42 U.S.C. § 1395cc-1 : US Code - Section 1395CC-1: Demonstration of application of physician volume increases to group practices

Search 42 U.S.C. § 1395cc-1 : US Code - Section 1395CC-1: Demonstration of application of physician volume increases to group practices

(a) Demonstration program authorized
(1) In general
The Secretary shall conduct demonstration projects to test and,
if proven effective, expand the use of incentives to health care
groups participating in the program under this subchapter that -
(A) encourage coordination of the care furnished to
individuals under the programs under parts A and B of this
subchapter by institutional and other providers, practitioners,
and suppliers of health care items and services;
(B) encourage investment in administrative structures and
processes to ensure efficient service delivery; and
(C) reward physicians for improving health outcomes.
Such projects shall focus on the efficiencies of furnishing
health care in a group-practice setting as compared to the
efficiencies of furnishing health care in other health care
delivery systems.
(2) Administration by contract
Except as otherwise specifically provided, the Secretary may
administer the program under this section in accordance with
section 1395cc-2 of this title.
(3) Definitions
For purposes of this section, terms have the following
meanings:
(A) Physician
Except as the Secretary may otherwise provide, the term
"physician" means any individual who furnishes services which
may be paid for as physicians' services under this subchapter.
(B) Health care group
The term "health care group" means a group of physicians (as
defined in subparagraph (A)) organized at least in part for the
purpose of providing physicians' services under this
subchapter. As the Secretary finds appropriate, a health care
group may include a hospital and any other individual or entity
furnishing items or services for which payment may be made
under this subchapter that is affiliated with the health care
group under an arrangement structured so that such individual
or entity participates in a demonstration under this section
and will share in any bonus earned under subsection (d) of this
section.
(b) Eligibility criteria
(1) In general
The Secretary is authorized to establish criteria for health
care groups eligible to participate in a demonstration under this
section, including criteria relating to numbers of health care
professionals in, and of patients served by, the group, scope of
services provided, and quality of care.
(2) Payment method
A health care group participating in the demonstration under
this section shall agree with respect to services furnished to
beneficiaries within the scope of the demonstration (as
determined under subsection (c) of this section) -
(A) to be paid on a fee-for-service basis; and
(B) that payment with respect to all such services furnished
by members of the health care group to such beneficiaries shall
(where determined appropriate by the Secretary) be made to a
single entity.
(3) Data reporting
A health care group participating in a demonstration under this
section shall report to the Secretary such data, at such times
and in such format as the Secretary requires, for purposes of
monitoring and evaluation of the demonstration under this
section.
(c) Patients within scope of demonstration
(1) In general
The Secretary shall specify, in accordance with this
subsection, the criteria for identifying those patients of a
health care group who shall be considered within the scope of the
demonstration under this section for purposes of application of
subsection (d) of this section and for assessment of the
effectiveness of the group in achieving the objectives of this
section.
(2) Other criteria
The Secretary may establish additional criteria for inclusion
of beneficiaries within a demonstration under this section, which
may include frequency of contact with physicians in the group or
other factors or criteria that the Secretary finds to be
appropriate.
(3) Notice requirements
In the case of each beneficiary determined to be within the
scope of a demonstration under this section with respect to a
specific health care group, the Secretary shall ensure that such
beneficiary is notified of the incentives, and of any waivers of
coverage or payment rules, applicable to such group under such
demonstration.
(d) Incentives
(1) Performance target
The Secretary shall establish for each health care group
participating in a demonstration under this section -
(A) a base expenditure amount, equal to the average total
payments under parts A and B of this subchapter for patients
served by the health care group on a fee-for-service basis in a
base period determined by the Secretary; and
(B) an annual per capita expenditure target for patients
determined to be within the scope of the demonstration,
reflecting the base expenditure amount adjusted for risk and
expected growth rates.
(2) Incentive bonus
The Secretary shall pay to each participating health care group
(subject to paragraph (4)) a bonus for each year under the
demonstration equal to a portion of the medicare savings realized
for such year relative to the performance target.
(3) Additional bonus for process and outcome improvements
At such time as the Secretary has established appropriate
criteria based on evidence the Secretary determines to be
sufficient, the Secretary shall also pay to a participating
health care group (subject to paragraph (4)) an additional bonus
for a year, equal to such portion as the Secretary may designate
of the saving to the program under this subchapter resulting from
process improvements made by and patient outcome improvements
attributable to activities of the group.
(4) Limitation
The Secretary shall limit bonus payments under this section as
necessary to ensure that the aggregate expenditures under this
subchapter (inclusive of bonus payments) with respect to patients
within the scope of the demonstration do not exceed the amount
which the Secretary estimates would be expended if the
demonstration projects under this section were not implemented.