§1395cc–1 — Title 42 The Public Health and Welfare | U.S. Code

Summary

The Secretary must run test projects that try pay incentives for health care groups in Medicare. The goal is to get doctors, hospitals, and other providers to work together on care for people in Medicare Parts A and B, to encourage investment in better administration and service delivery, and to reward doctors for improving patient health. The Secretary may run the projects under rules like those used for other Medicare demonstrations. A "physician" means anyone who provides services Medicare treats as doctor services. A "health care group" means a group of those physicians formed at least partly to provide Medicare doctor services and that can include hospitals or other providers who join and share any bonus. The Secretary sets who can join based on size, patients served, services offered, and quality. Groups in the test must accept fee-for-service payment and may have payments sent to one entity. They must give the Secretary data the Secretary asks for. The Secretary will decide which patients count in the test, may add rules (like visit frequency), and must tell those patients about the incentives and any rule waivers. For each group the Secretary will set a base amount (average Parts A and B payments in a base period) and a yearly per-person spending target adjusted for risk and growth. Groups earn a yearly bonus that is part of the Medicare savings compared to the target. The Secretary can also award extra bonuses for proven process and outcome improvements. Bonus payments are limited so total Medicare spending (including bonuses) does not exceed what would have been spent without the tests.

Title 42, §1395cc–1

The Public Health and Welfare — Source: USLM XML via OLRC

(a)(1)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 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.

(2)Except as otherwise specifically provided, the Secretary may administer the program under this section in accordance with section 1395cc–2 of this title.

(3)For purposes of this section, terms have the following meanings:

(A)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)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).

(b)(1)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)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))—

(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)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)(1)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) and for assessment of the effectiveness of the group in achieving the objectives of this section.

(2)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)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)(1)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 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)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)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)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.

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

GAO Report Pub. L. 106–554, § 1(a)(6) [title IV, § 412(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A–515, provided that: “Not later than 2 years after the date on which the demonstration project under section 1866A of the Social Security Act [42 U.S.C. 1395cc–1], as added by subsection (a), is implemented, the Comptroller General of the United States shall submit to Congress a report on such demonstration project. The report shall include such recommendations with respect to changes to the demonstration project that the Comptroller General determines appropriate.”

§1395cc–1 Demonstration of application of physician volume increases to group practices

Summary

Title 42, §1395cc–1

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

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