S.Amdt. 2943

SA 2943. Mr. CARPER (for himself and Mr. Conrad) submitted an
amendment intended to be proposed to amendment SA 2786 proposed by Mr.
Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the bill
H.R. 3590, to amend the Internal Revenue Code of 1986 to modify the
first-time homebuyers credit in the case of members of the Armed Forces
and certain other Federal employees, and for other purposes; which was
ordered to lie on the table; as follows:

On page 722, after line 20, insert the following:

SEC. 3016. ADVANCING IMPLEMENTATION OF CERTAIN VALUE-BASED
PURCHASING PROGRAMS.

(a) Advancing Implementation of Hospital Value-Based
Purchasing Program.--
(1) In general.--Section 1886(o) of the Social Security
Act, as added by section 3001, is amended--
(A) in paragraph (1)(B--
(i) in the subparagraph heading, by striking ``2013'' and
inserting ``2012''; and
(ii) by striking ``2012'' and inserting ``2011'';
(B) in paragraph (2)(B)--
(i) in clause (i), by striking ``2013'' each place it
appears and inserting ``2012''; and
(ii) in clause (ii), by striking ``2014'' and inserting
``2013''; and
(C) in paragraph (7)--
(i) in subparagraph (B)(i), by striking ``2013'' and
inserting ``2012'';
(ii) in subparagraph (C)--

(I) in clause (i), by striking ``2013'' and inserting
``2012'';
(II) in clause (ii), by striking ``2014'' and inserting
``2013'';
(III) in clause (iii), by striking ``2015'' and inserting
``2014'';
(IV) in clause (iv), by striking ``2016'' and inserting
``2015''; and
(V) in clause (v), by striking ``2017'' and inserting
``2016''; and

(iii) in subparagraph (D)(ii)(I), by striking ``2012 and
2013'' and inserting ``2011, 2012, and 2013''.
(2) Conforming amendment.--Section 1886(b)(3)(B)(viii) of
the Social Security Act, as amended by section 3001, is
further amended--
(A) in subclause (V), by striking ``2012'' and inserting
``2011''; and
(B) in each of subclauses (VIII) and (IX), by striking
``2013'' each place it appears and inserting ``2012''.
(b) Advancing Implementation of National Pilot Program on
Payment Bundling.--Section 1866D(a)(3) of the Social Security
Act, as added by section 3023, is amended by striking
``2013'' and inserting ``2012''.

SEC. 3017. INTEGRATED HEALTH CARE SYSTEM COLLABORATION
INITIATIVE.

(a) In General.--In order to improve health care quality
and reduce costs, the Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop, in consultation with major integrated health systems
that have consistently demonstrated high quality and low cost
(as determined by the Secretary and verified by a third
party) a collaboration initiative (referred to in this
section as ``the Collaborative''). The Collaborative shall
develop an exportable model of optimal health care delivery
to apply value-based measurement, integrated information
technology infrastructure, standard care pathways, and
population-based payment models, to measurably improve health
care quality, outcomes, and patient satisfaction and achieve
cost savings.
(b) Participation.--Prior to January 1, 2010, the Secretary
shall determine 5 initial participants who will form the
Collaborative and at least 6 additional participants who will
join the Collaborative beginning in the fourth year that the
Collaborative is in effect.
(1) Initial participants.--Initial participants selected by
the Secretary shall meet the following criteria:
(A) Be integrated health systems organized for the purpose
of providing health care services.
(B) Have demonstrated a record of providing high value
health care for at least the 5 previous years, as determined
by the Secretary in accordance with the Dartmouth Atlas of
Health Care.
(C) Any additional criteria specified by the Secretary.
(2) Additional participants.--Beginning January 1, 2013,
the Secretary shall select 6 or more additional participants
who represent diverse geographic areas and are situated in
areas of differing population densities who agree to comply
with the guidelines, processes, and requirements set forth
for the Collaborative. Such additional participants shall
meet the following additional criteria:
(A) Be organized for the provision of patient medical care.
(B) Be capable of implementing infrastructure and health
care delivery modifications necessary to enhance health care
quality and efficiency, as determined by the Secretary in
accordance with the Dartmouth Atlas of Health Care.
(C) The participant's cost and intensity of care do not
meet the definition of high value health care.
(3) Additional criteria.--In addition to the criteria
described in paragraphs (1) and (2), the participants in the
Collaborative shall meet the following criteria:
(A) Have a legal structure that would allow the participant
to receive incentive payments under this section.
(B) Agree to report on quality, cost, and efficiency in
such form, manner, and frequency as specified by the
Secretary.
(C) Provide care to patients enrolled in the Medicare
program.
(D) Agree to contribute to a best practices network and
website, that is maintained by the Collaborative for sharing
strategies on quality improvement, care coordination,
efficiency, and effectiveness.
(E) Use patient-centered processes of care, including those
that emphasize patient and caregiver involvement in shared
decision-making for treatment decisions.
(F) Meet other criteria determined to be appropriate by the
Secretary.
(c) Collaborative Initiative.--
(1) In general.--Beginning January 1, 2010, the
Collaborative shall begin a 2 year development phase in which
initial participants share the quantitative and qualitative
methods through which they have developed high value health
care followed by a dissemination of that learning model to
additional participants of the Collaborative.
(2) Coordinating member.--In consultation with the
Secretary, the Collaborative shall select a coordinating
member organization (hereafter identified as the Coordinating
Organization) of the Collaborative.
(3) Qualifications.--The Coordinating Organization will
have in place a comprehensive Medicare database and possess
experience using and analyzing Medicare data to

[[Page S12554]]

measure health care utilization, cost, and variation, such as
The Dartmouth Institute for Health Policy and Clinical
Practice. The Coordinating Organization shall be responsible
for reporting to the Secretary as required and for any other
requirements deemed necessary by the Secretary.
(4) Responsibilities.--The Coordinating Member shall--
(A) lead efforts to develop each aspect of the learning
model;
(B) organize efforts to disseminate the learning model for
high value health care, including educating participant
institutions; and
(C) provide administrative, technical, accounting,
reporting, organizational and infrastructure support needed
to carry out the goals of the Collaborative.
(5) Development of learning model.--
(A) In general.--Initial participants in the Collaborative
shall work together to develop a learning model based on
their experience that includes a reliance on evidence based
care that emphasizes quality and practice techniques that
emphasize efficiency, joint development and implementation of
health information technology, introduction of clinical
microsystems of care, shared decision-making, outcomes and
measurement, and the establishment of an e-learning
distributive network, which have been put into practice at
their respective institutions.
(B) Responsibilities.--The Coordinating Member shall do the
following:
(i) Partner with initial participants to comprehensively
understand each institution's contribution to providing
value-based health care.
(ii) Provide and measure value-based health care in a
manner that ensures that measures are aligned with current
measures approved by a consensus-based organization, such as
the National Quality Forum, or other measures as determined
appropriate by the Secretary, while also incorporating
patient self-reported status and outcomes.
(iii) Create a replicable and scalable infrastructure for
common measurement of value-based care that can be broadly
disseminated across the Collaborative and other institutions.
(iv) Implement care pathways for common conditions using
standard measures for assessment across institutions,
targeting high variation and high cost conditions, including
but not limited to--

(I) acute myocardial infarction (AMI) and angioplasty;
(II) coronary artery bypass graft surgery and percutaneous
coronary intervention;
(III) hip or knee replacement;
(IV) spinal surgery; and
(V) care for chronic diseases including, but not limited
to, diabetes, heart disease, and high blood pressure.

(v) Deploy and disseminate the comprehensive learning model
across initial participant institutions, achieving
improvements in care delivery and lowering costs, and
demonstrating the portability and viability of the processes.
(6) Additional best practices.--As additional methods of
improving health care quality and efficiency are identified
by members of the Collaborative or by other institutions,
Initial Participants in the Collaborative shall incorporate
those practices into the learning model.
(d) Implementation of Learning Model.--
(1) In general.--Beginning January 1, 2013, as additional
participants are selected by the Secretary, Initial
Participants in the Collaborative shall actively engage in
the deployment of the learning model to educate each
additional participant in the common conditions that have
been identified.
(A) Dissemination of learning model.--Dissemination methods
shall include but not be limited to the following methods:
(i) Specialized teams deployed by the Initial Participants
to teach and facilitate implementation on site.
(ii) Distance-learning, taking advantage of latest
interactive technologies.
(iii) On-line, fully accessible repositories of shared
learning and information related to best practices.
(iv) Advanced population health information technology
models.
(B) Evaluation of participants.--Evaluation of initial
participants shall be based on documented success in meeting
quality and efficiency targets. Specific statistically valid
measures of evaluation shall be determined by the Secretary.
(e) Efficiency and Quality Targets.--
(1) Efficiency target based on growth rate.--Initial
participants shall implement techniques under the
comprehensive learning model to meet a growth rate target
equal to, as selected by the Secretary with respect to the
participant--
(A) the percentage increase in the consumer price index for
all urban consumers (all items; United States city average)
over the previous year, plus 2 percentage points; or
(B) the percentage increase in the projected per capita
amount of National Health Expenditures from the calendar year
in which the previous fiscal year ends to the calendar year
in which the fiscal year involved ends, as most recently
published by the Secretary before the beginning of the fiscal
year, minus 1.5 percentage points.
(2) Quality target.--The Secretary shall establish a
quality target, based on measures endorsed by a consensus-
based quality organization, for the initial participants in
the first year and subsequently for the additional
participants.
(f) Payments.--
(1) Base payment.--With respect to each participant in the
Collaborative, the Secretary shall determine a base amount on
a per capita basis for the participant for purposes of
measuring the growth rate in total payments for common
conditions, based on the reimbursement amount paid to the
participant under title XVIII of the Social Security Act for
furnishing items and services with respect to such
conditions.
(2) Bonus payment.--If the growth rate in total payments
for services for common conditions does not exceed the growth
rate target selected for the participant under subsection
(e)(1), and the participant satisfies the quality target
established by the Secretary under subsection (e)(2), the
Secretary shall provide a bonus payment equal to 50 percent
of any per capita payment reductions that are below the
capita base amounts determined under paragraph (1).
(3) Penalty payment.--If the growth rate in total per
capita payments for furnishing items and services for common
conditions exceeds the growth rate target, the Secretary
shall pay only 25 percent of any additional expenses that
exceed the base amounts determined under paragraph (1).
(4) Budget neutrality limitation.--The Secretary shall
limit incentive payments to each of the participating
organizations under this section as necessary to ensure that
the aggregate expenditures with respect to applicable
beneficiaries under title XVIII of the Social Security Act
(inclusive of incentive payments described in this
subsection) do not exceed the amount that the Secretary
estimates would be expended for such beneficiaries if the
Collaborative under this section were not implemented.
(g) Administrative Payment.--Out of funds not otherwise
obligated in the Treasury, there are appropriated
$228,000,000, to remain available until expended, to be
distributed in the following manner:
(1) The Coordinating Organization shall receive $10,000,000
per year for program development related to the
Collaborative, including for health information technology
and other infrastructure, project evaluations, analysis, and
measurement, compliance, auditings and other reporting. Not
less than $5,000,000 of such funds shall be provided for
education and training, including for support for the
establishment of training teams for the Collaborative, to
assist in the integration of new health information
technology, best practices of care delivery, microsystems of
care delivery, and a distributive e-learning network for the
Collaborative.
(2) Each Initial Participant shall receive $4,000,000 per
year for internal program development for health information
technology and other infrastructure, education and training,
project evaluations, analysis, and measurement, and
compliance, auditing, and other reporting.
(3) Beginning in 2013, the Secretary may provide funding to
additional participants in the Collaborative in an amount not
to exceed $4,000,000 per participant per year under the same
use guidelines as apply to the Initial Participants.
(h) Continuation or Expansion.--
(1) Termination.--Subject to paragraph (2), the
Collaborative shall terminate on the date that is 6 years
after the date on which the Collaborative is established.
(2) Expansion.--The Secretary may continue or expand the
Collaborative if--
(A) participants meet the established growth rate targets
and consistently receive bonus payments during the first 4
years of the Collaborative and are consistently meeting
quality standards; or
(B) the Collaborative is consistently exceeding quality
standards and is not increasing spending under the program.
(i) Termination.--The Secretary may terminate an agreement
with the Collaborative or a participating organization under
the Collaborative if such organization did not qualify for
incentive payments or consistently failed to meet quality
standards in any of the first 3 years of the Collaborative.
(j) Reports.--
(1) Performance results reports.--The Secretary shall
provide such data as is necessary for the Collaborative to
measure the efficacy of the Collaborative and facilitate
regular reporting on spending and cost savings results
relative to a value-based program initiative.
(2) Reports to congress.--Not later than 2 years after the
date the first agreement is entered into under this section,
and annually thereafter, the Secretary shall submit to
Congress and make publicly available a report on the
authority granted to the Secretary to carry out the
Collaborative under this section. Each report shall address
the impact of the use of such authority on expenditures for,
access to, and quality of, care under title XVIII of the
Social Security Act.
(k) Definitions.--In this section:
(1) Beneficiary.--The term ``beneficiary'' means a Medicare
beneficiary enrolled under part B and entitled to benefits
under part A who is not enrolled in Medicare Advantage under
Part C or a PACE program under section 1894, and meets other
criteria as the Secretary determines appropriate.
(2) High value health care.--The term ``high value health
care'' means the care delivered by organizations shown by
statistically valid methods to meet the highest quality
measures established by the Secretary as of or after the date
of enactment of this Act and to be delivering low-cost care

[[Page S12555]]

with high patient satisfaction and clinical outcomes.
(3) Learning model.--The term ``learning model'' means a
standardized model developed by the Initial Participants in
the Collaborative and based on best practices, as jointly
developed and put into practice at the Initial Participant's
respective institutions.
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(l) Additional Monitoring.--The Secretary may monitor data
on expenditures and quality of services under title XVIII of
the Social Security Act with respect to a beneficiary after
the beneficiary discontinues receiving services under the
Collaborative.
(m) Other Provisions.--
(1) Limitations on review.--There shall be no
administrative or judicial review under this section or
otherwise of--
(A) the elements, parameters, scope, and duration of the
Collaborative, including the selection of participants in the
Collaborative;
(B) the establishment of targets, measurement of
performance;
(C) determinations with respect to whether savings have
been achieved and the amount of savings;
(D) determinations regarding whether, to whom, and in what
amounts incentive payments are paid; and
(E) decisions about the extension or expansion of the
Collaborative.
(2) Administration.--Chapter 35 of title 44, 4 United
States Code shall not apply to this section.
(3) Evaluation.--The Secretary shall evaluate the payment
incentive model for the Collaborative to assess impacts on
beneficiaries and on the Medicare program under title XVIII
of the Social Security Act. The Secretary shall make such
evaluation publicly available within 60 days of the date of
completion of such report.
(4) Monitoring.--The Inspector General of the Department of
Health and Human Services shall provide for monitoring of the
operation of the Collaborative with regard to violations of
section 1877 of the Social Security Act (popularly known as
the ``Stark law'').
(5) Anti-discrimination.--The Secretary shall not enter
into an agreement with an entity to provide health care items
or services under the Collaborative, or with an entity to
administer the Collaborative, unless such entity guarantees
that it will not deny, limit, or condition the coverage or
provision of benefits under the Collaborative for
beneficiaries to participate in the Collaborative, based on
any health status-related factor described in section
2702(a)(1) of the Public Health Service Act.
______