[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 1396 Introduced in Senate (IS)]
114th CONGRESS
1st Session
S. 1396
To establish a demonstration program requiring the utilization of
Value-Based Insurance Design in order to demonstrate that reducing the
copayments or coinsurance charged to Medicare beneficiaries for
selected high-value prescription medications and clinical services can
increase their utilization and ultimately improve clinical outcomes,
enhance beneficiary satisfaction, and lower health care expenditures.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 20, 2015
Mr. Thune (for himself and Ms. Stabenow) introduced the following bill;
which was read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To establish a demonstration program requiring the utilization of
Value-Based Insurance Design in order to demonstrate that reducing the
copayments or coinsurance charged to Medicare beneficiaries for
selected high-value prescription medications and clinical services can
increase their utilization and ultimately improve clinical outcomes,
enhance beneficiary satisfaction, and lower health care expenditures.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Value-Based Insurance Design Seniors
Copayment Reduction Act of 2015''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) A growing body of evidence demonstrates that increases
in patient-level financial barriers (including deductibles,
copayments, and coinsurance) for high-value medical services
(such as prescription medications, clinician visits, diagnostic
tests, and procedures) systematically reduces the use of such
services. Savings attributable to cost-related, decreased
utilization of specific services may lead to an increase in
total medical expenditures due to increased use of other
related clinical services, such as hospitalizations and
emergency room visits.
(2) Empirical research studies demonstrate that reductions
in beneficiary out-of-pocket expenses for high-value
prescription medications and clinical services can mitigate the
adverse health and financial consequences attributable to cost-
related decreased utilization of high-value services.
(3) Financial barriers to prescription medications and
clinical services that are deemed to be high-value should be
reduced or eliminated to increase their use.
(4) Value-Based Insurance Design is a methodology that
adjusts patient out-of-pocket costs for prescription
medications and clinical services according to the clinical
value, not exclusively the cost. Value-Based Insurance Design
is based on the concept of clinical nuance that recognizes--
(A) prescription medications and clinical services
differ in the clinical benefit provided; and
(B) the clinical benefit derived from a specific
prescription medication or clinical service depends on
the clinical situation, the provider, and where the
care is delivered.
(5) The current ``one-size-fits-all'' copayment or
coinsurance design for prescription medications and clinical
services provided under the Medicare program does not recognize
the well-established value differences in health outcomes
produced by various medical interventions.
(6) The establishment by Medicare of copayment and
coinsurance requirements using Value-Based Insurance Design
methodologies will improve patient-centered health outcomes,
enhance personal responsibility, and afford a more efficient
use of taxpayer dollars.
SEC. 3. DEMONSTRATION PROGRAM.
(a) In General.--Not later than 1 year after the date of enactment
of this Act, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall establish a
demonstration program to test Value-Based Insurance Design
methodologies in Medicare Advantage plans under part C of title XVIII
of the Social Security Act for beneficiaries with chronic clinical
conditions.
(b) Demonstration Program Design.--
(1) In general.--The Secretary shall select not less than 2
Medicare Advantage plans to participate in the demonstration
program under this section.
(2) Requirements.--A Medicare Advantage plan selected to
participate in the demonstration program under paragraph (1)
shall meet the following requirements:
(A) The plan offers a coordinated Medicare Part D
drug benefit.
(B) The plan and the Medicare Advantage
organization offering the plan meet such other criteria
as the Secretary determines appropriate.
(c) Expansion of Demonstration Program.--The Secretary shall expand
the demonstration program by issuing regulations to implement, on a
permanent basis, the components of the demonstration program that are
beneficial to Medicare beneficiaries and the Medicare program, unless
the report under subsection (e) or (f)(3) contains an evaluation that
the demonstration program under this section--
(1) increases Medicare program expenditures for
beneficiaries participating in the demonstration program; or
(2) decreases the quality of health care services provided
to Medicare beneficiaries participating in the demonstration
program.
(d) Value-Based Insurance Design Methodology.--
(1) Value-based insurance design.--For purposes of this
section, ``Value-Based Insurance Design'' is a methodology for
identifying specific prescription medications and clinical
services for which copayments or coinsurance should be reduced
or eliminated due to the high-value and effectiveness of such
medications and services for specific clinical conditions.
(2) Reduction of copayments and coinsurance.--Under the
demonstration program, a Medicare Advantage organization, using
Value-Based Insurance Design methodologies, shall identify each
prescription medication and clinical service for which the
amount of the copayment or coinsurance payable should be
reduced or eliminated.
(3) Reduction of copayments and coinsurance to encourage
use of specific clinical services.--Under the demonstration
program, the Medicare Advantage organization, using Value-Based
Insurance Design, may lower cost-sharing under the plan for the
purpose of encouraging enrollees to use prescription
medications and clinical services (such as preventive care,
primary care, specialty visits, diagnostic tests, procedures,
and durable medical equipment) that such organization has
identified as high-value for the management of specified
clinical conditions in paragraph (5). Any such variation on
copayment or coinsurance by a Medicare Advantage organization
must occur on an annual basis and be evidence-based.
(4) Reduction of copayments and coinsurance to encourage
use of specific high-performing providers.--Under the
demonstration program, the Medicare Advantage organization,
using Value-Based Insurance Design, may lower cost-sharing
under the plan for the purpose of encouraging enrollees to use
providers that such organization has identified as high-
performing based on quality metrics. Any such variation on
copayment or coinsurance by a Medicare Advantage organization
must occur on an annual basis.
(5) Specific clinical conditions.--In identifying clinical
conditions for purposes of paragraph (3), the Medicare
Advantage organization shall, at a minimum, consider the
services utilized across the spectrum of care in the management
of the following clinical conditions:
(A) Asthma.
(B) Atrial fibrillation.
(C) Deep venous thrombosis.
(D) Cancer.
(E) Chronic obstructive pulmonary disease.
(F) Chronic renal failure/End stage renal disease.
(G) Congestive heart failure.
(H) Ischemic heart disease/Myocardial infarction.
(I) Depression.
(J) Diabetes mellitus.
(K) Hyperlipidemia.
(L) Hypertension.
(M) Osteoporosis.
(N) Stroke.
(O) Tobacco abuse disorder.
(6) Prohibition of increases of copayments and
coinsurance.--A Medicare Advantage plan selected to participate
in the demonstration program under paragraph (1) may not raise
cost-sharing on any item or service to discourage its use.
(e) Report on Implementation.--
(1) In general.--Not later than 1 year after the date of
the enactment of this Act, the Secretary shall submit to
Congress a report on the implementation by the Secretary of the
demonstration program under this section.
(2) Elements.--The report required by paragraph (1) shall
include the following:
(A) A statement setting forth each medication and
clinical service identified pursuant to subsection
(d)(3).
(B) For each such medication or clinical service
identified pursuant to subsection (d)(3), a statement
of the amount of the copayment or coinsurance required
to be paid for such service and the amount of the
reduction from previous cost-sharing levels.
(C) For each such high-performing provider
identified pursuant to subsection (d)(4), a statement
of the amount of the copayment or coinsurance required
to be paid for such clinician visit and the amount of
the reduction from previous cost-sharing levels.
(f) Review and Assessment of Utilization of Value-Based Insurance
Design Methodologies.--
(1) In general.--The Secretary shall enter into a contract
or agreement with an independent, nonbiased entity having
expertise in Value-Based Insurance Design to review and assess
the implementation of the demonstration program under this
section. The review and assessment shall include the following:
(A) An assessment of the utilization of Value-Based
Insurance Design methodologies referred to in
subsection (d).
(B) An analysis of whether reducing or eliminating
the copayment or coinsurance for each medication and
clinical service identified pursuant to subsection
(d)(3) resulted in increased adherence to medication
regimens, increased service utilization, improvement in
quality metrics, better health outcomes, or enhanced
beneficiary experience.
(C) An analysis of the cost-savings resulting from
reducing or eliminating the copayment or coinsurance
for each medication or clinical service so identified.
(D) An analysis of whether reducing or eliminating
the copayment or coinsurance for each high-performing
provider identified pursuant to subsection (d)(4)
resulted in improvement in quality metrics, better
health outcomes, or enhanced beneficiary experience.
(E) An analysis of the cost-savings resulting from
reducing or eliminating the copayment or coinsurance
for each high-performing provider so identified.
(F) Such other matters as the Secretary considers
appropriate.
(2) Report.--The contract or agreement entered into under
paragraph (1) shall require the entity concerned to submit to
the Secretary a report on the review and assessment conducted
by the entity under that paragraph in time for the inclusion of
the results of such report in the report required by paragraph
(3).
(3) Report to congress.--Not later than 3 years after the
date of the enactment of this Act, the Secretary shall submit
to Congress a report on the review and assessment conducted
under this subsection. The report shall include the following:
(A) A description of the results of the review and
assessment.
(B) Such recommendations as the Secretary considers
appropriate for enhancing the utilization of the
methodologies referred to in subsection (d)(1) so as to
reduce copayments and coinsurance paid by Medicare
beneficiaries for high-value prescription medications
and clinical services furnished under the Medicare
program and to otherwise improve the quality of health
care provided under such Medicare program.
(g) Waiver.--The Secretary may waive such provisions of titles XI
and XVIII of the Social Security Act as may be necessary to carry out
the demonstration program under this section.
(h) Implementation Funding.--For purposes of carrying out the
demonstration program under this section, the Secretary shall provide
for the transfer from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and the
Federal Supplementary Insurance Trust Fund under section 1841 of the
Social Security Act (42 U.S.C. 1395t), including the Medicare
Prescription Drug Account in such Trust Fund, in such proportion as
determined appropriate by the Secretary, of such sums as may be
necessary.
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