PRIA, Government Policy, Made Personal

Summary

Creates a Center for Innovation for Care and Payment inside the Department of Veterans Affairs to run pilot programs that test new ways to pay for and deliver care. The Center may try models meant to cut costs while keeping or improving access, quality, timeliness, and patient satisfaction. Tests must target places or groups with care problems and may use things like care planning, patient-centered teams, technology to coordinate care, and links with other payers. Each pilot can run no more than 5 years. No more than 10 pilots can run at the same time. Funding must come from VA appropriations and IT funds. The Secretary must publish each pilot in the Federal Register and tell veterans who could join. The Secretary must evaluate and publicly report on quality, patient outcomes, and spending. If a pilot is not improving care or saving money, the Secretary must either propose a change in an interim report or end the pilot within 30 days. The Secretary must get advice from the Under Secretary for Health and a medical advisory group and consult other agencies and experts. The Secretary may ask to waive certain VA rules to run pilots, but only after sending a detailed report to congressional leaders and relevant committees that explains what will be waived, what standards will replace those rules, metrics, costs, budget, and reporting plans. Congress must approve such waivers by a joint resolution introduced within five legislative days of the report. Annual spending on pilots is normally limited to $50,000,000 unless more is justified and approved by Veterans’ Affairs committee chairs after a report. Decisions under these pilots are final and not subject to court review. For this law, “Federal health care program” means certain federal insurance programs, Medicaid state plans, and TRICARE.

Title 38, §1703E

Veterans' Benefits, Source: USLM XML via OLRC

(a)In General.—

(1)There is established within the Department a Center for Innovation for Care and Payment (in this section referred to as the “Center”).

(2)The Secretary, acting through the Center, may carry out such pilot programs the Secretary determines to be appropriate to develop innovative approaches to testing payment and service delivery models in order to reduce expenditures while preserving or enhancing the quality of care furnished by the Department.

(3)The Secretary, acting through the Center, shall test payment and service delivery models to determine whether such models—

(A)improve access to, and quality, timeliness, and patient satisfaction of care and services; and

(B)create cost savings for the Department.

(4)(A)The Secretary shall test a model in a location where the Secretary determines that the model will addresses deficits in care (including poor clinical outcomes or potentially avoidable expenditures) for a defined population.

(B)The Secretary shall focus on models the Secretary expects to reduce program costs while preserving or enhancing the quality of care received by individuals receiving benefits under this chapter.

(C)The models selected may include those described in section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a(b)(2)(B)).

(5)In selecting a model for testing, the Secretary may consider, in addition to other factors identified in this subsection, the following factors:

(A)Whether the model includes a regular process for monitoring and updating patient care plans in a manner that is consistent with the needs and preferences of individuals receiving benefits under this chapter.

(B)Whether the model places the individual receiving benefits under this chapter (including family members and other caregivers of such individual) at the center of the care team of such individual.

(C)Whether the model uses technology or new systems to coordinate care over time and across settings.

(D)Whether the model demonstrates effective linkage with other public sector payers, private sector payers, or statewide payment models.

(6)(A)Models tested under this section may not be designed in such a way that would allow the United States to recover or collect reasonable charges from a Federal health care program for care or services furnished by the Secretary to a veteran under pilot programs carried out under this section.

(B)In this paragraph, the term “Federal health care program” means—

(i)an insurance program described in section 1811 of the Social Security Act (42 U.S.C. 1395c) or established by section 1831 of such Act (42 U.S.C. 1395j);

(ii)a State plan for medical assistance approved under title XIX of such Act (42 U.S.C. 1396 et seq.); or

(iii)a TRICARE program operated under section 1075, 1075a, 1076, 1076a, 1076c, 1076d, 1076e, or 1076f of title 10.

(b)Duration.—

Each pilot program carried out by the Secretary under this section shall terminate no later than 5 years after the date of the commencement of the pilot program.

(c)Location.—

The Secretary shall ensure that each pilot program carried out under this section occurs in an area or areas appropriate for the intended purposes of the pilot program. To the extent practicable, the Secretary shall ensure that the pilot programs are located in geographically diverse areas of the United States.

(d)Budget.—

Funding for each pilot program carried out by the Secretary under this section shall come from appropriations—

(1)provided in advance in appropriations acts for the Veterans Health Administration; and

(2)provided for information technology systems.

(e)Notice.—

The Secretary shall—

(1)publish information about each pilot program under this section in the Federal Register; and

(2)take reasonable actions to provide direct notice to veterans eligible to participate in such pilot programs.

(f)Waiver of Authorities.—

(1)Subject to reporting under paragraph (2) and approval under paragraph (3), in implementing a pilot program under this section, the Secretary may waive such requirements in subchapters I, II, and III of this chapter as the Secretary determines necessary solely for the purposes of carrying out this section with respect to testing models described in subsection (a).

(2)Before waiving any authority under paragraph (1), the Secretary shall submit to the Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and each standing committee with jurisdiction under the rules of the Senate and of the House of Representatives to report a bill to amend the provision or provisions of law that would be waived by the Department, a report on a request for waiver that describes in detail the following:

(A)The specific authorities to be waived under the pilot program.

(B)The standard or standards to be used in the pilot program in lieu of the waived authorities.

(C)The reasons for such waiver or waivers.

(D)A description of the metric or metrics the Secretary will use to determine the effect of the waiver or waivers upon the access to and quality, timeliness, or patient satisfaction of care and services furnished through the pilot program.

(E)The anticipated cost savings, if any, of the pilot program.

(F)The schedule for interim reports on the pilot program describing the results of the pilot program so far and the feasibility and advisability of continuing the pilot program.

(G)The schedule for the termination of the pilot program and the submission of a final report on the pilot program describing the result of the pilot program and the feasibility and advisability of making the pilot program permanent.

(H)The estimated budget of the pilot program.

(3)(A)Upon receipt of a report submitted under paragraph (2), each House of Congress shall provide copies of the report to the chairman and ranking member of each standing committee with jurisdiction under the rules of the House of Representatives or the Senate to report a bill to amend the provision or provisions of law that would be waived by the Department under this subsection.

(B)The waiver requested by the Secretary under paragraph (2) shall be considered approved under this paragraph if there is enacted into law a joint resolution approving such request in its entirety.

(C)For purposes of this paragraph, the term “joint resolution” means only a joint resolution which is introduced within the period of five legislative days beginning on the date on which the Secretary transmits the report to the Congress under such paragraph (2), and—

(i)which does not have a preamble; and

(ii)the matter after the resolving clause of which is as follows: “that Congress approves the request for a waiver under section 1703E(f) of title 38, United States Code, as submitted by the Secretary on __________”, the blank space being filled with the appropriate date.

(D)(i)Any committee of the House of Representatives to which a joint resolution is referred shall report it to the House without amendment not later than 15 legislative days after the date of introduction thereof. If a committee fails to report the joint resolution within that period, the committee shall be discharged from further consideration of the joint resolution.

(ii)It shall be in order at any time after the third legislative day after each committee authorized to consider a joint resolution has reported or has been discharged from consideration of a joint resolution, to move to proceed to consider the joint resolution in the House. All points of order against the motion are waived. Such a motion shall not be in order after the House has disposed of a motion to proceed on a joint resolution addressing a particular submission. The previous question shall be considered as ordered on the motion to its adoption without intervening motion. The motion shall not be debatable. A motion to reconsider the vote by which the motion is disposed of shall not be in order.

(iii)The joint resolution shall be considered as read. All points of order against the joint resolution and against its consideration are waived. The previous question shall be considered as ordered on the joint resolution to its passage without intervening motion except two hours of debate equally divided and controlled by the proponent and an opponent. A motion to reconsider the vote on passage of the joint resolution shall not be in order.

(E)(i)A joint resolution introduced in the Senate shall be referred to the Committee on Veterans’ Affairs.

(ii)Any committee of the Senate to which a joint resolution is referred shall report it to the Senate without amendment not later than 15 session days after the date of introduction of a joint resolution described in paragraph (C). If a committee fails to report the joint resolution within that period, the committee shall be discharged from further consideration of the joint resolution and the joint resolution shall be placed on the calendar.

(iii)(I)Notwithstanding Rule XXII of the Standing Rules of the Senate, it is in order at any time after the third session day on which the Committee on Veterans’ Affairs has reported or has been discharged from consideration of a joint resolution described in paragraph (C) (even though a previous motion to the same effect has been disagreed to) to move to proceed to the consideration of the joint resolution, and all points of order against the joint resolution (and against consideration of the joint resolution) are waived. The motion to proceed is not debatable. The motion is not subject to a motion to postpone. A motion to reconsider the vote by which the motion is agreed to or disagreed to shall not be in order. If a motion to proceed to the consideration of the resolution is agreed to, the joint resolution shall remain the unfinished business until disposed of.

(II)Consideration of the joint resolution, and on all debatable motions and appeals in connection therewith, shall be limited to not more than two hours, which shall be divided equally between the majority and minority leaders or their designees. A motion further to limit debate is in order and not debatable. An amendment to, or a motion to postpone, or a motion to proceed to the consideration of other business, or a motion to recommit the joint resolution is not in order.

(III)If the Senate has voted to proceed to a joint resolution, the vote on passage of the joint resolution shall occur immediately following the conclusion of consideration of the joint resolution, and a single quorum call at the conclusion of the debate if requested in accordance with the rules of the Senate.

(IV)Appeals from the decisions of the Chair relating to the application of the rules of the Senate, as the case may be, to the procedure relating to a joint resolution shall be decided without debate.

(F)A joint resolution considered pursuant to this paragraph shall not be subject to amendment in either the House of Representatives or the Senate.

(G)(i)If, before the passage by one House of the joint resolution of that House, that House receives the joint resolution from the other House, then the following procedures shall apply:

(I)The joint resolution of the other House shall not be referred to a committee.

(II)With respect to the joint resolution of the House receiving the joint resolution—

(aa)the procedure in that House shall be the same as if no joint resolution had been received from the other House; but

(bb)the vote on passage shall be on the joint resolution of the other House.

(ii)If the Senate fails to introduce or consider a joint resolution under this paragraph, the joint resolution of the House shall be entitled to expedited floor procedures under this subparagraph.

(iii)If, following passage of the joint resolution in the Senate, the Senate then receives the companion measure from the House of Representatives, the companion measure shall not be debatable.

(H)This subparagraph is enacted by Congress—

(i)as an exercise of the rulemaking power of the Senate and House of Representatives, respectively, and as such it is deemed a part of the rules of each House, respectively, but applicable only with respect to the procedure to be followed in that House in the case of a joint resolution, and it supersedes other rules only to the extent that it is inconsistent with such rules; and

(ii)with full recognition of the constitutional right of either House to change the rules (so far as relating to the procedure of that House) at any time, in the same manner, and to the same extent as in the case of any other rule of that House.

(g)Limitations.—

(1)The Secretary may not carry out more than 10 pilot programs concurrently.

(2)(A)Subject to subparagraph (B), the Secretary may not expend more than $50,000,000 in any fiscal year from amounts under subsection (d).

(B)The Secretary may expend more than the amount in subparagraph (A) if—

(i)the Secretary determines that the additional expenditure is necessary to carry out pilot programs under this section;

(ii)the Secretary submits to the Committees on Veterans’ Affairs of the Senate and the House of Representatives a report setting forth the amount of the additional expenditure and a justification for the additional expenditure; and

(iii)the Chairmen of the Committees on Veterans’ Affairs of the Senate and the House of Representatives transmit to the Secretary a letter approving of the additional expenditure.

(3)The waiver provisions in subsection (f) shall not apply unless the Secretary, in accordance with the requirements in subsection (f), submits the first proposal for a pilot program not later than 18 months after the date of the enactment of the Caring for Our Veterans Act of 2018.

(4)Notwithstanding section 502 of this title, decisions by the Secretary under this section shall, consistent with section 511 of this title, be final and conclusive and may not be reviewed by any other official or by any court, whether by an action in the nature of mandamus or otherwise.

(5)(A)If the Secretary determines that a pilot program is not improving the quality of care or producing cost savings, the Secretary shall—

(i)propose a modification to the pilot program in the interim report that shall also be considered a report under subsection (f)(2) and shall be subject to the terms and conditions of subsection (f)(2); or

(ii)terminate such pilot program not later than 30 days after submitting the interim report to Congress.

(B)If the Secretary terminates a pilot program under subparagraph (A)(ii), for purposes of subparagraphs (F) and (G) of subsection (f)(2), such interim report will also serve as the final report for that pilot program.

(h)Evaluation and Reporting Requirements.—

(1)The Secretary shall conduct an evaluation of each model tested, which shall include, at a minimum, an analysis of—

(A)the quality of care furnished under the model, including the measurement of patient-level outcomes and patient-centeredness criteria determined appropriate by the Secretary; and

(B)the changes in spending by reason of that model.

(2)The Secretary shall make the results of each evaluation under this subsection available to the public in a timely fashion and may establish requirements for other entities participating in the testing of models under this section to collect and report information that the Secretary determines is necessary to monitor and evaluate such models.

(i)Coordination and Advice.—

(1)The Secretary shall obtain advice from the Under Secretary for Health and the Special Medical Advisory Group established pursuant to section 7312 of this title in the development and implementation of any pilot program operated under this section.

(2)In carrying out the duties under this section, the Secretary shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The Secretary shall use appropriate mechanisms to seek input from interested parties.

(j)Expansion of Successful Pilot Programs.—

Taking into account the evaluation under subsection (f), the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of a model that is being tested under subsection (a) to the extent determined appropriate by the Secretary, if—

(1)the Secretary determines that such expansion is expected to—

(A)reduce spending without reducing the quality of care; or

(B)improve the quality of patient care without increasing spending; and

(2)the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits for individuals receiving benefits under this chapter.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsec. (a)(6)(B)(ii), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XIX of the Act is classified generally to subchapter XIX (§ 1396 et seq.) of chapter 7 of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. The date of the enactment of the Caring for Our Veterans Act of 2018, referred to in subsec. (g)(3), is the date of enactment of Pub. L. 115–182, which was approved June 6, 2018.

§1703E Center for Innovation for Care and Payment

Summary

Title 38, §1703E

Notes & Related Subsidiaries

Editorial Notes

References in Text

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