[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5013 Introduced in House (IH)]
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118th CONGRESS
1st Session
H. R. 5013
To direct the Secretary of Health and Human Services to revise certain
regulations in relation to the Medicare shared savings program and
other alternative payment arrangements to encourage participation in
such program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 27, 2023
Mr. LaHood (for himself, Ms. DelBene, Mr. Wenstrup, Ms. Schrier, Mr.
Bucshon, and Mr. Blumenauer) 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 consideration 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 alternative payment arrangements to encourage participation in
such program, and for other purposes.
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 in Health Care Act of 2023''.
SEC. 2. ENCOURAGING PARTICIPATION IN THE MEDICARE SHARED SAVINGS
PROGRAM.
(a) Removing Barriers to Shared Savings Program Participation.--
Prior to the beginning of the first performance year (as defined in
section 425.20 of title 42, Code of Federal Regulations (or a successor
regulation)) that begins at least 90 days after the date of enactment
of this Act, the Secretary of Health and Human Services shall revise
part 425 of title 42, Code of Federal Regulations, or any successor
regulation, to--
(1) eliminate any distinction in requirements in such part
between a low revenue ACO and a high revenue ACO (as such terms
are defined in section 425.20 of title 42, Code of Federal
Regulations, or a successor regulation) and, with respect to
such a low revenue ACO or high revenue ACO and except as
otherwise modified in this Act, apply the requirements of such
part as such requirements applied to low revenue ACOs on July
1, 2024, except that the Secretary of Health and Human Services
may, if the Secretary determines appropriate, apply less
stringent requirements than those requirements that applied to
low revenue ACOs as of such date; and
(2) remove any provision requiring an accountable care
organization to assume responsibility for repayment of any
shared losses or participate in a two-sided risk model before
the organization has participated for at least 3 years in any
program subject to the provisions of part 425 of title 42, Code
of Federal Regulations, or any successor regulation, provided
that such an organization shall be allowed to elect to
participate in such two-sided risk models or models requiring
repayment of such losses.
(b) Financial Methodology Enhancements To Promote Success of Shared
Savings Program.--Prior to the beginning of the first performance year
(as defined for purposes of subsection (a)) that begins at least 90
days after the date of enactment of this Act, the Secretary shall--
(1) ensure that any methodology used to establish, adjust,
or update benchmark expenditures be developed and implemented
in a clear and transparent manner, including by making publicly
available sufficient information and data to allow interested
members of the public to replicate the methodology used by the
Secretary and to evaluate the accuracy of the Secretary's
benchmark expenditure calculations;
(2) implement a process that allows ACOs to appeal the
accuracy of benchmark expenditures in a hearing before an
administrative law judge, and ensure that any such appeal be
heard within a 90-day period beginning on the date a request
for hearing is filed; and
(3) require that any regional contributions or expenditures
(below the national level) used directly or indirectly to
establish, update, or adjust benchmark expenditures be
calculated in a manner that excludes the expenditure impact of
ACOs in the applicable region, including any regional
expenditures associated with Medicare fee-for-service
beneficiaries assigned to such ACOs.
(c) Shared Savings Option.--Prior to the beginning of the first
performance year (as defined for purposes of subsection (a)) that
begins after the date of the enactment of this Act, and notwithstanding
any other provision of law, the Secretary of Health and Human Services
shall establish a voluntary full-risk option under the Medicare Shared
Savings Program (as described in section 1899 of the Social Security
Act (42 U.S.C. 1395jjj) under which the percent of shared savings paid
to an ACO under section 1899(d)(2) of the Social Security Act (42
U.S.C. 1395jjj(d)(2)) shall be set at 100 percent, with the ACO bearing
commensurate risk of any shared losses.
(d) Report.--Not later than 90 days after the date of enactment of
this Act, the Administrator of the Centers for Medicare & Medica
Services shall submit to the appropriate committees of Congress a
report on mechanisms that the agency can take to avoid penalizing ACOs
for achieving cost savings and account for regional variations in
spending in a manner that prevents arbitrary Medicare Shared Savings
Program outcomes for ACOs. Such report shall include specific actions
that the Centers for Medicare & Medicaid Services can take to develop
and implement effective benchmarks and guardrails for any changes made
to the agency's benchmarking policies.
SEC. 3. ADVANCED PAYMENT MODEL INCENTIVE, PARTICIPATION, AND THRESHOLD
MODIFICATIONS.
(a) In General.--Section 1833(z) of the Social Security Act (42
U.S.C. 1395l(z)) is amended--
(1) in paragraph (1)(A), by striking ``2025'' and inserting
``2027'' and by adding after ``5 percent (or, with respect to
2025, 3.5 percent'' and before the close parenthesis ``or, with
respect to 2026 and any subsequent year, the scaled percentage
amount'';
(2) in paragraph (2)(C)--
(A) in clause (i), by striking ``75 percent''and
inserting ``the applicable percent (as defined in
clause (iv)) for such year'';
(B) in clause (ii)(I)--
(i) in the matter preceding item (aa), by
striking ``75 percent'' and inserting ``the
applicable percent (as defined in clause (iv))
for such year''; and
(ii) in item (bb)--
(I) by striking ``and other than
payments made under title XIX'' and
inserting ``other than payments made
under title XIX''; and
(II) by striking ``State program
under that title),'' and inserting
``State program under that title, and
other than payments made by payers in
which no payment or program meeting the
requirements described in clause
(iii)(II) is available from the payer
for participation by the eligible
professional)''; and
(C) by adding at the end the following new clause:
``(iv) Applicable percent defined.--For
purposes of clauses (i) and (ii), the term
`applicable percent' means--
``(I) for 2026 through 2027, 50
percent; and
``(II) for 2028 and any subsequent
year, a percent specified by the
Secretary, but in no case less than the
percent specified under this clause for
the preceding year or more than the
lesser of 75 percent or 5 percentage
points higher than the percent
specified under this clause for the
preceding year.
``(v) Alternative applicable percent.--
Notwithstanding any other provision of law, the
Secretary may define the applicable percent for
purposes of a given alternative payment model
(or for purposes of partial qualifying APM
participants under section
1848(q)(1)(C)(iii)(III)) to mean a percentage
amount that is lower than the amount (or range)
otherwise specified in such preceding clause
(or, as applicable, under section
1848(q)(1)(C)(iii)(III)), if there is good
cause to support such alternative applicable
percent, including where an alternative payment
model's design warrants use of such alternative
applicable percent. In no case shall the
Secretary designate an alternative applicable
percent that exceeds the maximum applicable
percent specified in the preceding clause (or,
as applicable, under section
1848(q)(1)(C)(iii)(III)) for the applicable
year; and
``(vi) Scaled percentage amount.--For
purposes of this subsection (including
paragraph (1)), the term `scaled percentage
amount' means a progressively scaled percentage
amount designated by the Secretary. The
Secretary shall determine an appropriate
progressive percentage scale for different
categories of eligible professionals based on
programmatic interests in efficiency, equity,
and alignment of appropriate incentives. The
maximum scaled percentage amount shall be 5
percent, and such maximum amount shall apply to
an eligible professional that meets or exceeds
the applicable percent (as defined in paragraph
(2)(C)(iv)). In no case may an eligible
professional below the applicable percent
qualify for the maximum scaled percentage
amount''; and
(3) in paragraph (4)(B), by adding after ``5 percent (or,
with respect to 2025, 3.5 percent'' and before the close
parenthesis ``or, with respect to 2026 and any subsequent year,
the scaled percentage amount''.
(b) Technical Assistance.--The Secretary of Health and Human
Services shall provide education and technical assistance to ACOs and
other types of providers (as defined under section 414.1305 of title
42, Code of Federal Regulations (or a successor regulation)) that the
Secretary determines to target or otherwise operate in rural or
medically underserved areas or to involve material participation by
small practice or safety net groups of providers of services and
suppliers. Such education and technical assistance may include
infrastructure support or access to data analytics to support ACO
implementation in such rural or medically underserved areas or to
benefit small practice or safety net groups of providers of services
and suppliers, or other groups of providers of services and suppliers
deemed to require additional support, such as providers of services or
suppliers that are new to APMs, including specialists.
(c) Partial Qualifying APM Participant Modification.--Section
1848(q)(1)(C)(iii)(III) of the Social Security Act (42 U.S.C. 1395w-
4(q)(1)(C)(iii)(III)) is amended--
(1) in item (aa), by striking ``50 percent was instead a
reference to 40 percent'' and inserting ``the applicable
percent were instead a reference to 10 percentage points less
than the applicable percent''; and
(2) in item (bb)--
(A) by striking ``75 percent'' and inserting ``the
applicable percent''; and
(B) by striking ``50 percent'' and inserting ``10
percentage points less than the applicable percent''.
SEC. 4 STUDY ON ALTERNATIVE PAYMENT MODELS AND MEDICARE+CHOICE.
Not later than 18 months after the date of enactment of this Act,
the Comptroller General of the Government Accountability Office shall
study and submit to the appropriate committees of Congress a report
evaluating the benefits and flexibilities provided to support
alternative payment models (as defined under section 414.1305 of title
42, Code of Federal Regulations (or a successor regulation)) and
Medicare+Choice Organizations (as defined in section 1859(a)(1) of the
Social Security Act (42 U.S.C. 1395w-28(a)(1)). The objective of such
report shall be to better understand the effect of these programs'
different policies on different types of participating patients and
providers, including specialty, safety net, small practice, and rural
providers, with the goal of identifying areas to enhance alignment
between such programs' policies and benchmarks including through
mechanisms that could facilitate greater alignment in policies and
benchmarks and to encourage the adoption of value-based arrangements
across payers or that could otherwise increase parity in the
flexibilities available to alternative payment models and
Medicare+Choice Organizations.
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