Value in Health Care Act of 2020

I 116TH CONGRESS 2D SESSION H. R. 7791 To direct the Secretary of Health and Human Services to revise certain regulations in relation to the Medicare shared savings program and other advanced alternative payment arrangements to encourage participa- tion in such program, and for other purposes. IN THE HOUSE OF REPRESENTATIVES JULY 24, 2020 Mr. WELCH (for himself, Ms. DELBENE, and MR. LAHOOD) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consider- ation of such provisions as fall within the jurisdiction of the committee concerned A BILL To direct the Secretary of Health and Human Services to revise certain regulations in relation to the Medicare shared savings program and other advanced alternative payment arrangements to encourage participation in such program, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Value in Health Care 4 Act of 2020’’. 5 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 7791 IH SEC. 2. ENCOURAGING PARTICIPATION IN THE MEDICARE 1 SHARED SAVINGS PROGRAM. 2 (a) INCREASING SHARED SAVINGS RATES FOR CER- 3 TAIN ACCOUNTABLE CARE ORGANIZATIONS.—Prior to the 4 beginning of the first performance year (as defined in sec- 5 tion 425.20 of title 42, Code of Federal Regulations (or 6 a successor regulation)) that begins after the date of the 7 enactment of this Act, the Secretary of Health and 8 Human Services shall revise section 425.605(d)(1) of title 9 42, Code of Federal Regulations (or a successor regula- 10 tion), to provide that the shared savings rate for an ac- 11 countable care organization participating in— 12 (1) Level A (as described in paragraph (i)(A) of 13 such section) or Level B (as described in paragraph 14 (ii)(A) of such section) of the BASIC track shall be 15 at least 50 percent of all the savings under the up- 16 dated benchmark (as so described), as determined 17 on the basis of such organization’s quality perform- 18 ance; 19 (2) Level C (as described in paragraph (iii)(A) 20 of such section) or Level D (as described in para- 21 graph (iv)(A) of such section) of the BASIC track 22 shall be at least 55 percent of all the savings under 23 the updated benchmark (as so described), as deter- 24 mined on the basis of such organization’s quality 25 performance; or 26 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 7791 IH (3) Level E (as described in paragraph (v)(A) 1 of such section) shall be at least 60 percent of all 2 the savings under the updated benchmark (as so de- 3 scribed), as determined on the basis of such organi- 4 zation’s quality performance. 5 (b) MODIFYING RISK ADJUSTMENT METHOD- 6 OLOGY.—Prior to the beginning of the first performance 7 year (as defined for purposes of subsection (a)) that be- 8 gins after the date of the enactment of this Act, the Sec- 9 retary of Health and Human Services shall revise— 10 (1) section 425.605(a)(1)(i) of title 42, Code of 11 Federal Regulations, or a successor regulation, to 12 provide that positive adjustments, if applicable, in 13 prospective HCC risk scores (as applied for purposes 14 of such section) are subject to a cap of no less than 15 5 percent, and any negative adjustments, if applica- 16 ble, in prospective HCC risk scores (as applied for 17 purposes of such section) shall be between 0 and 18 negative 5 percent; 19 (2) section 425.610(a)(2)(i) of title 42, Code of 20 Federal Regulations, or a successor regulation, to 21 provide that positive adjustments, if applicable, in 22 prospective HCC risk scores (as applied for purposes 23 of such section) are subject to a cap of no less than 24 5 percent, and any negative adjustments, if applica- 25 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 7791 IH ble, in prospective HCC risk scores (as applied for 1 purposes of such section) shall be between 0 and 2 negative 5 percent; and 3 (3) section 425.609(c)(3)(i)(A) of title 42, Code 4 of Federal Regulations, or a successor regulation, to 5 provide that the cap described in such section ref- 6 erences no less than 5 percent, and any negative ad- 7 justments, if applicable, in prospective HCC risk 8 scores (as applied for purposes of such section) shall 9 be between 0 and negative 5 percent. 10 (c) REMOVING BARRIERS TO SHARED SAVINGS PRO- 11 GRAM PARTICIPATION.—Prior to the beginning of the first 12 performance year (as defined for purposes of subsection 13 (a)) that begins after the date of the enactment of this 14 Act, the Secretary of Health and Human Services shall 15 revise part 425 of title 42, Code of Federal Regulations, 16 or any successor regulation, to— 17 (1) eliminate any distinction in requirements in 18 such part between a low revenue ACO and a high 19 revenue ACO (as such terms are defined in section 20 425.20 of title 42, Code of Federal Regulations, or 21 a successor regulation) and, with respect to such a 22 low revenue ACO or high revenue ACO and except 23 as otherwise modified in this Act, apply the require- 24 ments of such part as such requirements applied to 25 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 7791 IH low revenue ACOs on July 1, 2019, except that the 1 Secretary of Health and Human Services may, if the 2 Secretary determines appropriate, apply less strin- 3 gent requirements than those requirements that ap- 4 plied to low revenue ACOs as of such date; and 5 (2) remove any provision requiring an account- 6 able care organization to assume responsibility for 7 repayment of any shared losses or participate in a 8 two-sided risk model before the organization has 9 participated for at least 3 years in any program sub- 10 ject to the provisions of part 425 of title 42, Code 11 of Federal Regulations, or any successor regulation, 12 provided that such an organization shall be allowed 13 to elect to participate in such two-sided risk models 14 or models requiring repayment of such losses. 15 (d) ENSURING FAIR AND ACCURATE BENCH- 16 MARKS.—Prior to the beginning of the first performance 17 year (as defined for purposes of subsection (a)) that be- 18 gins after the date of the enactment of this Act, the Sec- 19 retary of Health and Human Services shall revise part 425 20 of title 42, Code of Federal Regulations, to remove Medi- 21 care beneficiaries who are assigned to an accountable care 22 organization from the methodology for calculating the re- 23 gional expenditures used to establish, adjust, and update 24 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 7791 IH the benchmark expenditures for ACO performance periods 1 beginning on or after July 1, 2019. 2 SEC. 3. PROVIDING EDUCATIONAL AND TECHNICAL SUP- 3 PORT FOR THE MEDICARE SHARED SAVINGS 4 PROGRAM. 5 Section 1899 of the Social Security Act (42 U.S.C. 6 1395jjj) is amended by adding at the end the following 7 new subsection: 8 ‘‘(n) EDUCATIONAL AND TECHNICAL SUPPORT.— 9 ‘‘(1) IN GENERAL.—The Secretary shall estab- 10 lish a program to assist eligible ACOs in meeting 11 start-up and ongoing operational costs associated 12 with establishing and participating in the shared 13 savings program established under subsection (a). 14 The Secretary shall establish through notice-and- 15 comment rulemaking the requirements for participa- 16 tion and use of funds in the program established in 17 the preceding sentence. 18 ‘‘(2) REDUCTION IN SHARED SAVINGS PAY- 19 MENTS.—The Secretary shall reduce any shared sav- 20 ings payment owed to an ACO under subsection (d) 21 in an amount equal to any funds provided to such 22 ACO under the program established under para- 23 graph (1).’’. 24 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 7791 IH SEC. 4. ADVANCED PAYMENT MODEL INCENTIVE, PARTICI- 1 PATION, AND THRESHOLD MODIFICATIONS. 2 (a) IN GENERAL.—Section 1833(z) of the Social Se- 3 curity Act (42 U.S.C. 1395l(z)) is amended— 4 (1) in paragraph (1)(A), by striking ‘‘2024’’ 5 and inserting ‘‘2030’’; and 6 (2) in paragraph (2)— 7 (A) in subparagraph (B)— 8 (i) by striking the header and insert- 9 ing ‘‘2021 AND SUBSEQUENT YEARS’’; 10 (ii) in the matter preceding clause (i), 11 by striking ‘‘2021 and 2022’’ and inserting 12 ‘‘2021 or a subsequent year’’; 13 (iii) in clause (i), by striking ‘‘50 per- 14 cent’’ and ‘‘the applicable percent (as de- 15 fined in clause (iv)) for such year’’; 16 (iv) in clause (ii)(I)— 17 (I) in the matter preceding item 18 (aa), by striking ‘‘50 percent’’ and in- 19 serting ‘‘the applicable percent (as de- 20 fined in clause (iv)) for such year’’; 21 and 22 (II) in item (bb)— 23 (aa) by striking ‘‘and other 24 than payments made under title 25 XIX’’ and inserting ‘‘other than 26 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 8 •HR 7791 IH payments made under title XIX’’; 1 and 2 (bb) by striking ‘‘State pro- 3 gram under that title),’’ and in- 4 serting ‘‘State program under 5 that title, and other than pay- 6 ments made by payers in which 7 no payment or program meeting 8 the requirements described in 9 clause (iii)(II) is available from 10 the payer for participation by the 11 eligible professional)’’; and 12 (v) by adding at the end the following 13 new clause: 14 ‘‘(iv) APPLICABLE PERCENT DE- 15 FINED.—For purposes of clauses (i) and 16 (ii), the term ‘applicable percent’ means— 17 ‘‘(I) for 2021, 50 percent; and 18 ‘‘(II) for a subsequent year, a 19 percent specified by the Secretary, but 20 in no case less than the percent speci- 21 fied under this clause for the pre- 22 ceding year or more than 5 percent- 23 age points higher than the percent 24 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 9 •HR 7791 IH specified under this clause for such 1 preceding year.’’; 2 (B) by striking subparagraph (C); and 3 (C) by redesignating subparagraph (D) as 4 subparagraph (C). 5 (b) PARTIAL QUALIFYING APM PARTICIPANT MODI- 6 FICATIONS.—Section 1848(q)(1)(C)(iii) of the Social Se- 7 curity Act (42 U.S.C. 1395w–4(q)(1)(C)(iii)) is amend- 8 ed— 9 (1) in subclause (I), by adding ‘‘and’’ at the 10 end; 11 (2) in subclause (II)— 12 (A) in the matter preceding item (aa), by 13 striking ‘‘2022’’ and inserting ‘‘subsequent 14 years’’; 15 (B) in item (aa), by striking ‘‘50 percent 16 was instead a reference to 40 percent’’ and in- 17 serting ‘‘the applicable percent were instead a 18 reference to 10 percentage points less than the 19 applicable percent’’; and 20 (C) in item (bb)— 21 (i) by striking ‘‘50 percent’’ and in- 22 serting ‘‘the applicable percent’’; and 23 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 10 •HR 7791 IH (ii) by striking ‘‘40 percent’’ and in- 1 serting ‘‘10 percentage points less than the 2 applicable percent’’; and 3 (3) by striking subclause (III). 4 (c) EFFECTIVE DATE.—The amendments made by 5 this section shall apply with respect to years beginning on 6 or after January 1, 2021. 7 SEC. 5. ADDRESSING OVERLAP IN VALUE BASED CARE PRO- 8 GRAMS. 9 (a) IN GENERAL.— 10 (1) CMI.—Section 1115A(a)(5) of the Social 11 Security Act (42 U.S.C. 1315a(a)(5)) is amended by 12 adding at the end the following new sentence: ‘‘In 13 establishing such limits, the Secretary shall take into 14 account payment and service delivery models in 15 progress in such geographic areas.’’. 16 (2) REPEAL OF MEDICARE DUPLICATION PRO- 17 HIBITION.—Section 1899(b) of the Social Security 18 Act (42 U.S.C. 1395jjj(b)) is amended by striking 19 paragraph (4). 20 (b) REPORT.—Not later than 1 year after the date 21 of the enactment of this Act, the Secretary of Health and 22 Human Services shall conduct an assessment and submit 23 to Congress a report on alternative payment model overlap 24 VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS 11 •HR 7791 IH in the Medicare program. Such report shall include a de- 1 scription of and recommendations relating to— 2 (1) any issues regarding the existence of mul- 3 tiple alternative payment model participation oppor- 4 tunities for health care providers; and 5 (2) obstacles created by competing incentives 6 with respect to alternative payment models. 7 Æ VerDate Sep 11 2014 00:04 Aug 26, 2020 Jkt 099200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6301 E:\BILLS\H7791.IH H7791 pamtmann on DSKBC07HB2PROD with BILLS