Value in Health Care Act of 2021
Bill: H.R.4587 | Sponsor: Rep. Welch, Peter (D-VT)
Policy area: Health

Summary:
Value in Health Care Act of 2021
This bill makes a series of changes to certain methodologies and components used in the Medicare Shared Savings Program. The program enables accountable care organizations (ACOs) to receive payments for savings stemming from care coordination and management.
Among other changes, the bill requires the Centers for Medicare & Medicaid Services to increase the shared savings rate for participating ACOs, as specified, and to establish a program that assists ACOs with start-up and operational costs of participation. The bill also extends certain incentive payments for health professionals who participate in eligible alternative payment models.
The Government Accountability Office must report on health outcomes and racial disparities among beneficiaries who receive care from providers under alternative payment models compared to beneficiaries who receive care from providers under the traditional fee-for-service system.

To direct the Secretary of Health and Human Services to revise certain 
  regulations in relation to the Medicare shared savings program and 
     other advanced alternative payment arrangements to encourage 
         participation in such program, and for other purposes.

    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 ``Value in Health Care Act of 2021''.

SEC. 2. ENCOURAGING PARTICIPATION IN THE MEDICARE SHARED SAVINGS 
              PROGRAM.

    (a) Increasing Shared Savings Rates for Certain Accountable Care 
Organizations.--Prior to the beginning of the first performance year 
(as defined in section 425.20 of title 42, Code of Federal Regulations 
(or a successor regulation)) that begins after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
revise section 425.605(d)(1) of title 42, Code of Federal Regulations 
(or a successor regulation), to provide that the shared savings rate 
for an accountable care organization participating in--
            (1) Level A (as described in paragraph (i)(A) of such 
        section) or Level B (as described in paragraph (ii)(A) of such 
        section) of the BASIC track shall be at least 50 percent of all 
        the savings under the updated benchmark (as so described), as 
        determined on the basis of such organization's quality 
        performance;
            (2) Level C (as described in paragraph (iii)(A) of such 
        section) or Level D (as described in paragraph (iv)(A) of such 
        section) of the BASIC track shall be at least 55 percent of all 
        the savings under the updated benchmark (as so described), as 
        determined on the basis of such organization's quality 
        performance; or
            (3) Level E (as described in paragraph (v)(A) of such 
        section) shall be at least 60 percent of all the savings under 
        the updated benchmark (as so described), as determined on the 
        basis of such organization's quality performance.
    (b) Modifying Risk Adjustment Methodology.--Prior to the beginning 
of the first performance year (as defined for purposes of subsection 
(a)) that begins after the date of the enactment of this Act, the 
Secretary of Health and Human Services shall revise--
            (1) section 425.605(a)(1)(i) of title 42, Code of Federal 
        Regulations, or a successor regulation, to provide that 
        positive adjustments, if applicable, in prospective HCC risk 
        scores (as applied for purposes of such section) are subject to 
        a cap of no less than 5 percent, and any negative adjustments, 
        if applicable, in prospective HCC risk scores (as applied for 
        purposes of such section) shall be between 0 and negative 5 
        percent;
            (2) section 425.610(a)(2)(i) of title 42, Code of Federal 
        Regulations, or a successor regulation, to provide that 
        positive adjustments, if applicable, in prospective HCC risk 
        scores (as applied for purposes of such section) are subject to 
        a cap of no less than 5 percent, and any negative adjustments, 
        if applicable, in prospective HCC risk scores (as applied for 
        purposes of such section) shall be between 0 and negative 5 
        percent; and
            (3) section 425.609(c)(3)(i)(A) of title 42, Code of 
        Federal Regulations, or a successor regulation, to provide that 
        the cap described in such section references no less than 5 
        percent, and any negative adjustments, if applicable, in 
        prospective HCC risk scores (as applied for purposes of such 
        section) shall be between 0 and negative 5 percent.
    (c) Removing Barriers to Shared Savings Program Participation.--
Prior to the beginning of the first performance year (as defined for 
purposes of subsection (a)) that begins after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall revise 
part 425 of title 42, Code of Federal Regulations, or any successor 
regulation, to--
            (1) eliminate any distinction in requirements in such part 
        between a low revenue ACO and a high revenue ACO (as such terms 
        are defined in section 425.20 of title 42, Code of Federal 
        Regulations, or a successor regulation) and, with respect to 
        such a low revenue ACO or high revenue ACO and except as 
        otherwise modified in this Act, apply the requirements of such 
        part as such requirements applied to low revenue ACOs on July 
        1, 2019, except that the Secretary of Health and Human Services 
        may, if the Secretary determines appropriate, apply less 
        stringent requirements than those requirements that applied to 
        low revenue ACOs as of such date; and
            (2) remove any provision requiring an accountable care 
        organization to assume responsibility for repayment of any 
        shared losses or participate in a two-sided risk model before 
        the organization has participated for at least 3 years in any 
        program subject to the provisions of part 425 of title 42, Code 
        of Federal Regulations, or any successor regulation, provided 
        that such an organization shall be allowed to elect to 
        participate in such two-sided risk models or models requiring 
        repayment of such losses.
    (d) Ensuring Fair and Accurate Benchmarks.--Prior to the beginning 
of the first performance year (as defined for purposes of subsection 
(a)) that begins after the date of the enactment of this Act, the 
Secretary of Health and Human Services shall revise part 425 of title 
42, Code of Federal Regulations, to remove Medicare beneficiaries who 
are assigned to an accountable care organization from the methodology 
for calculating the regional expenditures used to establish, adjust, 
and update the benchmark expenditures for ACO performance periods 
beginning on or after July 1, 2019.

SEC. 3. PROVIDING EDUCATIONAL AND TECHNICAL SUPPORT FOR THE MEDICARE 
              SHARED SAVINGS PROGRAM.

    Section 1899 of the Social Security Act (42 U.S.C. 1395jjj) is 
amended by adding at the end the following new subsection:
    ``(n) Educational and Technical Support.--
            ``(1) In general.--The Secretary shall establish a program 
        to assist eligible ACOs in meeting start-up and ongoing 
        operational costs associated with establishing and 
        participating in the shared savings program established under 
        subsection (a). The Secretary shall establish through notice-
        and-comment rulemaking the requirements for participation and 
        use of funds in the program established in the preceding 
        sentence.
            ``(2) Reduction in shared savings payments.--The Secretary 
        shall reduce any shared savings payment owed to an ACO under 
        subsection (d) in an amount equal to any funds provided to such 
        ACO under the program established under paragraph (1).''.

SEC. 4. ADVANCED PAYMENT MODEL INCENTIVE, PARTICIPATION, AND THRESHOLD 
              MODIFICATIONS.

    (a) In General.--Section 1833(z) of the Social Security Act (42 
U.S.C. 1395l(z)) is amended--
            (1) in paragraph (1)(A), by striking ``2024'' and inserting 
        ``2030''; and
            (2) in paragraph (2)(C)--
                    (A) in clause (i), by striking ``75 percent'' and 
                inserting ``the applicable percent (as defined in 
                clause (iv)) for such year'';
                    (B) in clause (ii)(I)--
                            (i) in the matter preceding item (aa), by 
                        striking ``75 percent'' and inserting ``the 
                        applicable percent (as defined in clause (iv)) 
                        for such year''; and
                            (ii) in item (bb)--
                                    (I) by striking ``and other than 
                                payments made under title XIX'' and 
                                inserting ``other than payments made 
                                under title XIX''; and
                                    (II) by striking ``State program 
                                under that title),'' and inserting 
                                ``State program under that title, and 
                                other than payments made by payers in 
                                which no payment or program meeting the 
                                requirements described in clause 
                                (iii)(II) is available from the payer 
                                for participation by the eligible 
                                professional)''; and
                    (C) by adding at the end the following new clause:
                            ``(iv) Applicable percent defined.--For 
                        purposes of clauses (i) and (ii), the term 
                        `applicable percent' means--
                                    ``(I) for 2025, a percent specified 
                                by the Secretary, but in no case less 
                                than 50 percent or more than 55 
                                percent; and
                                    ``(II) for a subsequent year, a 
                                percent specified by the Secretary, but 
                                in no case less than the percent 
                                specified under this clause for the 
                                preceding year or more than 5 
                                percentage points higher than the 
                                percent specified under this clause for 
                                such preceding year.''.
    (b) Partial Qualifying APM Participant Modifications.--Section 
1848(q)(1)(C)(iii)(III) of the Social Security Act (42 U.S.C. 1395w-
4(q)(1)(C)(iii)(III)) is amended--
            (1) in item (aa), by striking ``50 percent was instead a 
        reference to 40 percent'' and inserting ``the applicable 
        percent were instead a reference to 10 percentage points less 
        than the applicable percent''; and
            (2) in item (bb)--
                    (A) by striking ``75 percent'' and inserting ``the 
                applicable percent'';
                    (B) by striking ``50 percent'' and inserting ``10 
                percentage points less than the applicable percent''.

SEC. 5. ADDRESSING OVERLAP IN VALUE BASED CARE PROGRAMS.

    (a) In General.--
            (1) CMI.--Section 1115A(a)(5) of the Social Security Act 
        (42 U.S.C. 1315a(a)(5)) is amended by adding at the end the 
        following new sentence: ``In establishing such limits, the 
        Secretary shall take into account payment and service delivery 
        models in progress in such geographic areas.''.
            (2) Repeal of medicare duplication prohibition.--Section 
        1899(b) of the Social Security Act (42 U.S.C. 1395jjj(b)) is 
        amended by striking paragraph (4).
    (b) Report.--Not later than 1 year after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall conduct 
an assessment and submit to Congress a report on alternative payment 
model overlap in the Medicare program. Such report shall include a 
description of and recommendations relating to--
            (1) any issues regarding the existence of multiple 
        alternative payment model participation opportunities for 
        health care providers; and
            (2) obstacles created by competing incentives with respect 
        to alternative payment models.

SEC. 6. STUDY ON RACIAL HEALTH DISPARITIES.

    Not later than 18 months after the date of enactment of this Act, 
the Comptroller General of the United States shall submit to the 
appropriate committees of Congress a report on health outcomes and 
racial disparities among Medicare beneficiaries assigned to providers 
reimbursed under alternative payment models compared to such 
beneficiaries receiving care from fee-for-service providers. Such 
report shall include, to the extent to which data is available, an 
analysis comparing the beneficiaries assigned to a provider 
participating in the Medicare shared savings program to beneficiaries 
not participating in Medicare Advantage and not assigned to any 
provider reimbursed under an alternative payment model with respect to 
at least the following individual outcomes measures:
            (1) Control of hypertension.
            (2) Colorectal cancer screenings.
            (3) Influenza immunization.
            (4) Completion of an annual wellness visit.
            (5) Breast cancer screening.
            (6) Screening for depression and performance of a follow-up 
        plan (if appropriate).
            (7) Hemoglobin A1c control.
            (8) Emergency room visits.
            (9) Such other measures as the Comptroller General 
        determines appropriate.
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