I 115th CONGRESS 2d Session H. R. 5160 IN THE HOUSE OF REPRESENTATIVES March 5, 2018 Mr. DeSaulnier (for himself and Mr. Poe of Texas ) 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 provide for coverage of cancer care planning and coordination under the Medicare program.

1. Short title (a) Short title This Act may be cited as the Cancer Care Planning and Communications Act of 2018 . (b) Findings Congress makes the following findings: (1) Cancer care in the United States is often described as the best in the world because patients have access to many treatment options, including cutting-edge therapies that save lives and improve the quality of life. (2) Access to the best treatment options is not equal across all populations and in all communities. The 1999 Institute of Medicine report entitled The Unequal Burden of Cancer found that low-income people often lack access to adequate cancer care and that ethnic minorities have not benefitted fully from cancer treatment advances. (3) In addition, despite access to high-quality treatment options for many, individuals with cancer often do not have access to a cancer care system that incorporates shared decision-making and the coordination of all elements of care. (4) Cancer survivors often experience the under-diagnosis and under-treatment of the symptoms of cancer and side effects of cancer treatment, a problem that begins at the time of diagnosis and may become more severe with disease progression and at the end of life. The failure to treat the symptoms, side effects, and late effects of cancer and cancer treatment may have a serious adverse impact on the health, survival, well-being, and quality of life of cancer survivors. (5) Individuals with cancer often do not participate in a shared decision-making process that considers all treatment options and do not benefit from coordination of all elements of active treatment and palliative care. (6) Quality cancer care should incorporate access to psychosocial services and management of the symptoms of cancer and the symptoms of cancer treatment, including pain, nausea, vomiting, fatigue, and depression. (7) Quality cancer care should include a means for engaging cancer survivors in a shared decision-making process that produces a comprehensive care summary and a plan for follow-up care after primary treatment to ensure that cancer survivors have access to follow-up monitoring and treatment of possible late effects of cancer and cancer treatment, including appropriate psychosocial services. (8) The Institute of Medicine report entitled Ensuring Quality Cancer Care described the elements of quality care for an individual with cancer to include— (A) the development of initial treatment recommendations by an experienced health care provider; (B) the development of a plan for the course of treatment of the individual and communication of the plan to the individual; (C) access to the resources necessary to implement the course of treatment; (D) access to high-quality clinical trials; (E) a mechanism to coordinate services for the treatment of the individual; and (F) psychosocial support services and compassionate care for the individual. (9) In its report From Cancer Patient to Cancer Survivor: Lost in Transition , the Institute of Medicine recommended that individuals with cancer completing primary treatment be provided a comprehensive summary of their care along with a follow-up survivorship plan of treatment. (10) In Cancer Care for the Whole Patient , the Institute of Medicine stated that the development of a plan that includes biomedical and psychosocial care should be a standard for quality cancer care in any quality measurement system. (11) The Commission on Cancer has encouraged survivorship care planning by making the development of such plans for patients one of the standards of accreditation for cancer care providers, but cancer care professionals report difficulties completing the plans. (12) Because more than half of all cancer diagnoses occur among elderly Medicare beneficiaries, addressing cancer care inadequacies through Medicare reforms will provide benefits to millions of Americans. Providing Medicare beneficiaries more routine access to cancer care plans and survivorship care plans is a key to shared decisionmaking and better coordination of care. (13) Important payment and delivery reforms that incorporate cancer care planning and coordination are already being tested in the Medicare program; the Oncology Care Model has been implemented in a number of oncology practices, and additional models that will include care planning have been proposed. (14) The alternative payment models, including the Oncology Care Model, provide access to cancer care planning for Medicare beneficiaries who receive their cancer care in practices that are part of the Oncology Care Model. Other Medicare beneficiaries who are not enrolled in these delivery demonstrations may not have access to a cancer care plan or appropriate care coordination. (15) The failure to provide a cancer care plan to patients in many care settings relates in part to inadequate Medicare payment for such planning and coordination services. (16) Changes in Medicare payment for cancer care planning and coordination will support shared decisionmaking that reviews all treatment options and will contribute to improved care for individuals with cancer from the time of diagnosis through the end of the life. Medicare payment for cancer care planning may begin a reform process that helps us realize the well-planned and well-coordinated cancer care that has been recommended by the Institute of Medicine/National Academy of Medicine and that is preferred by cancer patients across the Nation. 2. Coverage of cancer care planning and coordination services (a) In general Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended— (1) in subsection (s)(2)— (A) by striking and at the end of subparagraph (FF); (B) by adding and at the end of subparagraph (GG); and (C) by adding at the end the following new subparagraph: (HH) cancer care planning and coordination services (as defined in subsection (jjj)) ; and (2) by adding at the end the following new subsection: (jjj) Cancer Care Planning and Coordination Services (1) The term cancer care planning and coordination services means— (A) with respect to an individual who is diagnosed with cancer, the development of a treatment plan by a physician, nurse practitioner, or physician assistant that— (i) includes an assessment of the individual’s diagnosis, health status, treatment needs, functional status, pain control, and psychosocial needs; (ii) engages the individual in a shared decision-making process that reviews all treatment options; (iii) details, to the greatest extent practicable all aspects of the care to be provided to the individual with respect to the treatment of such cancer, including any curative treatment, comprehensive symptom management, and palliative care; (iv) is furnished in person, in written form, to the individual within a period specified by the Secretary that is as soon as practicable after the date on which the individual is so diagnosed; (v) is furnished, to the greatest extent practicable, in a form that appropriately takes into account cultural and linguistic needs of the individual in order to make the plan accessible to the individual; and (vi) is in accordance with standards determined by the Secretary to be appropriate; (B) with respect to an individual for whom a treatment plan has been developed under subparagraph (A), the revision of such treatment plan as necessary to account for any substantial change in the condition of the individual, recurrence of disease, changes in the individual’s treatment preferences, or significant revision of the elements of curative care or symptom management for the individual, if such revision— (i) is in accordance with clauses (i), (ii), (iv) and (v) of such subparagraph; and (ii) is furnished in written form to the individual within a period specified by the Secretary that is as soon as practicable after the date of such revision; (C) with respect to an individual who has completed the primary treatment for cancer, as defined by the Secretary, the development of a follow-up survivorship care plan that— (i) includes an assessment of the individual’s diagnosis, health status, treatment needs, functional status, pain control, and psychosocial needs; (ii) engages the individual in a shared decision-making process that reviews all survivorship care options; (iii) describes the elements of the primary treatment, including symptom management and palliative care, furnished to such individual; (iv) provides recommendations for the subsequent care of the individual with respect to the cancer involved; (v) is furnished, in person, in written form, to the individual within a period specified by the Secretary that is as soon as practicable after the completion of such primary treatment; (vi) is furnished, to the greatest extent practicable, in a form that appropriately takes into account cultural and linguistic needs of the individual in order to make the plan accessible to the individual; and (vii) is in accordance with standards determined by the Secretary to be appropriate; and (D) with respect to an individual for whom a follow-up cancer care plan has been developed under subparagraph (C), the revision of such plan as necessary to account for any substantial change in the condition of the individual, diagnosis of a second cancer, change in the individual’s preference for survivorship care, or significant revision of the plan for follow-up care, if such revision— (i) is in accordance with clauses (i), (ii), (iii), (v), and (vi) of such subparagraph; and (ii) is furnished in written form to the individual within a period specified by the Secretary that is as soon as practicable after the date of such revision. (2) The Secretary shall establish standards to carry out paragraph (1) in consultation with appropriate organizations representing suppliers and providers of services related to cancer treatment and organizations representing survivors of cancer. Such standards shall include standards for determining the need and frequency for revisions of the treatment plans and follow-up survivorship care plans based on changes in the condition of the individual or elements and intent of treatment and standards for the communication of the plan to the individual. (3) In this subsection, the term shared decision-making process means, with respect to an individual, a process in which the individual and the individual’s health care providers consider the individual’s diagnosis, treatment options, the medical evidence related to treatment options, the risks and benefits of all treatment options, and the individual’s preferences regarding treatment, and then jointly develop and implement a treatment plan. . (b) Payment under physician fee schedule (1) In general Section 1848(j)(3) of the Social Security Act ( 42 U.S.C. 1395w–4(j)(3) ) is amended by inserting (HH), after health risk assessment), . (2) Initial rates Unless the Secretary of Health and Human Services otherwise provides, the payment rate specified under the physician fee schedule under the amendment made by paragraph (1) for cancer care planning and coordination services shall be the same payment rate as provided for transitional care management services (as defined in CPT code 99496). (c) Effective date The amendments made by this section shall apply to services furnished on or after the first day of the first calendar year that begins after the date of the enactment of this Act.