H. R. 1—261
‘‘(A) the implementation of continuous quality improve-
ment mechanisms that are aimed at integrating commu-
nity-based support services, primary care, and referral care;
‘‘(B) the implementation of activities to increase the
delivery of effective care to beneficiaries;
‘‘(C) encouraging patient participation in preference-
based decisions;
‘‘(D) the implementation of activities to encourage the
coordination and integration of medical service delivery;
and
‘‘(E) the implementation of activities to measure and
document the financial impact on the health care market-
place of altering the incentives of health care delivery
and changing the allocation of resources; and
‘‘(3) meet such other requirements as the Secretary may
establish.
‘‘(e) WAIVER
AUTHORITY.—The Secretary may waive such
requirements of titles XI and XVIII as may be necessary to carry
out the purposes of the demonstration program established under
this section.
‘‘(f) BUDGET NEUTRALITY.—With respect to the 5-year period
of the demonstration program under subsection (b), the aggregate
expenditures under this title for such period shall not exceed the
aggregate expenditures that would have been expended under this
title if the program established under this section had not been
implemented.
‘‘(g) NOTICE REQUIREMENTS.—In the case of an individual that
receives health care items or services under a demonstration pro-
gram carried out under this section, the Secretary shall ensure
that such individual is notified of any waivers of coverage or pay-
ment rules that are applicable to such individual under this title
as a result of the participation of the individual in such program.
‘‘(h) PARTICIPATION AND SUPPORT BY FEDERAL AGENCIES.—In
carrying out the demonstration program under this section, the
Secretary may direct—
‘‘(1) the Director of the National Institutes of Health to
expand the efforts of the Institutes to evaluate current medical
technologies and improve the foundation for evidence-based
practice;
‘‘(2) the Administrator of the Agency for Healthcare
Research and Quality to, where possible and appropriate, use
the program under this section as a laboratory for the study
of quality improvement strategies and to evaluate, monitor,
and disseminate information relevant to such program; and
‘‘(3) the Administrator of the Centers for Medicare & Med-
icaid Services and the Administrator of the Center for Medicare
Choices to support linkages of relevant medicare data to reg-
istry information from participating health care groups for the
beneficiary populations served by the participating groups, for
analysis supporting the purposes of the demonstration program,
consistent with the applicable provisions of the Health Insur-
ance Portability and Accountability Act of 1996.’’.
SEC. 647. MEDPAC STUDY ON DIRECT ACCESS TO PHYSICAL THERAPY
SERVICES.
(a) STUDY.—The Medicare Payment Advisory Commission (in
this section referred to as the ‘‘Commission’’) shall conduct a study
H. R. 1—262
on the feasibility and advisability of allowing medicare fee-for-
service beneficiaries direct access to outpatient physical therapy
services and physical therapy services furnished as comprehensive
rehabilitation facility services.
(b) REPORT.—Not later than January 1, 2005, the Commission
shall submit to Congress a report on the study conducted under
subsection (a) together with recommendations for such legislation
or administrative action as the Commission determines to be appro-
priate.
(c) DIRECT ACCESS DEFINED.—The term ‘‘direct access’’ means,
with respect to outpatient physical therapy services and physical
therapy services furnished as comprehensive outpatient rehabilita-
tion facility services, coverage of and payment for such services
in accordance with the provisions of title XVIII of the Social Security
Act, except that sections 1835(a)(2), 1861(p), and 1861(cc) of such
Act (42 U.S.C. 1395n(a)(2), 1395x(p), and 1395x(cc), respectively)
shall be applied—
(1) without regard to any requirement that—
(A) an individual be under the care of (or referred
by) a physician; or
(B) services be provided under the supervision of a
physician; and
(2) by allowing a physician or a qualified physical therapist
to satisfy any requirement for—
(A) certification and recertification; and
(B) establishment and periodic review of a plan of
care.
SEC. 648. DEMONSTRATION PROJECT FOR CONSUMER-DIRECTED
CHRONIC OUTPATIENT SERVICES.
(a) ESTABLISHMENT.—
(1) IN GENERAL.—Subject to the succeeding provisions of
this section, the Secretary shall establish demonstration
projects (in this section referred to as ‘‘demonstration projects’’)
under which the Secretary shall evaluate methods that improve
the quality of care provided to individuals with chronic condi-
tions and that reduce expenditures that would otherwise be
made under the medicare program on behalf of such individuals
for such chronic conditions, such methods to include permitting
those beneficiaries to direct their own health care needs and
services.
(2) INDIVIDUALS WITH CHRONIC CONDITIONS DEFINED.—In
this section, the term ‘‘individuals with chronic conditions’’
means an individual entitled to benefits under part A of title
XVIII of the Social Security Act, and enrolled under part B
of such title, but who is not enrolled under part C of such
title who is diagnosed as having one or more chronic conditions
(as defined by the Secretary), such as diabetes.
(b) DESIGN OF PROJECTS.—
(1) EVALUATION BEFORE IMPLEMENTATION OF PROJECT.—
(A) IN GENERAL.—In establishing the demonstration
projects under this section, the Secretary shall evaluate
best practices employed by group health plans and practices
under State plans for medical assistance under the med-
icaid program under title XIX of the Social Security Act,
as well as best practices in the private sector or other
areas, of methods that permit patients to self-direct the
H. R. 1—263
provision of personal care services. The Secretary shall
evaluate such practices for a 1-year period and, based
on such evaluation, shall design the demonstration project.
(B) REQUIREMENT FOR ESTIMATE OF BUDGET NEUTRAL
COSTS.—As part of the evaluation under subparagraph (A),
the Secretary shall evaluate the costs of furnishing care
under the projects. The Secretary may not implement the
demonstration projects under this section unless the Sec-
retary determines that the costs of providing care to
individuals with chronic conditions under the project will
not exceed the costs, in the aggregate, of furnishing care
to such individuals under title XVIII of the Social Security
Act, that would otherwise be paid without regard to the
demonstration projects for the period of the project.
(2) SCOPE
OF
SERVICES.—The Secretary shall determine
the appropriate scope of personal care services that would
apply under the demonstration projects.
(c) VOLUNTARY PARTICIPATION.—Participation of providers of
services and suppliers, and of individuals with chronic conditions,
in the demonstration projects shall be voluntary.
(d) DEMONSTRATION PROJECTS SITES.—Not later than 2 years
after the date of the enactment of this Act, the Secretary shall
conduct a demonstration project in at least one area that the
Secretary determines has a population of individuals entitled to
benefits under part A of title XVIII of the Social Security Act,
and enrolled under part B of such title, with a rate of incidence
of diabetes that significantly exceeds the national average rate
of all areas.
(e) EVALUATION AND REPORT.—
(1) EVALUATIONS.—The Secretary shall conduct evaluations
of the clinical and cost effectiveness of the demonstration
projects.
(2) REPORTS.—Not later than 2 years after the commence-
ment of the demonstration projects, and biannually thereafter,
the Secretary shall submit to Congress a report on the evalua-
tion, and shall include in the report the following:
(A) An analysis of the patient outcomes and costs of
furnishing care to the individuals with chronic conditions
participating in the projects as compared to such outcomes
and costs to other individuals for the same health condi-
tions.
(B) Evaluation of patient satisfaction under the dem-
onstration projects.
(C) Such recommendations regarding the extension,
expansion, or termination of the projects as the Secretary
determines appropriate.
(f) WAIVER AUTHORITY.—The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) to such extent and for such period as
the Secretary determines is necessary to conduct demonstration
projects.
(g) AUTHORIZATION OF APPROPRIATIONS.—(1) Payments for the
costs of carrying out the demonstration project under this section
shall be made from the Federal Supplementary Medical Insurance
Trust Fund under section 1841 of such Act (42 U.S.C. 1395t).
(2) There are authorized to be appropriated from such Trust
Fund such sums as may be necessary for the Secretary to enter
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into contracts with appropriate organizations for the deign,
implementation, and evaluation of the demonstration project.
(3) In no case may expenditures under this section exceed
the aggregate expenditures that would otherwise have been made
for the provision of personal care services.
SEC. 649. MEDICARE CARE MANAGEMENT PERFORMANCE DEM-
ONSTRATION.
(a) ESTABLISHMENT.—
(1) IN GENERAL.—The Secretary shall establish a pay-for-
performance demonstration program with physicians to meet
the needs of eligible beneficiaries through the adoption and
use of health information technology and evidence-based out-
comes measures for—
(A) promoting continuity of care;
(B) helping stabilize medical conditions;
(C) preventing or minimizing acute exacerbations of
chronic conditions; and
(D) reducing adverse health outcomes, such as adverse
drug interactions related to polypharmacy.
(2) SITES.—The Secretary shall designate no more than
4 sites at which to conduct the demonstration program under
this section, of which—
(A) two shall be in an urban area;
(B) one shall be in a rural area; and
(C) one shall be in a State with a medical school
with a Department of Geriatrics that manages rural out-
reach sites and is capable of managing patients with mul-
tiple chronic conditions, one of which is dementia.
(3) DURATION.—The Secretary shall conduct the demonstra-
tion program under this section for a 3-year period.
(4) CONSULTATION.—In carrying out the demonstration pro-
gram under this section, the Secretary shall consult with pri-
vate sector and non-profit groups that are undertaking similar
efforts to improve quality and reduce avoidable hospitalizations
for chronically ill patients.
(b) PARTICIPATION.—
(1) IN GENERAL.—A physician who provides care for a min-
imum number of eligible beneficiaries (as specified by the Sec-
retary) may participate in the demonstration program under
this section if such physician agrees, to phase-in over the course
of the 3-year demonstration period and with the assistance
provided under subsection (d)(2)—
(A) the use of health information technology to manage
the clinical care of eligible beneficiaries consistent with
paragraph (3); and
(B) the electronic reporting of clinical quality and out-
comes measures in accordance with requirements estab-
lished by the Secretary under the demonstration program.
(2) SPECIAL RULE.—In the case of the sites referred to
in subparagraphs (B) and (C) of subsection (a)(2), a physician
who provides care for a minimum number of beneficiaries with
two or more chronic conditions, including dementia (as specified
by the Secretary), may participate in the program under this
section if such physician agrees to the requirements in subpara-
graphs (A) and (B) of paragraph (1).