in consultation with the End-Stage Renal 
Disease Advisory Committee established 
under section 201 of the Kidney Care 
Quality and Education Act of 2007 (in this 
subsection referred to as the ‘ESRD Advi-
sory Committee’), shall evaluate and make 
recommendations to Congress regarding 
the feasibility of incorporating pediatric fa-
cilities, providers, and physicians described 
in clause (i) fully into the quality initiative 
if the initiative were to extend beyond 
2010. 
‘‘(3) DURATION.—The quality initiative shall be 
conducted during a period of 3 years beginning Jan-
uary 1, 2008. 
‘‘(4) FUNDING.— 
‘‘(A) BONUS POOL FOR PROVIDERS AND 
FACILITIES.—During 2008, 2009, and 2010, 
the Secretary shall set aside at least 1⁄4, but no 
more than 1⁄2, of the ESRD market basket 
amount under subsection (b)(12)(G) for each 
year, respectively, to establish a bonus pool to 
be used to provide bonus payments for pro-
viders and facilities described in paragraph 
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(2)(A) that demonstrate improvements in qual-
ity or attainment of quality benchmarks. 
‘‘(B) BONUS
POOL
FOR
PHYSICIANS.— 
During 2008, 2009, and 2010, the Secretary 
shall set aside at least 1⁄4, but no more than 1⁄2, 
of the portion of the physician fee schedule up-
date under section 1848(d) that applies to phy-
sicians who receive the monthly capitated pay-
ment under this title with respect to end-stage 
renal disease items and services for each year 
respectively to establish a bonus pool to be used 
to provide bonus payments for physicians de-
scribed in paragraph (2)(B) that demonstrate 
improvements in quality or attainment of qual-
ity benchmarks. 
‘‘(5) ESTABLISHMENT OF QUALITY INCENTIVE 
PAYMENTS.— 
‘‘(A) INCENTIVES
FOR
REPORTING
IN 
2008.— 
‘‘(i) IN GENERAL.—During 2008, the 
Secretary shall make quality incentive pay-
ments from the bonus pool described in 
paragraph (4)(A) to facilities and providers 
and from the bonus pool described in para-
graph (4)(B) to physicians described in 
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subparagraphs (A) and (B) of paragraph 
(2) for reporting data about clinical and 
quality of life measures adopted by the 
Secretary in consultation with the ESRD 
Advisory Committee. 
‘‘(ii) EXTENSION.—If the Secretary 
determines that there are problems associ-
ated with reporting that should be resolved 
before implementing the quality payment 
system under subparagraph (B), the Sec-
retary may extend the reporting period an 
additional year. 
‘‘(iii) EXCEPTION TO REPORTING RE-
QUIREMENT.—The Secretary shall estab-
lish criteria for an application for a hard-
ship exception that would allow small or 
rural facilities and providers to receive the 
full update under subsection (b)(12)(G) 
even if they are not able to report data. 
‘‘(B) QUALITY
INCENTIVE
PAYMENTS
IN 
2009 AND 2010.— 
‘‘(i) IN GENERAL.—During 2009 and 
2010, the Secretary shall make quality in-
centive payments from their respective 
bonus pools under paragraph (4) to facili-
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ties, providers, and physicians described in 
subparagraphs (A) and (B) of paragraph 
(2) with respect to a year if the Secretary 
determines that the quality of care pro-
vided in that year by the facility, provider, 
or physician to individuals with end-stage 
renal disease who are enrolled under part 
B— 
‘‘(I) has substantially improved 
(as determined by the Secretary in 
consultation with the ESRD Advisory 
Committee) over the prior year; or 
‘‘(II) exceeds a threshold estab-
lished by the Secretary in consultation 
with the ESRD Advisory Committee. 
‘‘(ii) 
REQUIREMENTS.—In 
deter-
mining which facilities, providers, or physi-
cians qualify for the quality incentive pay-
ments under clause (i), the Secretary shall 
do the following: 
‘‘(I) Adopt clinical and quality of 
life measures in consultation with the 
ESRD Advisory Committee. 
‘‘(II) For 2008, ensure that pay-
ments will be based on the reporting 
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of data regarding clinical and quality 
of life measures adopted by the Sec-
retary in consultation with the ESRD 
Advisory Committee. 
‘‘(III) For 2009 and 2010, sub-
ject to subparagraph (C), ensure that 
payments will be based upon the com-
posite score awarded to the facilities, 
providers, and physicians. The com-
posite score will be based upon the 
submission of data about clinical and 
quality of life measures adopted by 
the Secretary in consultation with the 
ESRD Advisory Committee. 
‘‘(C) DETERMINATION OF AMOUNT OF IN-
CENTIVE PAYMENT.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the Secretary shall determine the 
amount of a quality incentive payment to 
a facility, provider, or physician based 
upon a quintile scale of a weighted com-
posite score of clinical and quality of life 
measures. 
‘‘(ii) 
LIMITATION.—The 
Secretary 
shall establish the quality incentive pay-
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ments so that the total amount of such 
payments made in a year— 
‘‘(I) to facilities and providers 
from the bonus pool under paragraph 
(4)(A) is equal to the total amount 
available for such payments for the 
year under such paragraph; and 
‘‘(II) to physicians from the 
bonus pool under paragraph (4)(B) is 
equal to the total amount available for 
such payments for the year under 
such paragraph. 
‘‘(D) REQUIREMENTS
FOR
ESTABLISH-
MENT OF THE COMPOSITE SCORE.—In estab-
lishing the composite score under this sub-
section, the Secretary shall— 
‘‘(i) consult with the ESRD Advisory 
Committee to develop the clinical and qual-
ity of life measures and formula used to 
calculate the weighted composite score; 
‘‘(ii) use a transparent process con-
sistent with the requirements of chapter 5 
of title 5, United States Code (commonly 
referred to as the ‘Administrative Proce-
dure Act’) to develop the measures and the 
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formula used to calculate the weighted 
composite score; and 
‘‘(iii) assure that the payments reward 
facilities, providers, and physicians for— 
‘‘(I) the attainment of minimum 
quality targets; and 
‘‘(II) 
substantial 
improvement 
over the previous year, as dem-
onstrated by the movement of a facil-
ity, provider, or physician from 1 
quintile to another. 
‘‘(6) REQUIREMENTS
FOR
INCENTIVE
PAY-
MENTS.— 
‘‘(A) IN GENERAL.—In order for a facility, 
provider, or physician to be eligible for quality 
incentive payments described in paragraph (5) 
for a year, the provider, facility, or physician 
must have provided for the submission of data 
in accordance with subparagraph (B) with re-
spect to that year. 
‘‘(B) SUBMISSION
OF
DATA.—For 2008, 
2009, and 2010, each facility, provider, and 
physician described in subparagraphs (A) and 
(B) of paragraph (2) shall submit to the Sec-
retary such data that the Secretary determines 
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