National Pilot Program on Payment Bundling344
The Secretary will establish a pilot program for integrated care during an episode of care345 provided to an applicable beneficiary346 around a hospitalization in order to improve the coordination, quality and efficiency of health care services. A payment methodology tested under the pilot program will include payment for the furnishing of applicable services,347 such as care coordination, medication reconciliation, discharge planning, transitional care services and other patient-centered activities.348 The Secretary will establish quality measures related to care provided by participating entities.349 Quality measures will include measures of functional status improvement, 350 reducing rates of avoidable hospital readmissions,351 rates of admission to an emergency room after a hospitalization,352 incidence of health care acquired infections,353 measures of patient-centeredness of care,354 and measures of patient perception of care.355 An entity will submit data to the Secretary on these quality measures during each year of the pilot program.356 To the extent practicable, the Secretary will specify that data on measures be submitted through use of a qualified electronic health record.357 The Secretary will conduct an independent evaluation of the pilot program,358 including the extent to which the program has improved quality measures,359 health outcomes,360 and applicable beneficiary access to care.361 The Secretary will submit to Congress a report on the initial results of this independent evaluation two years after the pilot program has been implemented362and within three years after implementation, will send Congress the final results of this evaluation.363
Footnotes
- 344. Social Security Act § 1866D, 42 U.S.C. 1395cc-4.
- 345. Episode of care is defined in Social Security Act § 1866D(a)(2)(D), 42 U.S.C. 1395cc-4(a)(2)(D).
- 346. “Applicable beneficiary” is defined as an individual who is admitted to a hospital for an applicable condition and is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B, but not enrolled under part C or a PACE program. Social Security Act § 1866D(a)(2)(A), 42 U.S.C. 1395cc-4(a)(2)(A). “Applicable condition” means 1 or more of 10 conditions selected by the Secretary. Social Security Act § 1866D(a)(2)(B), 42 U.S.C. 1395cc-4(a)(2)(A).
- 347. “Applicable services” is defined in Social Security Act § 1866D(a)(2)(C), 42 U.S.C. 1395cc-4(a)(2)(C).
- 348. Social Security Act § 1866D(c)(3)(B), 42 U.S.C. 1395cc-4(c)(3)(B).
- 349. Social Security Act § 1866D(c)(4)(A), 42 U.S.C. 1395cc-4(c)(4)(A).
- 350. Social Security Act § 1866D(c)(4)(A)(i), 42 U.S.C. 1395cc-4(c)(4)(A)(i).
- 351. Social Security Act § 1866D(c)(4)(A)(ii), 42 U.S.C. 1395cc-4(c)(4)(A)(ii).
- 352. Social Security Act § 1866D(c)(4)(A)(iv), 42 U.S.C. 1395cc-4(c)(4)(A)(iv).
- 353. Social Security Act § 1866D(c)(4)(A)(v), 42 U.S.C. 1395cc-4(c)(4)(A)(v).
- 354. Social Security Act § 1866D(c)(4)(A)(vii), 42 U.S.C. 1395cc-4(c)(4)(A)(vii).
- 355. Social Security Act § 1866D(c)(4)(A)(viii), 42 U.S.C. 1395cc-4(c)(4)(A)(viii).
- 356. Social Security Act § 1866D(c)(4)(B)(i), 42 U.S.C. 1395cc-4(c)(4)(B)(i).
- 357. Social Security Act s 1866D(c)(4)(B)(ii), 42 U.S.C. 1395cc-4(c)(4)(B)(ii).
- 358. Social Security Act § 1866D(e)(1), 42 U.S.C. 1395cc-4(e)(1).
- 359. Social Security Act § 1866D(e)(1)(A), 42 U.S.C. 1395cc-4(e)(1)(A).
- 360. Social Security Act § 1866D(e)(1)(B), 42 U.S.C. 1395cc-4(e)(1)(B).
- 361. Social Security Act § 1866D(e)(1)(C), 42 U.S.C. 1395cc-4(e)(1)(C).
- 362. Social Security Act § 1866D(e)(2)(A), 42 U.S.C. 1395cc-4(e)(2)(A).
- 363. Social Security Act § 1866D(e)(2)(B), 42 U.S.C. 1395cc-4(e)(2)(B).
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