United States. Congress

“ IN GENERAL- The Secretary shall conduct a demonstration program (in this section referred to as the `demonstration program') to test a payment incentive and service delivery model that utilizes physician and nurse practitioner directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of items and services under this title to applicable beneficiaries (as defined in subsection (d) ) . ”

“ HIGH-RISK MEDICARE BENEFICIARY- The term `high-risk Medicare beneficiary' means a Medicare beneficiary who has attained a minimum hierarchical condition category score, as determined by the Secretary, based on a diagnosis of multiple chronic conditions or other risk factors associated with a hospital readmission or substandard transition into post-hospitalization care, which may include 1 or more of the following: (A) Cognitive impairment. ”

“ INCENTIVE PAYMENTS- Subject to performance on quality measures, a qualifying independence at home medical practice is eligible to receive an incentive payment under this section if actual expenditures for a year for the applicable beneficiaries it enrolls are less than the estimated spending target established under paragraph (1) for such year. ”

“ REPORTING REQUIREMENTS- An ACO shall submit data in a form and manner specified by the Secretary on measures the Secretary determines necessary for the ACO to report in order to evaluate the quality of care furnished by the ACO. Such data may include care transitions across health care settings, including hospital discharge planning and post-hospital discharge follow-up by ACO professionals, as the Secretary determines appropriate. ”

“ Facilitate inpatient care, including intensive care, of hospitalized applicable individuals at their local hospital through the use of electronic monitoring by specialists, including intensivists and critical care specialists, based at integrated health systems. ”

“ IN GENERAL- The Secretary shall select models to be tested from models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. ”

“ APPLICABLE HOSPITAL- The term `applicable hospital' means a subsection (d) hospital or a hospital that is paid under section 1814 (b) (3) , as the case may be. ` (D) APPLICABLE PERIOD- The term `applicable period' means, with respect to a fiscal year, such period as the Secretary shall specify. ` (E) READMISSION- The term `readmission' means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. ”

“ Funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams. ` (xv) Promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost health care institutions that is responsible for-- ` (I) developing, documenting, and disseminating best practices and proven care methods ”