42 U.S.C. § 1395cc-3 : US Code - Section 1395CC-3: Health care quality demonstration program

Search 42 U.S.C. § 1395cc-3 : US Code - Section 1395CC-3: Health care quality demonstration program

(a) Definitions
In this section:
(1) Beneficiary
The term "beneficiary" means an individual who is entitled to
benefits under part A of this subchapter and enrolled under part
B of this subchapter, including any individual who is enrolled in
a Medicare Advantage plan under part C of this subchapter.
(2) Health care group
(A) In general
The term "health care group" means -
(i) a group of physicians that is organized at least in
part for the purpose of providing physician's services under
this subchapter;
(ii) an integrated health care delivery system that
delivers care through coordinated hospitals, clinics, home
health agencies, ambulatory surgery centers, skilled nursing
facilities, rehabilitation facilities and clinics, and
employed, independent, or contracted physicians; or
(iii) an organization representing regional coalitions of
groups or systems described in clause (i) or (ii).
(B) Inclusion
As the Secretary determines appropriate, a health care group
may include a hospital or 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 hospital,
individual, or entity participates in a demonstration project
under this section.
(3) Physician
Except as otherwise provided for by the Secretary, the term
"physician" means any individual who furnishes services that may
be paid for as physicians' services under this subchapter.
(b) Demonstration projects
The Secretary shall establish a 5-year demonstration program
under which the Secretary shall approve demonstration projects that
examine health delivery factors that encourage the delivery of
improved quality in patient care, including -
(1) the provision of incentives to improve the safety of care
provided to beneficiaries;
(2) the appropriate use of best practice guidelines by
providers and services by beneficiaries;
(3) reduced scientific uncertainty in the delivery of care
through the examination of variations in the utilization and
allocation of services, and outcomes measurement and research;
(4) encourage shared decision making between providers and
patients;
(5) the provision of incentives for improving the quality and
safety of care and achieving the efficient allocation of
resources;
(6) the appropriate use of culturally and ethnically sensitive
health care delivery; and
(7) the financial effects on the health care marketplace of
altering the incentives for care delivery and changing the
allocation of resources.
(c) Administration by contract
(1) In general
Except as otherwise provided in this section, the Secretary may
administer the demonstration program established under this
section in a manner that is similar to the manner in which the
demonstration program established under section 1395cc-1 of this
title is administered in accordance with section 1395cc-2 of this
title.
(2) Alternative payment systems
A health care group that receives assistance under this section
may, with respect to the demonstration project to be carried out
with such assistance, include proposals for the use of
alternative payment systems for items and services provided to
beneficiaries by the group that are designed to -
(A) encourage the delivery of high quality care while
accomplishing the objectives described in subsection (b) of
this section; and
(B) streamline documentation and reporting requirements
otherwise required under this subchapter.
(3) Benefits
A health care group that receives assistance under this section
may, with respect to the demonstration project to be carried out
with such assistance, include modifications to the package of
benefits available under the original medicare fee-for-service
program under parts A and B of this subchapter or the package of
benefits available through a Medicare Advantage plan under part C
of this subchapter. The criteria employed under the demonstration
program under this section to evaluate outcomes and determine
best practice guidelines and incentives shall not be used as a
basis for the denial of medicare benefits under the demonstration
program to patients against their wishes (or if the patient is
incompetent, against the wishes of the patient's surrogate) on
the basis of the patient's age or expected length of life or of
the patient's present or predicted disability, degree of medical
dependency, or quality of life.
(d) Eligibility criteria
To be eligible to receive assistance under this section, an
entity shall -
(1) be a health care group;
(2) meet quality standards established by the Secretary,
including -
(A) the implementation of continuous quality improvement
mechanisms that are aimed at integrating community-based
support services, primary care, and referral care;
(B) the implementation of activities to increase the delivery
of effective care to beneficiaries;
(C) encouraging patient participation in preference-based
decisions;
(D) the implementation of activities to encourage the
coordination and integration of medical service delivery; and
(E) the implementation of activities to measure and document
the financial impact on the health care marketplace of altering
the incentives of health care delivery and changing the
allocation of resources; and
(3) meet such other requirements as the Secretary may
establish.
(e) Waiver authority
The Secretary may waive such requirements of this subchapter and
subchapter XI of this chapter as may be necessary to carry out the
purposes of the demonstration program established under this
section.
(f) Budget neutrality
With respect to the 5-year period of the demonstration program
under subsection (b) of this section, the aggregate expenditures
under this subchapter for such period shall not exceed the
aggregate expenditures that would have been expended under this
subchapter if the program established under this section had not
been implemented.
(g) Notice requirements
In the case of an individual that receives health care items or
services under a demonstration program carried out under this
section, the Secretary shall ensure that such individual is
notified of any waivers of coverage or payment rules that are
applicable to such individual under this subchapter as a result of
the participation of the individual in such program.
(h) Participation and support by Federal agencies
In carrying out the demonstration program under this section, the
Secretary may direct -
(1) the Director of the National Institutes of Health to expand
the efforts of the Institutes to evaluate current medical
technologies and improve the foundation for evidence-based
practice;
(2) the Administrator of the Agency for Healthcare Research and
Quality to, where possible and appropriate, use the program under
this section as a laboratory for the study of quality improvement
strategies and to evaluate, monitor, and disseminate information
relevant to such program; and
(3) the Administrator of the Centers for Medicare&Medicaid
Services and the Administrator of the Center for Medicare Choices
to support linkages of relevant medicare data to registry
information from participating health care groups for the
beneficiary populations served by the participating groups, for
analysis supporting the purposes of the demonstration program,
consistent with the applicable provisions of the Health Insurance
Portability and Accountability Act of 1996.