II 114th CONGRESS 2d Session S. 3191 IN THE SENATE OF THE UNITED STATES July 13, 2016 Mr. Franken (for himself and Ms. Heitkamp ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XVIII and XIX of the Social Security Act to improve the quality of health care furnished in rural areas, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Rural Health Care Quality Improvement Act of 2016 . (b) Table of contents The table of contents of this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Rural health care Sec. 101. Establishment of core set of rural health care quality measures. Sec. 102. Revisions to Medicare rural grants. TITLE II—Rural-based payment reforms Sec. 201. Integrating core set of rural health care quality measures into certain payment models. Sec. 202. Center for Medicare and Medicaid Innovation testing of providing financial incentives for rural providers of services and suppliers to submit data on quality measures. Sec. 203. Center for Medicare and Medicaid Innovation testing of value-based payment models for rural providers of services and suppliers. Sec. 204. Center for Medicare and Medicaid Innovation testing of hospital readmissions reduction program for rural hospitals. Sec. 205. Participation by rural health clinics and Federally qualified health centers in Comprehensive Primary Care Plus model. TITLE III—Improving rural representation Sec. 301. Inclusion of rural representation on CMS Rural Health Council. Sec. 302. Ensuring rural representation on the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission. I Rural health care 101. Establishment of core set of rural health care quality measures (a) In general Title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) is amended by inserting after section 1890A the following new section: 1890B. Rural health care quality measures (a) Establishment Not later than January 1, 2018, the Secretary shall, using the process described in section 1890(b)(7), establish a core set of relevant quality measures that address the following with respect to rural providers of services and suppliers who furnish items and services to individuals in rural areas: (1) Improving patient outcomes, such as mortality rates, hospital acquired infections, hospital readmissions, and other patient-reported outcomes. (2) Improving care coordination, transitions, and medicine reconciliation. (3) Reducing costs. (4) Improving patient safety. (5) Use of preventive care services, including immunizations and screening tests. (6) Improving care for individuals with chronic disease, including cardiovascular disease, diabetes, behavioral health, and other chronic conditions. (7) Other purposes specified by the Secretary. (b) Aligning measures with existing quality reporting requirements In establishing the core set of quality measures under subsection (a), the Secretary shall reduce reporting burdens for small rural providers of services and suppliers (as determined by the Secretary) by, to the extent practicable, ensuring that such quality measures are consistent with measures applicable under other quality and value-based payment reporting requirements under this title, as determined by the Secretary, including the Merit-Based Incentive Payment System under section 1848(q) and incentive payments for the meaningful use of certified EHR technology under section 1886(b)(3)(B)(ix). (c) Implementation The provisions of paragraphs (4) and (5) of section 1890A(a) shall apply to the establishment of the core set of quality measures under subsection (a) in the same manner as such provisions apply to the selection of quality and efficiency measures described in section 1890(b)(7)(B). (d) Annual updating The Secretary shall, using the process described in section 1890A, review and update the core set of quality measures established under subsection (a) in accordance with section 1890A(c) to ensure such quality measures remain reliable, scientifically valid, and appropriate for quality measurement purposes. . (b) Conforming amendment Section 1890(b)(5)(A)(iv) of the Social Security Act ( 42 U.S.C. 1395aaa(b)(5)(A)(iv) ) is amended by inserting and (beginning with 2019) rural health care quality measures under section 1890B after Public Health Service Act . 102. Revisions to Medicare rural grants (a) Reauthorization Section 1820(j) of the Social Security Act ( 42 U.S.C. 1395i–4(j) ) is amended— (1) by striking Appropriations .—There and inserting the following: Appropriations .— (1) HI Trust fund There ; and (2) by adding at the end the following new paragraph: (2) General revenues There are authorized to be appropriated, from amounts in the Treasury not otherwise appropriated, for making grants to all States under subsection (g), $50,000,000 in each of fiscal years 2017 through 2021, to remain available until expended. . (b) Medicare rural emergency medical services grants Section 1820(g)(2)(A) of the Social Security Act ( 42 U.S.C. 1395i–4(g)(2)(A) ) is amended by inserting the following before the period at the end: , which may include plans to support emergency medical transportation services, particularly in rural communities that have lost their rural hospital . (c) Grants To provide technical assistance for quality improvement reporting by critical access hospitals Section 1820(g) of the Social Security Act ( 42 U.S.C. 1395i–4(g) ) is amended by adding at the end the following new paragraph: (8) Technical assistance for quality improvement reporting by critical access hospitals (A) Grants The Secretary may award grants to critical access hospitals that have submitted applications in accordance with subparagraph (B) for— (i) assisting such hospitals in establishing or expanding a quality improvement reporting program; and (ii) supporting the provision of technical assistance for quality improvement reporting. (B) Application A critical access hospital seeking a grant under this paragraph shall submit an application to the Secretary on or before such date and in such form and manner as the Secretary specifies. (C) Reporting requirement in order to continue to receive grants after second year The Secretary may not award a grant under this paragraph to a critical access hospital for more than 2 years unless the hospital agrees to submit, for each year after that second year, such relevant quality data specified by the Secretary, including data on rural health care quality measures established under section 1890B, as appropriate. (D) Availability to public The Secretary shall establish procedures for making data submitted under subparagraph (C) available to the public. (E) Opportunity to review The procedures established under subparagraph (D) shall ensure that a critical access hospital has the opportunity to review the data that are to be made public with respect to the hospital prior to such data being made public. (F) Measures The Secretary shall report quality measures of process, structure, outcome, patients’ perspective on care, efficiency, and costs of care that relate to services furnished in such hospitals on the Internet website of the Centers for Medicare & Medicaid Services. . II Rural-based payment reforms 201. Integrating core set of rural health care quality measures into certain payment models Section 1890B of the Social Security Act, as added by section 101, is amended by adding at the end the following new subsection: (e) Inclusion under alternative payment models and value-Based demonstration projects Effective beginning with calendar year or fiscal year 2021, as applicable, the Secretary shall ensure that rural health care quality measures established under this section are included in quality reporting under alternative payment models and value-based payment demonstration projects under this title, as appropriate, including the shared savings program under section 1899 and the Merit-Based Incentive Payment System under section 1848(q). . 202. Center for Medicare and Medicaid Innovation testing of providing financial incentives for rural providers of services and suppliers to submit data on quality measures Section 1115A of the Social Security Act ( 42 U.S.C. 1315a ) is amended— (1) in subsection (b)(2)(A), by adding at the end the following new sentence: The models selected under this subparagraph shall include the model described in subsection (h). ; and (2) by adding at the end the following new subsection: (h) Providing financial incentives for rural providers of services and suppliers To submit data on quality measures The Secretary shall test a model providing financial incentives to providers of services and suppliers located in rural areas to submit data on applicable quality measures under title XVIII, including rural health care quality measures established under section 1890B. . 203. Center for Medicare and Medicaid Innovation testing of value-based payment models for rural providers of services and suppliers Section 1115A of the Social Security Act ( 42 U.S.C. 1315a ), as amended by section 202, is amended— (1) in subsection (b)(2)(A), by striking model described in subsection (h) and inserting models described in subsections (h) and (i) ; and (2) by adding at the end the following new subsection: (i) Value-Based payment models for rural providers of services and suppliers The Secretary shall test value-based payment models, including value-based purchasing, for items and services furnished by providers of services and suppliers located in rural areas under title XVIII, including critical access hospitals. . 204. Center for Medicare and Medicaid Innovation testing of hospital readmissions reduction program for rural hospitals Section 1115A of the Social Security Act ( 42 U.S.C. 1315a ), as amended by sections 202 and 203, is amended— (1) in subsection (b)(2)(A), by striking and (i) and inserting , (i), and (j) ; and (2) by adding at the end the following new subsection: (j) Hospital readmissions reduction program for rural hospitals The Secretary shall test a hospital readmissions reduction program under title XVIII for hospitals located in rural areas that are not otherwise subject to the program under section 1886(q). . 205. Participation by rural health clinics and Federally qualified health centers in Comprehensive Primary Care Plus model Notwithstanding any other provision of law, the Secretary of Health and Human Services shall permit a rural health clinic (as defined in section 1861(aa)(2) of the Social Security Act ( 42 U.S.C. 1395x(aa)(2) )) or a Federally qualified health center (as defined in section 1861(aa)(4) of such Act ( 42 U.S.C. 1395x(aa)(4) )) to participate in the Comprehensive Primary Care Plus model tested under section 1115A of such Act ( 42 U.S.C. 1315a ). III Improving rural representation 301. Inclusion of rural representation on CMS Rural Health Council (a) In general To the extent the Administrator of the Centers for Medicare & Medicaid Services (in this section referred to as the Administrator ) establishes a CMS Rural Health Council, the Administrator shall ensure that such Council includes external stakeholders who have objective rural health expertise, such as representatives of rural health research centers, quality improvement organizations, and State offices of rural health, who shall serve in an ex officio capacity as nonvoting members. (b) Collaboration with Health Care Payment Learning and Action Network The Council described in subsection (a) shall, to the extent practicable, work in collaboration with the Health Care Payment Learning and Action Network within the Department of Health and Human Services. 302. Ensuring rural representation on the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission (a) Medicare Payment Advisory Commission (1) In general Section 1805(c)(2)(A) of the Social Security Act ( 42 U.S.C. 1395b–6(c)(2)(A) ) is amended by inserting the following before the period at the end: , including at least two members who represent a rural area . (2) Applicable to future appointments Any appointment to the Medicare Payment Advisory Commission made by the Comptroller General of the United States after the date of enactment of this Act shall be made in a manner that complies with the requirements of section 1805(c)(2)(A) of the Social Security Act, as amended by paragraph (1). (b) Medicaid and CHIP Payment and Access Commission (1) In general Section 1900(c)(2)(A) of the Social Security Act ( 42 U.S.C. 1396(c)(2)(A) ) is amended by inserting the following before the period at the end: , including at least two members who represent a rural area . (2) Applicable to future appointments Any appointment to the Medicaid and CHIP Payment and Access Commission made by the Comptroller General of the United States after the date of enactment of this Act shall be made in a manner that complies with the requirements of section 1900(c)(2)(A) of the Social Security Act, as amended by paragraph (1).