S. 1969 (112th): Quality Care for Moms and Babies Act

112th Congress, 2011–2013. Text as of Dec 08, 2011 (Introduced).

Status & Summary | PDF | Source: GPO

II

112th CONGRESS

1st Session

S. 1969

IN THE SENATE OF THE UNITED STATES

December 8, 2011

(for herself and Mr. Menendez) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To amend title XI of the Social Security Act to improve the quality, health outcomes, and value of maternity care under the Medicaid and CHIP programs by developing a maternity care quality measurement program, evaluating maternity care home models, and supporting maternity care quality collaboratives.

1.

Short title; table of contents

(a)

Short title

This Act may be cited as the Quality Care for Moms and Babies Act.

(b)

Table of contents

The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Quality measures for maternity care under Medicaid and CHIP.

Sec. 3. Quality collaboratives.

Sec. 4. Woman- and family-centered maternity care home demonstration program.

2.

Quality measures for maternity care under Medicaid and CHIP

(a)

In general

Title XI of the Social Security Act is amended by inserting after section 1139B (42 U.S.C. 1320b–9b) the following new section:

1139C.

Maternity care quality measurement

(a)

In general

The Secretary shall develop a maternity care quality measurement program for care provided to childbearing women and newborns for voluntary use by—

(1)

a State in administering a State plan under title XIX or a State child health plan under title XXI;

(2)

health insurance issuers (as such term is defined in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91)) and managed care entities that enter into contracts with States for the purpose of administering such plans; and

(3)

providers of items and services (including accountable care organizations) with respect to items and services provided under such plans.

(b)

Coordination with other quality measures

(1)

Medicaid quality measurement program

The maternity care quality measurement program under subsection (a) shall be developed, administered, and evaluated on an ongoing basis as part of, and in coordination with, the Medicaid Quality Measurement Program established under section 1139B(b)(5)(A) and the pediatric quality measures program established under section 1139A(b). In coordination with the publication requirements under section 1139A(b)(5) and 1139B(b)(5)(B), the Secretary annually shall publish recommended changes to the core set of maternity care quality measures published under subsection (c) that shall reflect the development, testing, validation, and consensus process described in subsection (d).

(2)

Identification of measurement gaps

The maternity care quality measurement program under subsection (a) shall include procedures for identifying quality measure gaps and establishing priorities for the development and advancement of new or modified quality measures under the maternity care quality measurement program, the Medicaid Quality Measurement Program established under section 1139B(b)(5)(A) and the pediatric quality measures program established under section 1139A(b).

(3)

Reports to congress and macpac

Not later than January 1, 2017, and every 3 years thereafter, the Secretary shall include in the reports required under sections 1139A(a)(6) and 1139B(b)(4) to Congress and the Medicaid and CHIP Payment and Access Commission information similar to the information required under such sections with respect to the measures established under this section.

(c)

Identification of an initial set of maternity care quality measures

(1)

Consultation and public comment

Not later than January 1, 2014, the Secretary shall—

(A)

solicit public comment on a recommended initial core set of maternity care quality measures; and

(B)

consult with stakeholders identified in subsection (i)(1) regarding such measures.

(2)

Publication

Not later than January 1, 2015, the Secretary shall identify, and publish, from maternity care quality measures endorsed under section 1890(b)(2), an initial core set of maternity care quality measures.

(3)

Standardized reporting

The Secretary shall develop a standardized format for reporting information based on the initial core set of maternity care quality measure for voluntary use in data collection and reporting by—

(A)

a State in administering a State plan under title XIX or a State Child Health Plan under title XXI;

(B)

health insurance issuers and managed care entities that enter into contracts with States for the purpose of administering such plans; and

(C)

providers of items and services (including accountable care organizations) with respect to items and services provided under such plans.

(d)

Development of additional quality measures

(1)

Contracts with qualified entities

Not later than the end of the 6-month period beginning on the date the Secretary publishes the initial measures under subsection (c)(2), subject to subsection (b), the Secretary, acting through the Agency for Healthcare Research and Quality, in consultation with the Centers for Medicare & Medicaid Services, shall enter into grants, contracts, or intergovernmental agreements with qualified measure development entities for the purpose of developing, testing, and validating maternity care quality measures in areas that are not adequately covered by the measures so published.

(2)

Qualified measure development entity defined

For purposes of this subsection, the term qualified measure development entity means an entity that—

(A)

has demonstrated expertise and capacity in the development and testing of quality measures;

(B)

has adopted procedures for quality measure development that ensure the inclusion of—

(i)

the views of the individuals and entities referred to in subsection (e)(2)(E) and whose performance will be assessed by the measures; and

(ii)

the views of other individuals and entities (including patients, consumers, and health care purchasers) who will use the data generated as a result of the use of the quality measures;

(C)

for the purpose of ensuring that the quality measures developed under this subsection meet the requirements to be considered for endorsement under section 1890(b)(2), has provided assurances to the Secretary that the measure development entity will collaborate with—

(i)

the Secretary;

(ii)

the consensus-based entity with a contract under section 1890(a)(1); and

(iii)

stakeholders (including those stakeholders identified in subsection (i)(1)), as practicable;

(D)

has transparent policies regarding governance and conflicts of interest; and

(E)

submits an application to the Secretary at such time, and in such form and manner, as the Secretary may require.

(3)

eMeasures

(A)

In general

A qualified measure development entity with a grant, contract, or intergovernmental agreement under paragraph (1), in developing quality measures, shall consult with the voluntary consensus standards setting organizations and other organizations involved in the advancement of evidence-based measures of health care as the Secretary consults with under sections 1139A(b)(3)(H) and 1139B(b)(5)(A) to create eMeasures that are aligned with the measures developed under the Medicaid Quality Measurement Program established under section 1139B(b)(5)(A) and the pediatric quality measures program established under section 1139A(b).

(B)

eMeasure defined

For purposes of this section, the term eMeasure means a measure for which measurement data (including clinical data) will be collected electronically, including through the use of electronic health records and other electronic data sources.

(4)

Endorsement

Any maternity care quality measures developed under this subsection by a qualified measure development entity shall be submitted by the qualified measure development entity to the consensus-based entity with a contract under section 1890(a)(1) to be considered for endorsement under section 1890(b)(2).

(e)

Types of measures

(1)

In general

The maternity quality measures identified under subsection (c) and the measures developed under subsection (d) shall—

(A)

be evidence-based;

(B)

utilize risk adjustment or risk stratification methodologies, if appropriate;

(C)

utilize attribution methods to specify the clinicians, facilities, and other entities that the measures are applicable to;

(D)

be pilot-tested with regards to scientific validity, feasibility, and attribution method; and

(E)

include a balance of each of the types of measures listed in paragraph (2).

(2)

List of types of measures

The measures listed in this paragraph are the following:

(A)

Measures of the process, experience, efficiency, and outcomes of maternity care, including postpartum outcomes.

(B)

Measures that apply to—

(i)

women and newborns who are healthy and at low risk, including measures of appropriately low-intervention, physiologic birth in low-risk women; and

(ii)

women and newborns at higher risk.

(C)

Measures that apply to—

(i)

childbearing women; and

(ii)

newborns.

(D)

Measures that apply to care during—

(i)

pregnancy;

(ii)

intrapartum period; and

(iii)

the postpartum period.

(E)

Measures that apply to—

(i)

clinicians and clinician groups;

(ii)

facilities;

(iii)

health plans; and

(iv)

accountable care organizations.

(F)

Measurement of—

(i)

disparities;

(ii)

care coordination; and

(iii)

shared decisionmaking.

(3)

Physiologic defined

For purposes of this subsection, the term physiologic means characteristic of or conforming to the normal functioning or state of the body or a tissue or organ, normal, and not pathologic.

(4)

Construction

Nothing in this subsection shall be construed as supporting the restriction of coverage, under title XIX or XXI or otherwise, to only those services that are evidence-based, or in anyway limiting available services.

(f)

Maternity Consumer Assessment of Healthcare Providers and Systems surveys

(1)

Adaption of surveys

Not later than January 1, 2016, for the purpose of measuring the care experiences of childbearing women and newborns, the Agency for Healthcare Research and Quality shall adapt the Consumer Assessment of Healthcare Providers and Systems program surveys of—

(A)

providers;

(B)

facilities; and

(C)

health plans.

(2)

Surveys must be effective

The Agency for Healthcare Research and Quality shall ensure that the surveys adapted under paragraph (1) are effective in measuring aspects of care that childbearing women and newborns experience, which may include—

(A)

various types of care settings;

(B)

various types of caregivers;

(C)

considerations relating to pain;

(D)

shared decisionmaking;

(E)

supportive care around the time of birth; and

(F)

other topics relevant to the quality of the experience of childbearing women and newborns.

(3)

Languages

The surveys adapted under paragraph (1) shall be available in English and Spanish.

(4)

Endorsement

The Agency for Healthcare Research and Quality shall submit any Consumer Assessment of Healthcare Providers and Systems surveys adapted under this subsection to the consensus-based entity with a contract under section 1890(a)(1) to be considered for endorsement under section 1890(b)(2).

(5)

Consultation

The adaption of (and process for applying) the surveys under paragraph (1) shall be conducted in consultation with the stakeholders identified in subsection (i)(1).

(g)

Annual state reports regarding state-Specific quality of care measures applied under medicaid

(1)

Annual State reports

Each State with a State plan or waiver approved under title XIX shall annually report (separately or as part of an annual report required under section 1139A(c) or section 1139B(d)), to the Secretary on the—

(A)

State-specific maternity health quality measures applied by the State under the such plan; and

(B)

State-specific information on the quality of maternity care furnished to Medicaid eligible individuals under such plan, including information collected through external quality reviews of managed care organizations under section 1932 and benchmark plans under section 1937.

(2)

Publication

Not later than September 30, 2015, and annually thereafter, the Secretary shall collect, analyze, and make publicly available the information reported by States under subparagraph (A).

(h)

Conversion of currently endorsed measures and creation of initial quality data model To enable electronic health records To measure the care of childbearing women and newborns

(1)

In general

Not later than January 1, 2015, for the purpose of fostering automated patient-centered longitudinal quality measurement of maternal and newborn care using clinical data, the consensus-based entity with a contract under section 1890(b)(2) shall coordinate—

(A)

the conversion of endorsed measures for the care of childbearing women and newborns to eMeasures (as such term is defined in subsection (d)(3)(B)); and

(B)

the development of an initial quality data model for use within electronic health records of childbearing women and newborns enrolled in a program administered by a State through State plans under title XIX and State Child Health plans under title XXI for purposes of such eMeasures.

(2)

Requirements for eMeasure conversion and quality data model creation

The conversion to eMeasures and the quality data model creation under paragraph (1) shall, for each quality measure of the care of childbearing women or newborns that the consensus-based entity with a contract under section 1890(b)(2) has endorsed, use the entity’s measure authoring tool to—

(A)

specify standard data elements, quality data elements, and data flow connectors to electronic information;

(B)

specify quality measure logical statements;

(C)

test quality measure validity with an appropriate electronic health record test database;

(D)

finalize eMeasures for export to electronic health record systems; and

(E)

carry out this work in—

(i)

collaboration with the developer or sponsor of each endorsed measure, who is responsible, under an agreement with the entity that endorsed such measure, for updating such measure; and

(ii)

consultation with the stakeholders identified in subsection (i)(1).

(3)

Coordination with HITECH Act

In carrying out activities under this subsection, the consensus-based entity with a contract under section 1890(b)(2) shall take into account, and to the extent practicable, coordinate with, similar activities relating to the implementation of the Health Information Technology for Economic and Clinical Health Act established under title XIII of division A and title IV of division B of Public Law 111–5.

(i)

Stakeholders

(1)

In general

The stakeholders identified in this paragraph are—

(A)

the various clinical disciplines and specialties involved in providing maternity care;

(B)

State Medicaid administrators;

(C)

maternity care consumers and their advocates;

(D)

technical experts in quality measurement;

(E)

hospital, facility and health system leaders;

(F)

employers and purchasers; and

(G)

other individuals who are involved in the advancement of evidence-based maternity care quality measures.

(2)

Professional organizations

The stakeholders identified under paragraph (1) may include representatives from relevant national medical specialty and professional organizations and specialty societies.

(j)

Authorization of appropriations

There are authorized to be appropriated $28,000,000 to carry out this section. Funds appropriated under this subsection shall remain available until expended.

.

(b)

Conforming amendments

(1)

Section 1139A(a)(6) of the Social Security Act (42 U.S.C. 1320b–9a(a)(6)) is amended, in the matter preceding subparagraph (A), by inserting and the Medicaid and CHIP Payment and Access Commission after Congress.

(2)

Section 1139B(b)(4) of such Act (42 U.S.C. 1320b–9b(b)(4)) is amended by inserting and the Medicaid and CHIP Payment and Access Commission after Congress.

3.

Quality collaboratives

(a)

Grants

The Secretary of Health and Human Services (in this section referred to as the Secretary) may make grants to eligible entities to support—

(1)

the development of new State and regional maternity care quality collaboratives;

(2)

expanded activities of existing maternity care quality collaboratives; and

(3)

maternity care initiatives within established State and regional quality collaboratives that are not focused exclusively on maternity care.

(b)

Eligible entity

The following entities shall be eligible for a grant under subsection (a):

(1)

Quality collaboratives that focus entirely, or in part, on maternity care initiatives, to the extent that such collaboratives use such grant only for such initiatives.

(2)

Entities seeking to establish a maternity care quality collaborative.

(3)

State Medicaid agencies.

(4)

State departments of health.

(5)

Health insurance issuers (as such term is defined in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91).

(6)

Provider organizations, including associations representing—

(A)

health professionals; and

(B)

hospitals.

(c)

Eligible projects and programs

In order for a project or program of an eligible entity to be eligible for funding under subsection (a), the project or program must have goals that are designed to improve the quality of maternity care delivered, such as—

(1)

improving the appropriate use of cesarean section;

(2)

reducing maternal and newborn morbidity rates;

(3)

improving breast-feeding rates;

(4)

reducing hospital readmission rates;

(5)

identifying improvement priorities through shared peer review and third-party reviews of qualitative and quantitative data, and developing and carrying out projects or programs to address such priorities; or

(6)

delivering risk-appropriate levels of care.

(d)

Activities

Activities that may be supported by the funding under subsection (a) include the following:

(1)

Facilitating performance data collection and feedback reports to providers with respect to their performance, relative to peers and benchmarks, if any.

(2)

Developing, implementing, and evaluating protocols and checklists to foster safe, evidence-based practice.

(3)

Developing, implementing, and evaluating programs that translate into practice clinical recommendations supported by high-quality evidence in national guidelines, systematic reviews, or other well-conducted clinical studies.

(4)

Developing underlying infrastructure needed to support quality collaborative activities under this subsection.

(5)

Providing technical assistance to providers and institutions to build quality improvement capacity and facilitate participation in collaborative activities.

(6)

Developing the capability to access the following data sources:

(A)

A mother’s prenatal, intrapartum, and postpartum records.

(B)

A mother’s medical records.

(C)

An infant’s medical records since birth.

(D)

Birth and death certificates.

(E)

Any other relevant State-level generated data (such as data from the pregnancy risk assessment management system (PRAMS)).

(7)

Developing access to blinded liability claims data, analyzing the data, and using the results of such analysis to improve practice.

(e)

Special rule for births

(1)

In general

Subject to paragraph (2), if a grant under subsection (a) is for a project or program that focuses on births, at least 25 percent of the births addressed by such project or program must occur in health facilities that perform fewer than 1,000 births per year.

(2)

Exception

In the case of a grant under subsection (a) for a project or program located in a State in which less than 25 percent of the health facilities in the State perform less than 1,000 births per year, the percentage of births in such facilities addressed by such project or program shall be commensurate with the Statewide percentage of births performed at such facilities.

(f)

Use of quality measures

Projects and programs for which such a grant is made shall—

(1)

include data collection with rapid analysis and feedback to participants with a focus on improving practice and health outcomes;

(2)

develop a plan to identify and resolve data collection problems;

(3)

identify and document evidence-based strategies that will be used to improve performance on quality measures and other metrics; and

(4)

exclude from quality measure collection and reporting physicians and midwives who attend fewer than 30 births per year.

(g)

Reporting on quality measures

Any reporting requirements established by a project or program funded under subsection (a) shall be designed to—

(1)

minimize costs and administrative effort; and

(2)

use existing data resources when feasible.

(h)

Clearinghouse

The Secretary shall establish an online, open-access clearinghouse to make protocols, procedures, reports, tools, and other resources of individual collaboratives available to collaboratives and other entities that are working to improve maternity care quality.

(i)

Evaluation

A quality collaborative (or other entity receiving a grant under subsection (a)) shall—

(1)

develop and carry out plans for evaluating its maternity care quality improvement programs and projects; and

(2)

publish its experiences and results in articles, technical reports, or other formats for the benefit of others working on maternity care quality improvement activities.

(j)

Annual reports to Secretary

A quality collaborative or other eligible entity that receives a grant under subsection (a) shall submit an annual report to the Secretary containing the following:

(1)

A description of the activities carried out using the funding from such grant.

(2)

A description of any barriers that limited the ability of the collaborative or entity to achieve its goals.

(3)

The achievements of the collaborative or entity under the grant with respect to the quality, health outcomes, and value of maternity care.

(4)

A list of lessons learned from the grant.

Such reports shall be made available to the public.
(k)

Governance

(1)

In general

A maternity care quality collaborative or a maternity care program within a broader quality collaborative that is supported under subsection (a) shall be governed by a multi-stakeholder executive committee.

(2)

Composition

Such executive committee shall include individuals who represent—

(A)

physicians, including physicians in the fields of general obstetrics, maternal-fetal medicine, family medicine, neonatology, and pediatrics;

(B)

nurse-practitioners and nurses;

(C)

certified nurse-midwives and certified midwives;

(D)

health facilities and health systems;

(E)

consumers;

(F)

employers and other private purchasers;

(G)

Medicaid programs; and

(H)

other public health agencies and organizations, as appropriate.

Such committee also may include other individuals, such as individuals with expertise in health quality measurement and other types of expertise as recommended by the Secretary. Such committee also may be composed of a combination of general collaborative executive committee members and maternity specific project executive committee members.
(l)

Consultation

A quality collaborative or other eligible entity that receives a grant under subsection (a) shall engage in regular ongoing consultation with—

(1)

regional and State public health agencies and organizations;

(2)

public and private health insurers; and

(3)

regional and State organizations representing physicians, midwives, and nurses who provide maternity services.

(m)

Authorization of appropriations

There are authorized to be appropriated $15,000,000 to carry out this section. Funds appropriated under this subsection shall remain available until expended.

4.

Woman- and family-centered maternity care home demonstration program

(a)

Definitions

In this section:

(1)

CHIP

The term CHIP means the State Children's Health Insurance Program established under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.).

(2)

Eligible individuals

The term eligible individual means a childbearing woman who is receiving assistance under Medicaid or CHIP.

(3)

Eligible entity

The term eligible entity means a State, an entity or organization receiving payments under Medicaid or CHIP, a hospital, a freestanding birth center (as defined in section 1905(l)(3)(B) of the Social Security Act (42 U.S.C. 1396d(l)(3)(B)), an entity or organization receiving assistance under section 330 of the Public Health Service Act (42 U.S.C. 254b), a Federally qualified health center (as defined in subsection (l)(2)(C) of section 1905 of the Social Security Act (42 U.S.C. 1396d), a rural health clinic (as defined in subsection (l)(1) of such section), or an entity that receives assistance under title X or XX of the Public Health Service Act (42 U.S.C. 300 et seq., 300z et seq.), that submits an approved application to the Secretary to conduct a demonstration project under this section.

(4)

Medicaid

The term Medicaid means the Federal and State program for medical assistance established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).

(5)

Principal maternity care provider

The term principal maternity care provider means:

(A)

A physician (as defined in section 1861(r)(1) of the Social Security Act (42 U.S.C. 1395x(r)(1)) who meets the following requirements:

(i)

The physician is a board certified physician who specializes in women’s health issues, such as obstetrics and gynecology, or family practice, and who provides continuous and comprehensive care for individuals under the physician's care.

(ii)

The physician has the staff and resources to manage the comprehensive and coordinated health care of each such individual.

(iii)

The physician practices in a practice, health or birth center, clinic, or hospital recognized to be a maternity care home.

(iv)

Such other requirements as are defined by the Secretary.

(B)

An advanced practice nurse, a certified nurse-midwife (CNM) or certified midwife (CM) certified by the American Midwifery Certification Board, or physician assistant, who meets the following requirements:

(i)

The advanced practice nurse, midwife, or physician assistant specializes in women’s health issues, such as obstetrics and gynecology, and provides continuous and comprehensive care for patients.

(ii)

The advanced practice nurse, midwife, or physician assistant has the staff and resources to manage the comprehensive and coordinated health care of each such individual.

(iii)

The advanced practice nurse, midwife, or physician assistant practices in a practice or health or birth center recognized to be a maternity care home.

(iv)

Such other requirements as are defined by the Secretary.

(6)

Secretary

The term Secretary means the Secretary of Health and Human Services.

(7)

Maternity care home

The term maternity care home means a physician-led practice, or an advanced practice nurse-led, certified nurse-midwife-led, certified midwife-led, or physician assistant-led practice in those States in which State law does not require direct supervision of licensed advanced practice nurses, certified nurse-midwives, certified midwives, or physician assistants providing services in a hospital, practice, health or birth center, or clinic participating as maternity care home under the program that uses practice innovations and coordination agreements with other providers to improve the management and coordination of maternity care that meets the following standards:

(A)

The practice, health or birth center, clinic, or hospital is able to provide or coordinate maternity care for women, including preconception care, prenatal care, family planning, medical care, mental and behavioral health care, and screening, that, at a minimum, includes at least 3 of the following, and may include all of the following:

(i)

An initial health assessment and development of a maternity care plan.

(ii)

Pregnancy care to foster access of all women to preventive services and support, including guidance about nutrition, weight gain, exercise, stress management, rest, and environmental exposures.

(iii)

Pregnancy care to foster access of women with special needs to such services as help with smoking cessation; use of alcohol and other harmful substances; mood disorders; and domestic violence.

(iv)

Evaluation and development of a plan for appropriate use of any continuing and new prescription and over-the-counter medications.

(v)

Appropriate care for women who are deemed at risk for premature birth.

(vi)

Appropriate care for women who are members of a minority population that experiences pregnancy-related health disparities.

(vii)

Coordination with providers of services for any ongoing or new medical conditions.

(viii)

Care to foster initiation and establishment of breast feeding through effective prenatal, intrapartum, and postpartum services and practices.

(ix)

Plan for childbirth that supports utilization of evidence-based intrapartum practices.

(x)

Care of the newborn from birth until transition to the baby's primary care provider, including preventive practices promoting optimal feeding and attachment.

(xi)

Postpartum health services for the first two months after birth, including family planning, weight control, exercise, nutrition, and other preventive services; assessment and treatment for postpartum depression and other mood disorders; assessment and treatment of other new-onset conditions that may include infection, pain, and heavy bleeding; and any continuing needs for help with smoking cessation, substance abuse, and other health risks.

(xii)

At the conclusion of maternity services and as needed in the course of maternity services, communication with the primary care providers of the woman and newborn about care processes, outcomes of maternal and newborn care, and any continuing health care needs.

(xiii)

Any other services specified by the Secretary.

(B)

The practice, health or birth center, clinic, or hospital applies standards for access to care and communication with eligible individuals participating in the demonstration program established under this section, including direct and ongoing access to the principal maternity care provider who accepts responsibility for providing continuous care, including coordination for comprehensive maternity care to the whole person, in collaboration with a team of other health professionals, including other nurses, primary care and specialist physicians, and mental health professionals, as needed and appropriate. Care is patient and family centered, culturally and linguistically appropriate, structured to ensure women receive complete and accurate health information for shared decisionmaking, and structured to assure confidentiality so that teens and women may seek needed care in a timely way.

(C)

The practice, health or birth center, clinic, or hospital has readily accessible, clinically useful records on eligible individuals participating in the demonstration program established under this section, when feasible through electronic health records available in ambulatory and inpatient settings, that enable the practice to treat such individuals comprehensively and systematically.

(D)

The practice, health or birth center, clinic or hospital maintains continuous relationships with eligible individuals participating in the demonstration program established under this section by implementing clinical recommendations supported by high-quality evidence in national guidelines, systematic reviews, or other well-conducted clinical studies and applying them to the identified needs of such individuals over time and with the intensity needed by such individuals.

(E)

The practice, health or birth center, clinic, or hospital supports eligible individuals in self-care to pursue their goals and achieve optimal health.

(F)

The practice, health or birth center, clinic, or hospital assesses and addresses barriers to communication between health professions and eligible individuals.

(G)

The practice, health or birth center, clinic, or hospital has in place the resources and processes necessary to achieve improvements in the management and coordination of care for eligible individuals participating in the demonstration program established under this section, including—

(i)

providing training programs for personnel involved in the coordination of care;

(ii)

utilizing information technology to support optimal patient care, performance measurement and use of the results to improve practice, patient education, and enhanced communication; and

(iii)

implementation of programs to improve the quality of care.

(H)

The practice, health or birth center, clinic, or hospital meets the requirements imposed on a covered entity for purposes of applying part C of title XI of the Public Health Service Act (42 U.S.C. 300b–1 et seq.) and all regulatory provisions promulgated there under, including regulations (relating to privacy) adopted pursuant to the authority of the Secretary under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note).

(b)

Establishment

(1)

In general

Not later than 1 year after the date of enactment of this Act, the Secretary shall establish a maternity care home demonstration program (in this section referred to as the program).

(2)

Duration; scope

The program shall be conducted for a 3-year period (except that an eligible individual participating in the program shall remain eligible for items and services provided under the program through 2 months postpartum regardless of the termination of the program period) and shall include a nationally representative sample of physicians, advanced practice nurses, certified nurse midwives, certified midwives, and physician assistants who specialize in women’s health issues, such as obstetrics and gynecology, or family practice, and who serve urban, rural, and underserved areas in a total of no more than 8 States.

(3)

Comprehensiveness

The Secretary shall give priority under the program to demonstration projects that reflect a comprehensive inclusion of the care components identified under subsection (a)(7)(A).

(4)

Encouraging participation of small physician practices

The program shall be designed to include the participation of maternity care providers in practices with fewer than 4 full-time equivalent clinicians, as well as maternity care providers in larger practices, particularly in rural and underserved areas.

(5)

Program goals

The program shall be designed in order to determine whether and to what extent maternity care homes accomplish the following:

(A)

Increase—

(i)

cost efficiencies of maternity care delivery;

(ii)

the reliable provision of care supported by high-quality evidence in national guidelines, systematic reviews, or other well-conducted clinical studies;

(iii)

communication among maternity care providers, other health professionals, facilities, and eligible individuals; and

(iv)

the quality of maternity care services provided, as based on nationally endorsed quality measures.

(B)

Decrease—

(i)

inappropriate emergency room utilization;

(ii)

avoidable maternal and newborn hospitalizations and admissions to intensive care units;

(iii)

duplication of health care services provided; and

(iv)

health disparities.

(C)

Improve—

(i)

the woman’s experience of care and the maternity care provider’s experience of providing care; and

(ii)

health outcomes of women and newborns, such as—

(I)

decreased preterm and early term birth, postpartum morbidities, and untreated postpartum depression; and

(II)

increased vaginal birth and initiation and duration of exclusive breast feeding.

(6)

Eligible individual and eligible entity participation

(A)

Eligible individuals

The Secretary shall establish a process under which—

(i)

an eligible individual may elect to participate in a maternity care home under the program; and

(ii)

no cost sharing shall be imposed with respect to any service required under to be provided to the individual under the program.

(B)

Assurance of participation of eligible entities that are not participating providers or are in states with managed care

The Secretary shall establish a process to ensure that eligible entities that are not participating providers under Medicaid or CHIP in the State, or, in the case of a State that contracts with a private entity to manage parts of the Medicaid or CHIP in the State, do not participate with that entity, are able to participate in the program.

(7)

Standard setting process

In consultation with the stakeholders specified in subsection (d), the Secretary shall—

(A)

develop a maternity care home reimbursement methodology that takes into consideration, to the maximum extent practicable—

(i)

recognition of the value of maternity care provider and clinical staff work associated with patient care that falls outside the face-to-face visit, such as the time and effort spent on educating family members and arranging appropriate followup services with other health care professionals;

(ii)

reimbursement of services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources;

(iii)

recognition of expenses that the maternity care home practices will incur to acquire and utilize health information technology, such as clinical decision support tools, patient registries, or electronic medical records;

(iv)

reimbursement for separately identifiable e-mail and telephonic consultations, either as separately billable services or as part of a global management fee;

(v)

recognition of the value of provider work associated with remote monitoring of clinical data using technology;

(vi)

reimbursement for provision of preventive services, health education, and participation in shared decisionmaking;

(vii)

recognition and sharing of savings with respect to reduction of procedures and practices that are contrary to high-quality evidence in national guidelines, systematic reviews, or other well-conducted clinical studies and to reductions in the occurrence of health and pregnancy complications, hospitalization rates, medical errors, adverse drug reactions, and other occurrences;

(viii)

allowance for additional payments for achieving measurable and continuous quality improvements, including under a process established by the Secretary for paying a performance-based bonus to maternity care homes which meet or achieve substantial improvements in performance (as specified under clinical, patient experience of care, and efficiency benchmarks established by the Secretary);

(ix)

recognition of the existing payment methodology for Federally qualified health centers when determining the most appropriate mechanism for providing bonus payments for maternity care home services delivered at such centers; and

(x)

such other innovative methods as the Secretary finds appropriate;

(B)

develop appropriate risk-adjustment mechanisms to account for varying costs of maternity care homes based upon characteristics of the eligible individuals participating in the program;

(C)

make allowance for additional payments for achieving measurable and continuous quality improvements, including under a process established by the Secretary for paying a performance-based bonus to maternity care homes which meet or achieve substantial improvements in performance (as specified under clinical, patient experience, and efficiency benchmarks established by the Secretary in consultation with the stakeholders specified in subsection (d));

(D)

recognize the existing payment methodology for Federally qualified health centers when determining the most appropriate mechanism for providing bonus payments for maternity care home services delivered at such centers; and

(E)

establish such other methods as the Secretary, in consultation with the stakeholders specified in subsection (d), finds appropriate.

(8)

Planning or implementation grants

The Secretary may award planning or implementation grants to eligible entities desiring or selected to participate in the program.

(9)

Ongoing oversight and performance assessment

The Secretary shall establish procedures to ensure that hospitals, practices, health or birth centers, and clinics participating as maternity care homes under the program, and the physicians, advanced practice nurses, certified nurse-midwives, certified midwives, and physician assistants providing services at such hospitals, practices, centers, and clinics, have access to confidential feedback and benchmarking reports as a function of the hospital's, practice’s, health or birth center's, or clinic's monitoring of its clinical process and performance (including process and outcome measures).

(10)

Technical assistance

The Secretary shall establish mechanisms to provide technical assistance to hospitals, practices, health or birth centers, and clinics participating as maternity care homes under the program.

(11)

Payments to States

The Secretary shall pay each State participating in the program an amount equal to 100 percent of the amounts expended by the State for services provided to an eligible individual under the program, including administrative expenses.

(12)

Authorization of appropriations

There are authorized to be appropriated $50,000,000 to carry out this section. Funds appropriated under this paragraph shall remain available until expended.

(c)

Evaluations and program reports

(1)

Annual interim evaluations and reports

For each year of the program, the Secretary shall provide for an interim evaluation of the program and shall submit to Congress and the Medicaid and CHIP Payment and Access Commission established under section 1900 of the Social Security Act (42 U.S.C. 1396) (in this subsection referred to as MACPAC) reports on the results of such evaluations.

(2)

Final evaluation and report

The Secretary shall provide for a final evaluation of the program and shall submit to Congress and MACPAC, not later than 1 year after completion of the program, a final report on the program based on the results of such evaluation. Such final report shall include—

(A)

an assessment of improvements in quality and outcomes of childbearing women and newborns identified under the program goals specified in subsection (b)(4);

(B)

an assessment of the women's experience of care and the maternity care providers' satisfaction;

(C)

an assessment of which women, based on demographic factors, such as age, race, sexual orientation, disability, ethnicity, and socioeconomic status, benefit the most from participating in a maternity care home;

(D)

estimates of cost savings to Medicaid, CHIP, and other Federal programs resulting from the program; and

(E)

recommendations for such legislation and administrative action as the Secretary determines to be appropriate.

(d)

Consultation with relevant stakeholders

In carrying out the activities under this section, the Secretary shall consult with the following stakeholders on selection and evaluation of the program, setting of payment and incentives criteria, and other activities determined by the Secretary (in addition to the issues for which consultation with such stakeholders is required in other subsections of this section):

(1)

States.

(2)

National organizations and individuals representing obstetrician-gynecologists, family physicians, certified nurse-midwives and certified midwives, registered nurses, advanced practice nurses, and physician assistants.

(3)

National organizations representing consumers.

(4)

Health care providers that furnish care to women who live in urban and rural medically underserved communities and are at heightened risk for poor health outcomes.

(5)

National organizations and individuals with expertise in maternity health quality measurement and coding and reimbursement related issues.

(6)

National organizations and individuals that provide social and medical services to pregnant women, such as mental health professionals and social workers.