§1395cc–4 National Pilot Program on Payment Bundling

Summary

The Secretary must run a pilot program to test bundled care payments for people around a hospital stay. The goal is to improve how care is coordinated, raise quality, and lower costs. The program must be started by January 1, 2013. It will run for 5 years unless the Secretary expands it after January 1, 2016 if the expansion is expected to save money or improve care, the Chief Actuary certifies it will cut spending, and the Secretary finds it won’t limit or deny benefits. Key terms: Applicable beneficiary — a person with Medicare Part A and Part B (not Part C or PACE) who is admitted to a hospital for a chosen condition. Applicable condition — up to 10 conditions the Secretary selects using factors like whether they are chronic or acute, surgical or medical, have high post-acute costs, or show room for better care and lower spending. Applicable services — hospital inpatient care, doctors’ services, outpatient and ER care, and post-acute care like home health, skilled nursing, inpatient rehab, long-term care hospitals, and other services the Secretary allows. Episode of care — normally the 3 days before hospital admission, the hospital stay, and 30 days after discharge, though the Secretary may set a different period. Providers such as hospitals, doctor groups, skilled nursing facilities, and home health agencies can form an entity and apply to join. The Secretary will set rules so patients still have a choice of providers. Payment methods may include bundled payments or bids and must pay the participating entity. Payments should cover the listed services plus care coordination, medication reconciliation, discharge planning, and transitional care. The Secretary must set payments so an entity would not be paid more in a year than it would have been without the pilot, as the Secretary estimates. Rules will cover payment if extra post-acute care is needed beyond the episode. The Secretary will develop quality measures for episodes and for post-acute care (these must be site-neutral for post-acute care) and collect data from participating entities each year, preferably via certified electronic health records. The Secretary may waive Medicare rules as needed to run the pilot. An independent evaluation must check quality, health outcomes, access to care, and spending. The Secretary must report initial results to Congress not later than 2 years after the pilot starts and final results not later than 3 years after it starts. The Secretary must consult small rural and critical access hospitals about their participation and must separately test a continuing care hospital model with its own episode rules (full stay plus the first 30 days after discharge). Chapter 35 of title 44 does not apply to choosing, testing, or expanding the models.