I 114th CONGRESS 1st Session H. R. 1934 IN THE HOUSE OF REPRESENTATIVES April 22, 2015 Mrs. McMorris Rodgers (for herself and Mr. Israel ) 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 title XVIII of the Social Security Act to establish a national Oncology Medical Home Demonstration Project under the Medicare program for the purpose of changing the Medicare payment for cancer care in order to enhance the quality of care and to improve cost efficiency, and for other purposes.

1. Short title This Act may be cited as the Cancer Care Payment Reform Act of 2015 . 2. Establishing an Oncology Medical Home Demonstration Project under the Medicare program to improve quality of care and cost efficiency Title XVIII of the Social Security Act is amended by inserting after section 1866E ( 42 U.S.C. 1395cc–5 ) the following new section: 1866F. Oncology Medical Home Demonstration Project (a) Establishment of demonstration project Not later than six months after the date of the enactment of this section, the Secretary shall establish an Oncology Medical Home Demonstration Project (in this section referred to as the demonstration project ) to make payments in the amounts specified in subsection (f) to each participating oncology practice (as defined in subsection (b)). (b) Definition of participating oncology practice For purposes of this section, the term participating oncology practice means an oncology practice that— (1) submits to the Secretary an application to participate in the demonstration program in accordance with subsection (c); (2) is selected by the Secretary, in accordance with subsection (d), to participate in the demonstration program; and (3) is owned by a physician, or is owned by or affiliated with a hospital, that submitted a claim for reimbursement in the prior year for an item or service for which payment may be made under part B. (c) Application To Participate An application by an oncology practice to participate in the demonstration program shall include an attestation to the Secretary that the practice— (1) furnishes physicians’ services for which payment may be made under part B; (2) coordinates oncology services furnished to an individual by the practice with services that are related to such oncology services and that are furnished to such individual by medical professionals (including oncology nurses) inside or outside the practice in order to ensure that each such individual receives coordinated care; (3) meaningfully uses electronic health records; (4) will, not later than one year after the date on which the practice commences its participation in the demonstration project, be accredited as an Oncology Medical Home by the Commission on Cancer, the National Committee for Quality Assurance, or such other entity as the Secretary determines appropriate; (5) will repay all amounts paid by the Secretary to the practice under subsection (f)(1)(A) in the case that the practice does not, on a date that is not later than 60 days after the date on which the practice submits an application to the Secretary under subsection (b)(1), submit an application to an entity described in paragraph (4) for accreditation as an Oncology Medical Home in accordance with such paragraph; (6) will, for each year in which demonstration project is conducted, report to the Secretary, in such form and manner as is specified by the Secretary, on— (A) the performance of the practice with respect to not less than ten of the measures described in subsection (e), as selected by the practice; and (B) the level of satisfaction of individuals who are provided with oncology services by the practice for which payment may be made under part B, as measured by a patient satisfaction survey based on the Consumer Assessment of Healthcare Providers and Systems survey or by such similar survey as the Secretary determines appropriate; (7) agrees not to receive the payments described in subclauses (I) and (II) of subsection (f)(1)(B)(iii) in the case that the practice does not report to the Secretary in accordance with paragraph (6) with respect to performance of the practice during the 12-month period beginning on the date on which the practice submits the application described in this subsection to the Secretary; (8) will, for each year of the demonstration project, meet the minimum performance requirements developed under subsection (e)(4)(B) with respect to each of the measures on which the practice has agreed to report under paragraph (6)(A); and (9) has the capacity to utilize shared decision-making tools that facilitate the incorporation of the patient needs, preferences, and circumstances of an individual into the medical plan of the individual and that maintain provider flexibility to tailor care of the individual based on the full range of test and treatment options available to the individual. (d) Selection of participating practices (1) In general The Secretary shall, not later than six months after the date of the enactment of this section, select oncology practices that submit applications to the Secretary in accordance with subsection (c) to participate in the demonstration program. (2) Maximum number of practices In selecting an oncology practice to participate in the demonstration program under paragraph (1), the Secretary shall ensure that the participation of such practice in the demonstration project does not, on the date on which the practice commences its participation in the demonstration project, increase the total number of oncologists who participate in the demonstration program to a number that is greater than 1,500 oncologists. (3) Diversity of practices In selecting oncology practices to participate in the demonstration project under paragraph (1), the Secretary shall, to the extent practicable, include in such selection— (A) small-, medium-, and large-sized practices; and (B) practices located in different geographic areas. (4) No penalty for certain opt-outs by practices In the case that the Secretary selects an oncology practice to participate in the demonstration project under paragraph (1) that has agreed to participate in another model, under section 1115A or otherwise, for payment under this title for oncology services, such practice may not be assessed a penalty for electing not to participate in such other payment model if such practice makes such election— (A) prior to the receipt by the practice of any payment under such model; and (B) in order to participate in such demonstration project. (e) Measures (1) Development The Secretary shall use measures described in paragraph (2), and may use measures developed under paragraph (3), to assess the performance of each participating oncology practice, as compared to other participating oncology practices. (2) Measures described The measures described in this paragraph, with respect to individuals who receive treatment for cancer from a participating oncology practice, are the following: (A) Patient care measures (i) The percentage of such individuals that receives documented clinical or pathologic staging prior to initiation of a first course of cancer treatment. (ii) The percentage of such individuals that is undergoing advanced imaging and has been diagnosed with stage I or II breast cancer. (iii) The percentage of such individuals that is undergoing advanced imaging and has been diagnosed with stage I or II prostate cancer. (iv) The percentage of such individuals that, prior to receiving cancer treatment, had its performance status assessed by the practice. (v) The percentage of such individuals that— (I) is undergoing treatment with a chemotherapy regimen provided by the practice; (II) has at least a 20-percent risk of developing febrile neutropenia due to a combination of regimen risk and patient risk factors; and (III) has received from the practice either GCSF or white cell growth factor. (vi) With respect to such individuals who receive chemotherapy treatment from the practice, the percentage of such individuals so treated that receives a treatment plan prior to the administration of such chemotherapy. (vii) With respect to chemotherapy treatments administered to such individuals by the practice, the percentage of such treatments that adhere to guidelines published by the National Comprehensive Cancer Network or such other entity as the Secretary determines appropriate. (viii) With respect to antiemetic drugs dispensed by the practice to individuals as part of moderately or highly emetogenic chemotherapy regimens for such individuals, the extent to which such drugs are administered in accordance with evidence-based guidelines or pathways that are compliant with guidelines published by the National Comprehensive Cancer Network or such other entity as the Secretary determines appropriate. (B) Resource utilization measures (i) With respect to emergency room visits in a year by such individuals who are receiving active chemotherapy treatment administered by the practice as of the date of such visits, the percentage of such visits that is associated with qualified cancer diagnoses of the individuals. (ii) With respect to hospital admissions in a year by such individuals who are receiving active chemotherapy treatment administered by the practice as of the date of such visits, the percentage of such admissions that is associated with qualified cancer diagnoses of the individuals. (C) Survivorship measures (i) Survival rates for such individuals who have been diagnosed with stage I through IV breast cancer. (ii) Survival rates for such individuals who have been diagnosed with stage I through IV colorectal cancer. (iii) Survival rates for such individuals who have been diagnosed with stage I through IV lung cancer. (iv) With respect to such individuals who receive chemotherapy treatment from the practice, the percentage of such individuals so treated that receives a survivorship plan not later than 45 days after the completion of the administration of such chemotherapy to such individuals. (v) With respect to such individuals who receive chemotherapy treatment from the practice, the percentage of such individuals that receives psychological screening. (D) End-of-life care measures (i) The number of times that such an individual receives chemotherapy treatment from the practice not later than 30 days prior to the death of the individual. (ii) With respect to such individuals who have a stage IV disease and have received treatment for such disease from the practice, the percentage of such individuals so treated who have had a documented end-of-life care conversation with a physician in the practice or another health care provider who is a member of the cancer care team of the practice. (iii) With respect to such an individual who is referred to hospice care by a physician in the practice or a health care provider who is a member of the cancer care team of the practice, regardless of the setting in which such care is provided, the average number of days that the individual receives hospice care prior to the death of the individual. (iv) With respect to such individuals who die while receiving care from the practice, the percentage of such deceased individuals whose death occurred in an acute care setting. (3) Modification or addition of measures (A) In general The Secretary may, in conjunction with appropriate stakeholders, modify or add to the measures described in paragraph (2). (B) Appropriate stakeholders described For purposes of subparagraph (A), the term appropriate stakeholders includes oncology societies, oncologists who provide oncology services to one or more individuals for which payment may be made under part B, allied health professionals, health insurance issuers that have implemented alternative payment models for oncologists, patients and organizations that represent patients, and biopharmaceutical and other medical technology manufacturers. (4) Assessment (A) In general The Secretary shall, for each year in which the demonstration project is conducted, assess— (i) the performance of each participating oncology practice for such year with respect to the measures on which the practice has agreed to report to the Secretary under subsection (c)(6)(A), as compared to the performance of other participating oncology practices with respect to such measures; and (ii) the extent to which the practice has, during such year, used breakthrough or other best-in-class therapies. (B) Minimum performance requirements The Secretary shall, in conjunction with the appropriate stakeholders described in paragraph (3)(B), develop minimum performance requirements with respect to— (i) each of the measures developed under this subsection; and (ii) the level of satisfaction on which practices agree to report to the Secretary under subsection (c)(6)(B). (f) Payments for participating oncologists (1) Care coordination management fee (A) In general Subject to subparagraphs (D) and (E), the Secretary shall, in addition to any other payments made by the Secretary under this title to a participating oncology practice, make payment of a care coordination management fee to each such practice. (B) Timing of payments The care coordination management fee described in subparagraph (A) shall be paid to a participating oncology practice at the end of each of the following periods: (i) The period that ends 6 months after the date on which the practice submits the application described in subsection (c) to the Secretary under subsection (b)(1). (ii) The period that ends 12 months after the date on which the practice submits such application to the Secretary. (iii) Subject to subsection (c)(7)— (I) the period that ends 18 months after the date on which the practice submits such application to the Secretary; and (II) the period that ends 24 months after the date on which the practice submits such application to the Secretary. (C) Amount of payment The amount of the care coordination management fee described in subparagraph (A) shall be determined by the Secretary in conjunction with oncologists who provide oncology services for which payment may be made under part B. (2) Payment in subsequent years (A) In general Subject to subparagraphs (C) and (D), the Secretary shall make payments of an ongoing management fee to each participating oncology practice. (B) Timing of payments The ongoing management fee described in subparagraph (A) shall be paid to a participating oncology practice at the end of the third, fourth, and fifth years of the demonstration project. (C) Aggregate amount of payments With respect to each of the dates of payment described in subparagraph (B), the aggregate amount of payments to participating oncology practices on such date shall be determined by— (i) determining the amount by which the aggregate expenditures that would have been expended for the previous year under this title if the demonstration project had not been implemented exceeds the aggregate expenditures under this title for such previous year; (ii) calculating the amount that is half of the amount determined under clause (i); and (iii) subtracting from the amount calculated under clause (ii) the total amount of payments made under paragraph (1) that have not, in a prior application of this clause, previously been so subtracted from a payment determination made under this subparagraph. (D) Amount of payments to individual practices (i) Minimum performance requirements The Secretary may not make payments to a practice under subparagraph (A) at the end of a year of the demonstration project described in subparagraph (B) unless the practice meets or exceeds the minimum performance requirements developed under subsection (e)(4)(B) for such year with respect to— (I) the measures on which the practice has agreed to report to the Secretary under subsection (c)(6)(A); and (II) the level of satisfaction on which the practice has agreed to report to the Secretary under subsection (c)(6)(B). (ii) Consideration of performance assessment The Secretary shall, in conjunction with the appropriate stakeholders described in subsection (e)(3)(B), determine the amount of a payment to an individual oncology practice under subparagraph (A) for a year. In making a determination under the preceding sentence, the Secretary shall take into account the performance assessment of the practice under subsection (e)(4)(A) for the previous year, as compared to the performance assessment of other participating oncology practices under such subsection for such previous year. (3) Issuance of guidance Not later than the date that is six months after the date of the enactment of this section, the Secretary shall issue guidance detailing the methodology that the Secretary will use to implement subparagraphs (C) and (D) of paragraph (2). (g) Secretary reports to participating oncology practices The Secretary shall inform each participating oncology practice, on a quarterly basis, of— (1) the performance of the practice during the prior quarter with respect to the measures on which the practice has agreed to report to the Secretary under subsection (c)(6)(A); and (2) the amount by which the expenditures that would have been expended for the prior quarter under this title by a typical oncology practice if the demonstration project had not been implemented exceeds the actual expenditures by the participating oncology practice under this title for such quarter. (h) Applications From Entities To Provide Accreditations Not later than the date that is six months after the date of the enactment of this section, the Secretary shall establish a process for the acceptance and consideration of applications from entities for purposes of determining which entities may provide accreditation to practices under subsection (c)(4) in addition to the entities described in such subsection. (i) GAO report Not later than June 1, 2019, the Comptroller General of the United States shall submit a report to Congress evaluating the success of the demonstration project that includes an assessment of the impact of the project upon the quality and cost-efficiency of oncology services furnished to individuals under this title, including an assessment of the satisfaction of such individuals with respect to such services that were furnished under such project. Such report shall include recommendations regarding the possible expansion of the demonstration project, as well as any possible reforms that are based on the demonstration project that can be made to the program under this title with respect to payment for cancer care. .