Health Care Reform and Addiction:

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1 Health Care Reform and Addiction: An Exploration of Pressure Points Within the Patient Protection and Affordable Care Act Michael Bare Research Director and Program Coordinator Community Advocates Public Policy Institute Prepared By: David Riemer Director of Policy and Planning Community Advocates Public Policy Institute Prepared For: The Open Society Foundation and its Closing the Addiction Gap Grantees Made Possible By: A generous grant from the Robert Wood Johnson Foundation

2 TABLE OF CONTENTS Table of Contents I. Executive Summary and Introduction II. Research Method, Sources, and Glossary III. Pressure Points by Category A. Research and Workforce B. Information Dissemination C. Prevention D. Delivery and Coverage Systems 1. Medicaid 2. Exchanges 3. Medicare 4. Other E. New Plans and Plan Requirements IV. Additional Resources V. Advocacy Tools and Methods

3 1 I. EXECUTIVE SUMMARY AND INTRODUCTION On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. On March 30, 2010, he also signed the Health Care and Education Reconciliation Act of 2010 into law. Together, these bills form the health care reform package, one of the lengthiest and most wide-reaching pieces of legislation ever enacted by Congress. The Community Advocates Public Policy Institute has analyzed the new law with a focus on the many pressure points, as we refer to them, that the law has created for advocates of improved addition treatment to urge the adoption of the National Quality Forum s (NQF) Consensus Standards for Treatment of Substance Use Disorders. The National Quality Forum gathered numerous experts on substance use conditions to develop these standards. The eleven NQF standards are briefly described in the following table from NQF:

4 2 Our analysis led to the identification of more than 30 pressure points, including a web of new agencies, task forces and institutes; new research and preventive initiatives; expanded and new health delivery and coverage systems, including state health insurance exchanges; and new coverage plans and plan requirements. The scope of the reform effort necessitated that Congress leave much of the implementation efforts to federal agencies and state governments. This opened up pressure points for advocates at several stages in the reform s implementation process. In Section III, each pressure point is categorized and presented with a summary of the relevant section of the PPACA, a recommended strategy for advocates, and the full text of the section. This report also provides advocates with additional resources on health care reform and addiction, and general advocacy tools and methods to take advantage of the pressure points. The Community Advocates Public Policy Institute has developed this report and accompanying presentation and website for interested advocates to use as a guide in targeting their advocacy efforts. Advocacy strategies for improved addiction treatment are presented with the understanding that advocates must make their own judgments about which pressure points to focus on (because focusing on all of them would be a huge undertaking) and which advocacy methods to use to best improve addiction treatment. This report, the presentation, and further background material will be available at the Community Advocates Public Policy Institute s website in the near future: This report is the culmination of several months of analysis of the PPACA and several outside sources. The Community Advocates Public Policy Institute recognizes that the legislation and its ramifications are far reaching. We welcome comments and suggestions on improving and expanding this guide, especially as advocates learn from their own experiences with these pressure points. The Institute also stands ready to consult with advocates on these pressure points and offer further advice. Please feel free to contact us: Michael Bare Research Director and Program Coordinator Community Advocates Public Policy Institute Milwaukee, WI David Riemer Director of Policy and Planning Community Advocates Public Policy Institute Milwaukee, WI

5 3 II. RESEARCH METHOD, SOURCES AND GLOSSARY The preparation of this report relied on a review of health care reform literature. Wherever possible, this report quotes and cites the consolidated Patient Protection and Affordable Care Act, which is available at: Visit the National Quality Forum s website for more information on the National Voluntary Consensus Standards for the Treatment of Substance Use Conditions at: Treatment_of_Substance_Use_Conditions Evidence-Based_Treatment_Practices.aspx Full citations can be found in the footnotes throughout this report. Glossary of abbreviations: HHS: The federal Department of Health and Human Services NQF: the National Quality Forum NQF standards: This refers specifically to the National Quality Forum s National Voluntary Consensus Standards for the Treatment of Substance Use Conditions PPACA: the Patient Protection and Affordable Care Act

6 4 III. Pressure Points By Category The following pressure points have been identified from the text of the consolidated Patient Protection and Affordable Care Act (PPACA). These pressure points have been put into categories so that similar types of pressure points can be reviewed together. This section summarizes each pressure point and offers a brief advocacy strategy for each, followed by the relevant text of the PPACA. All cited section numbers refer to the consolidated PPACA. List of Pressure Points : A. Research and Workforce 1. HHS National Strategy for Quality Improvement in Health Care (Sec. 3011) 2. The Center for Quality Improvement and Patient Safety (Sec. 3501) 3. National Healthcare Workforce Commission (Sec. 5101) 4. Patient-Centered Outcomes Research Institute (Sec and 6302) B. Information Dissemination 1. Department of Health and Human Services Website for Residents of Any State to Identify Coverage Options in that State (Sec. 1103) 2. Preventive Health Outreach Campaign By HHS (Sec. 4004) C. Prevention 1. National Prevention, Health Promotion and Public Health Council to Develop a National Strategy for Prevention, Health Promotion and Public Health (Sec. 4001) 2. Prevention and Public Health Fund (Sec. 4002) 3. Preventive Services Task Forces (Sec. 4003) 4. CDC Assistance to Employer-Based Prevention and Wellness Programs (Sec. 4303) D. Delivery and Coverage Systems 1. Medicaid: a. Medicaid Eligibility Expanded to 133% of Federal Poverty Level for Parents and Childless Adults (Sec. 2001) b. Medicaid Health Homes (Sec. 2703) c. School-Based Health Centers (Sec. 4101) d. Medicaid Coverage of Evidence-Based Preventive Services with No Cost- Sharing (Sec. 4106) e. Medicaid Coverage for Tobacco-Cessation Services for Pregnant Women (Sec. 4107) f. Grant Program for Medicaid Programs to Develop Healthy Lifestyles and Prevent Chronic Diseases Such as Smoking (Sec. 4108) g. New Basic Health Plans for Uninsured Individuals with Incomes Between 133% and 200% (Sec. 1331) 2. Exchanges: a. State Health Care Exchanges Begin in 2013 (Sec. 1311(b)(1)) b. State Health Care Exchanges: Design of the Exchange By States (Sec. 1311(a) and (b)) c. State Health Care Exchanges: Certification, Recertification and Decertification of Plans Within the Exchanges (Sec. 1311(d)(4)(A)) d. State Health Care Exchanges: Additional Required Benefits (Sec. 1311(d)(3))

7 5 e. Provision of Information to State Health Care Exchanges Consumers: Operation of Toll-Free Hotline (Sec. 1311(d)(4)(B)) and Maintenance of a Website for Providing Information on Plans (Sec. 1311(d)(4)(C)) f. State Health Care Exchanges: Consulting with Stakeholders (Sec. 1311(d)(6)) g. State Health Care Exchanges: Navigator Programs (Sec. 1311(i)) h. OPM s Nationwide/Multi-State Plans (Sec. 1334) 3. Medicare: a. Accountable Care Organizations (Sec. 3022) b. Beginning of Medicare Annual Preventive/Wellness Visit and Waiver of All Cost Sharing for Preventive Services (Sec. 4103, 4104, and 4105) 4. Other: a. Community-Based Health Teams for Chronic Disease Management (Sec. 3502) b. Non-Profit Hospitals Must Conduct Community Needs Assessments (Sec. 9007(a)(r)(3)) c. Community Health Center Fund (Sec ) d. Interstate Health Choice Compacts (Sec. 1333) E. New Plans and Plan Requirements 1. Essential Health Benefits (Sec. 1302) 2. Prevention and Wellness Requirements for All New Group and Individual Plans to Provide First Dollar Coverage for Certain Preventive Services (Sec. 2713) 3. Establishment By HHS of a High-Risk Pool for People with Preexisting Conditions Through 2014 (Sec. 1101)

8 6 A. Research and Workforce There are several sections of the PPACA that establish new research and policy initiatives and research entities, or provide funding for existing research. These include a new national strategy for quality improvement in health care (Sec. 3011), new tasks for the Center for Quality Improvement and Patient Safety (Sec. 3501), and the massive Patient-Centered Outcomes Research Institute (Sec and 6302). These sections of the legislation offer advocates opportunities to influence government and non-profit research on substance use conditions and treatment. The bill also establishes the National Healthcare Workforce Commission (Sec. 5101), which could study and make recommendations about substance use conditions and treatment. The PPACA offers few opportunities for health care providers to be educated about the National Quality Forum s National Voluntary Consensus Standards for the Treatment of Substance Use Conditions (NQF standards), so advocates should consult with their local providers to ensure that providers are aware of the NQF standards.

9 7 1. HHS National Strategy for Quality Improvement in Health Care (Sec. 3011) Summary: This section requires the Secretary of the federal Department of Health and Human Services (HHS) to create a national strategy for quality improvement in health care, which is to be updated annually and shared on a website. The strategy is to include areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care. 1 Advocacy Strategy: Advocates could use this pressure point to ensure that 1) advocates and experts in addiction treatment in general and the NQF standards in particular are included in the statutorily required transparent collaborative process that leads to the establishment of the national strategy, and 2) that those who are crafting the strategy incorporate preventive services and treatments related to the NQF standards. If the strategy does not address advocates concerns, the annual update process offers advocates ongoing opportunities for seeking to improve the strategy. SEC NATIONAL STRATEGY. Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the following: PART S HEALTH CARE QUALITY PROGRAMS Subpart I National Strategy for Quality Improvement in Health Care SEC. 399HH [42 U.S.C. 280j]. NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE. (a) ESTABLISHMENT OF NATIONAL STRATEGY AND PRIORITIES. (1) NATIONAL STRATEGY. The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. (2) IDENTIFICATION OF PRIORITIES. (A) IN GENERAL. The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1). (B) REQUIREMENTS. The Secretary shall ensure that priorities identified under subparagraph (A) will (i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations; (ii) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care; (iii) address gaps in quality, efficiency, comparative effectiveness information (taking into consideration the limitations set forth in subsections (c) and (d) of section 1182 of the Social Security Act), and health outcomes measures and data aggregation techniques; [As revised by section 10302] (iv) improve Federal payment policy to emphasize quality and efficiency; (v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes; (vi) address the health care provided to patients with high-cost chronic diseases; (vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections; (viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and (ix) address other areas as determined appropriate by the Secretary. (C) CONSIDERATIONS. In identifying priorities under subparagraph (A), the Secretary shall take into consideration the recommendations submitted by the entity with a contract under section 1890(a) of the Social Security Act and other stakeholders. (D) COORDINATION WITH STATE AGENCIES. The Secretary shall collaborate, coordinate, and consult with State agencies responsible for administering the Medicaid program under title XIX of the Social Security Act and the Children s Health Insurance Program under title XXI of such Act with respect to developing and disseminating strategies, goals, models, and timetables 1 PPACA Sec. 3011

10 8 that are consistent with the national priorities identified under subparagraph (A). (b) STRATEGIC PLAN. (1) IN GENERAL. The national strategy shall include a comprehensive strategic plan to achieve the priorities described in subsection (a). (2) REQUIREMENTS. The strategic plan shall include provisions for addressing, at a minimum, the following: (A) Coordination among agencies within the Department, which shall include steps to minimize duplication of efforts and utilization of common quality measures, where available. Such common quality measures shall be measures identified by the Secretary under section 1139A or 1139B of the Social Security Act or endorsed under section 1890 of such Act. (B) Agency-specific strategic plans to achieve national priorities. (C) Establishment of annual benchmarks for each relevant agency to achieve national priorities. (D) A process for regular reporting by the agencies to the Secretary on the implementation of the strategic plan. (E) Strategies to align public and private payers with regard to quality and patient safety efforts. (F) Incorporating quality improvement and measurement in the strategic plan for health information technology required by the American Recovery and Reinvestment Act of 2009 (Public Law 111 5). (c) PERIODIC UPDATE OF NATIONAL STRATEGY. The Secretary shall update the national strategy not less than annually. Any such update shall include a review of short- and long-term goals. (d) SUBMISSION AND AVAILABILITY OF NATIONAL STRATEGY AND UPDATES. (1) DEADLINE FOR INITIAL SUBMISSION OF NATIONAL STRATEGY. Not later than January 1, 2011, the Secretary shall submit to the relevant committees of Congress the national strategy described in subsection (a). (2) UPDATES. (A) IN GENERAL. The Secretary shall submit to the relevant committees of Congress an annual update to the strategy described in paragraph (1). (B) INFORMATION SUBMITTED. Each update submitted under subparagraph (A) shall include (i) a review of the short- and long-term goals of the national strategy and any gaps in such strategy; (ii) an analysis of the progress, or lack of progress, in meeting such goals and any barriers to such progress; (iii) the information reported under section 1139A of the Social Security Act, consistent with the reporting requirements of such section; and (iv) in the case of an update required to be submitted on or after January 1, 2014, the information reported under section 1139B(b)(4) of the Social Security Act, consistent with the reporting requirements of such section. (C) SATISFACTION OF OTHER REPORTING REQUIREMENTS. Compliance with the requirements of clauses (iii) and (iv) of subparagraph (B) shall satisfy the reporting requirements under sections 1139A(a)(6) and 1139B(b)(4), respectively, of the Social Security Act. (e) HEALTH CARE QUALITY INTERNET WEBSITE. Not later than January 1, 2011, the Secretary shall create an Internet website to make public information regarding (1) the national priorities for health care quality improvement established under subsection (a)(2); (2) the agency-specific strategic plans for health care quality described in subsection (b)(2)(b); and (3) other information, as the Secretary determines to be appropriate..

11 9 2. The Center for Quality Improvement and Patient Safety (Sec. 3501) Summary: The Center for Quality Improvement and Patient Safety (CQuIPS) is a branch of the HHS Agency for Healthcare Research and Quality. It interfaces closely with the United States Preventive Services Task Force (USPSTF) (mentioned in Section III C 3 of this report) and acts as its research arm. CQuIPS, according to its website, 1. Conducts and supports user-driven research on patient safety and health care quality measurement, reporting, and improvement. 2. Develops and disseminates reports and information on health care quality measurement, reporting, and improvement. 3. Collaborates with stakeholders across the health care system to implement evidence-based practices, accelerating and amplifying improvements in quality and safety for patients. 4. Assesses our own practices to ensure continuous learning and improvement for the Center and its members. 2 The PPACA authorizes funding for CQuIPS at $20,000,000 for fiscal years 2010 through Advocacy Strategy: The work of CQuIPS has broad implications for substance use treatment advocates. CQuIPS states that it is interested in feedback from the private and public sectors on how our research findings or products are being used and their impact on organizations, service delivery, and quality of care. 3 Advocates could encourage CQuIPS to carry out research and make recommendations based on the NQF standards. Advocates that are also providers could in addition seek technical assistance grants that are created by this section of the PPACA and administered by CQuIPS. Advocates could also encourage Congress to fully fund this section of the PPACA. SEC HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY IMPROVEMENT TECHNICAL ASSISTANCE. Part D of title IX of the Public Health Service Act, as amended by section 3013, is further amended by adding at the end the following: Subpart II Health Care Quality Improvement Programs SEC. 933 [42 U.S.C. 299b 33]. HEALTH CARE DELIVERY SYSTEM RESEARCH. (a) PURPOSE. The purposes of this section are to (1) enable the Director to identify, develop, evaluate, disseminate, and provide training in innovative methodologies and strategies for quality improvement practices in the delivery of health care services that represent best practices (referred to as best practices ) in health care quality, safety, and value; and (2) ensure that the Director is accountable for implementing a model to pursue such research in a collaborative manner with other related Federal agencies. (b) GENERAL FUNCTIONS OF THE CENTER. The Center for Quality Improvement and Patient Safety of the Agency for Healthcare Research and Quality (referred to in this section as the Center ), or any other relevant agency or department designated by the Director, shall (1) carry out its functions using research from a variety of disciplines, which may include epidemiology, health services, sociology, psychology, human factors engineering, biostatistics, health economics, clinical research, and health informatics; (2) conduct or support activities consistent with the purposes described in subsection (a), and for (A) best practices for quality improvement practices in the delivery of health care services; and (B) that include changes in processes of care and the redesign of systems used by providers that will reliably result in intended health outcomes, improve patient safety, and reduce medical errors (such as skill development for health care providers in teambased health care delivery and rapid cycle process improvement) and facilitate adoption of improved workflow; 2 Mission Statement. Center for Quality Improvement and Patient Safety. < 3 Contact Us. Agency for Healthcare Research and Quality. <

12 10 (3) identify health care providers, including health care systems, single institutions, and individual providers, that (A) deliver consistently high-quality, efficient health care services (as determined by the Secretary); and (B) employ best practices that are adaptable and scalable to diverse health care settings or effective in improving care across diverse settings; (4) assess research, evidence, and knowledge about what strategies and methodologies are most effective in improving health care delivery; (5) find ways to translate such information rapidly and effectively into practice, and document the sustainability of those improvements; (6) create strategies for quality improvement through the development of tools, methodologies, and interventions that can successfully reduce variations in the delivery of health care; (7) identify, measure, and improve organizational, human, or other causative factors, including those related to the culture and system design of a health care organization, that contribute to the success and sustainability of specific quality improvement and patient safety strategies; (8) provide for the development of best practices in the delivery of health care services that (A) have a high likelihood of success, based on structured review of empirical evidence; (B) are specified with sufficient detail of the individual processes, steps, training, skills, and knowledge required for implementation and incorporation into workflow of health care practitioners in a variety of settings; (C) are designed to be readily adapted by health care providers in a variety of settings; and (D) where applicable, assist health care providers in working with other health care providers across the continuum of care and in engaging patients and their families in improving the care and patient health outcomes; (9) provide for the funding of the activities of organizations with recognized expertise and excellence in improving the delivery of health care services, including children s health care, by involving multiple disciplines, managers of health care entities, broad development and training, patients, caregivers and families, and frontline health care workers, including activities for the examination of strategies to share best quality improvement practices and to promote excellence in the delivery of health care services; and (10) build capacity at the State and community level to lead quality and safety efforts through education, training, and mentoring programs to carry out the activities under paragraphs (1) through (9). (c) RESEARCH FUNCTIONS OF CENTER. (1) IN GENERAL. The Center shall support, such as through a contract or other mechanism, research on health care delivery system improvement and the development of tools to facilitate adoption of best practices that improve the quality, safety, and efficiency of health care delivery services. Such support may include establishing a Quality Improvement Network Research Program for the purpose of testing, scaling, and disseminating of interventions to improve quality and efficiency in health care. Recipients of funding under the Program may include national, State, multi-state, or multi-site quality improvement networks. (2) RESEARCH REQUIREMENTS. The research conducted pursuant to paragraph (1) shall (A) address the priorities identified by the Secretary in the national strategic plan established under section 399HH; (B) identify areas in which evidence is insufficient to identify strategies and methodologies, taking into consideration areas of insufficient evidence identified by the entity with a contract under section 1890(a) of the Social Security Act in the report required under section 399JJ; (C) address concerns identified by health care institutions and providers and communicated through the Center pursuant to subsection (d); (D) reduce preventable morbidity, mortality, and associated costs of morbidity and mortality by building capacity for patient safety research; (E) support the discovery of processes for the reliable, safe, efficient, and responsive delivery of health care, taking into account discoveries from clinical research and comparative effectiveness research; (F) allow communication of research findings and translate evidence into practice recommendations that are adaptable to a variety of settings, and which, as soon as practicable after the establishment of the Center, shall include (i) the implementation of a national application of Intensive Care Unit improvement projects relating to the adult (including geriatric), pediatric, and neonatal patient populations; (ii) practical methods for addressing health care associated infections,

13 11 including Methicillin-Resistant Staphylococcus Aureus and Vancomycin- Resistant Entercoccus infections and other emerging infections; and (iii) practical methods for reducing preventable hospital admissions and readmissions; (G) expand demonstration projects for improving the quality of children s health care and the use of health information technology, such as through Pediatric Quality Improvement Collaboratives and Learning Networks, consistent with provisions of section 1139A of the Social Security Act for assessing and improving quality, where applicable; (H) identify and mitigate hazards by (i) analyzing events reported to patient safety reporting systems and patient safety organizations; and (ii) using the results of such analyses to developscientific methods of response to such events; (I) include the conduct of systematic reviews of existing practices that improve the quality, safety, and efficiency of health care delivery, as well as new research on improving such practices; and (J) include the examination of how to measure and evaluate the progress of quality and patient safety activities. (d) DISSEMINATION OF RESEARCH FINDINGS. (1) PUBLIC AVAILABILITY. The Director shall make the research findings of the Center available to the public through multiple media and appropriate formats to reflect the varying needs of health care providers and consumers and diverse levels of health literacy. (2) LINKAGE TO HEALTH INFORMATION TECHNOLOGY. The Secretary shall ensure that research findings and results generated by the Center are shared with the Office of the National Coordinator of Health Information Technology and used to inform the activities of the health information technology extension program under section 3012, as well as any relevant standards, certification criteria, or implementation specifications. (e) PRIORITIZATION. The Director shall identify and regularly update a list of processes or systems on which to focus research and dissemination activities of the Center, taking into account (1) the cost to Federal health programs; (2) consumer assessment of health care experience; (3) provider assessment of such processes or systems and opportunities to minimize distress and injury to the health care workforce; (4) the potential impact of such processes or systems on health status and function of patients, including vulnerable populations including children; (5) the areas of insufficient evidence identified under subsection(c)(2)(b); and (6) the evolution of meaningful use of health information technology, as defined in section (f) COORDINATION. The Center shall coordinate its activities with activities conducted by the Center for Medicare and Medicaid Innovation established under section 1115A of the Social Security Act. (g) FUNDING. There is authorized to be appropriated to carry out this section $20,000,000 for fiscal years 2010 through SEC. 934 [42 U.S.C. 299b 34]. QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND IMPLEMENTATION. (a) IN GENERAL. The Director, through the Center for Quality Improvement and Patient Safety of the Agency for Healthcare Research and Quality (referred to in this section as the Center ), shall award (1) technical assistance grants or contracts to eligible entities to provide technical support to institutions that deliver health care and health care providers (including rural and urban providers of services and suppliers with limited infrastructure and financial resources to implement and support quality improvement activities, providers of services and suppliers with poor performance scores, and providers of services and suppliers for which there are disparities in care among subgroups of patients) so that such institutions and providers understand, adapt, and implement the models and practices identified in the research conducted by the Center, including the Quality Improvement Networks Research Program; and (2) implementation grants or contracts to eligible entities to implement the models and practices described under paragraph(1). (b) ELIGIBLE ENTITIES. (1) TECHNICAL ASSISTANCE AWARD. To be eligible to receive a technical assistance grant or contract under subsection (a)(1), an entity (A) may be a health care provider, health care provider association, professional society, health care worker organization, Indian health organization, quality improvement organization, patient safety organization, local quality improvement

14 12 collaborative, the Joint Commission, academic health center, university, physician-based research network, primary care extension program established under section 399V 1, a Federal Indian Health Service program or a health program operated by an Indian tribe (as defined in section 4 of the Indian Health Care Improvement Act), or any other entity identified by the Secretary; and [As revised by section 10501(f)(2)] (B) shall have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement. (2) IMPLEMENTATION AWARD. To be eligible to receive an implementation grant or contract under subsection (a)(2), an entity (A) may be a hospital or other health care provider or consortium or providers, as determined by the Secretary; and (B) shall have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement. (c) APPLICATION. (1) TECHNICAL ASSISTANCE AWARD. To receive a technical assistance grant or contract under subsection (a)(1), an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing (A) a plan for a sustainable business model that may include a system of (i) charging fees to institutions and providers that receive technical support from the entity; and (ii) reducing or eliminating such fees for such institutions and providers that serve low-income populations; and (B) such other information as the Director may require. (2) IMPLEMENTATION AWARD. To receive a grant or contract under subsection (a)(2), an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing (A) a plan for implementation of a model or practice identified in the research conducted by the Center including (i) financial cost, staffing requirements, and timeline for implementation; and (ii) pre- and projected post-implementation quality measure performance data in targeted improvement areas identified by the Secretary; and (B) such other information as the Director may require. (d) MATCHING FUNDS. The Director may not award a grant or contract under this section to an entity unless the entity agrees that it will make available (directly or through contributions from other public or private entities) non-federal contributions toward the activities to be carried out under the grant or contract in an amount equal to $1 for each $5 of Federal funds provided under the grant or contract. Such non- Federal matching funds may be provided directly or through donations from public or private entities and may be in cash or in-kind, fairly evaluated, including plant, equipment, or services. (e) EVALUATION. (1) IN GENERAL. The Director shall evaluate the performance of each entity that receives a grant or contract under this section. The evaluation of an entity shall include a study of (A) the success of such entity in achieving the implementation, by the health care institutions and providers assisted by such entity, of the models and practices identified in the research conducted by the Center under section 933; (B) the perception of the health care institutions and providers assisted by such entity regarding the value of the entity; and (C) where practicable, better patient health outcomes and lower cost resulting from the assistance provided by such entity. (2) EFFECT OF EVALUATION. Based on the outcome of the evaluation of the entity under paragraph (1), the Director shall determine whether to renew a grant or contract with such entity under this section. (f) COORDINATION. The entities that receive a grant or contract under this section shall coordinate with health information technology regional extension centers under section 3012(c) and the primary care extension program established under section 399V 1 regarding the dissemination of quality improvement, system delivery reform, and best practices information. [As revised by section 10501(f)(2)].

15 13 3. National Healthcare Workforce Commission (Sec. 5101) Summary: This section establishes the National Health Care Workforce Commission, which will advise Congress, the President, states and localities on the education and training activities of the health care workforce, how to improve care, and how to foster innovation to address population needs and changes in technology. This section also makes specific references to how the health care workforce is addressing the needs of special populations, and mental and behavioral health care workforce capacity. It includes substance abuse prevention and treatment providers in the definition of health professionals that are the focus of this Commission. The PPACA authorizes such sums as may be necessary for this section, but requires the Commission to submit requests for appropriations in the same manner as the Comptroller General. Advocacy Strategy: Advocates could encourage this Commission to study and make recommendations regarding the education and training received by the health care workforce as they relate to the NQF standards. Advocates could also review the reports that the Commission is required to submit to Congress, and comment on how these reports address the NQF standards. Advocates could also encourage Congress to fully fund this section of the PPACA. SEC [42 U.S.C. 294q]. NATIONAL HEALTH CARE WORKFORCE COMMISSION. (a) PURPOSE. It is the purpose of this section to establish a National Health Care Workforce Commission that (1) serves as a national resource for Congress, the President, States, and localities; (2) communicates and coordinates with the Departments of Health and Human Services, Labor, Veterans Affairs, Homeland Security, and Education on related activities administered by one or more of such Departments; (3) develops and commissions evaluations of education and training activities to determine whether the demand for health care workers is being met; (4) identifies barriers to improved coordination at the Federal, State, and local levels and recommend ways to address such barriers; and (5) encourages innovations to address population needs, constant changes in technology, and other environmental factors. (b) ESTABLISHMENT. There is hereby established the National Health Care Workforce Commission (in this section referred to as the Commission ). (c) MEMBERSHIP. (1) NUMBER AND APPOINTMENT. The Commission shall be composed of 15 members to be appointed by the Comptroller General, without regard to section 5 of the Federal Advisory Committee Act (5 U.S.C. App.). (2) QUALIFICATIONS. (A) IN GENERAL. The membership of the Commission shall include individuals (i) with national recognition for their expertise in health care labor market analysis, including health care workforce analysis; health care finance and economics; health care facility management; health care plans and integrated delivery systems; health care workforce education and training; health care philanthropy; providers of health care services; and other related fields; and (ii) who will provide a combination of professional perspectives, broad geographic representation, and a balance between urban, suburban, rural, and frontier representatives. (B) INCLUSION. (i) IN GENERAL. The membership of the Commission shall include no less than one representative of (I) the health care workforce and health professionals; (II) employers, including representatives of small business and self-employed individuals; [As revised by section 10501(a)(1)] (III) third-party payers; (IV) individuals skilled in the conduct and interpretation of health care services and health economics research; (V) representatives of consumers;

16 14 (VI) labor unions; (VII) State or local workforce investment boards; and (VIII) educational institutions (which may include elementary and secondary institutions, institutions of higher education, including 2 and 4 year institutions, or registered apprenticeship programs). (ii) ADDITIONAL MEMBERS. The remaining membership may include additional representatives from clause (i) and other individuals as determined appropriate by the Comptroller General of the United States. (C) MAJORITY NON-PROVIDERS. Individuals who are directly involved in health professions education or practice shall not constitute a majority of the membership of the Commission. (D) ETHICAL DISCLOSURE. The Comptroller General shall establish a system for public disclosure by members of the Commission of financial and other potential conflicts of interest relating to such members. Members of the Commission shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act of Members of the Commission shall not be treated as special government employees under title 18, United States Code. (3) TERMS. (A) IN GENERAL. The terms of members of the Commission shall be for 3 years except that the Comptroller General shall designate staggered terms for the members first appointed. (B) VACANCIES. Any member appointed to fill a vacancy occurring before the expiration of the term for which the member s predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member s term until a successor has taken office. A vacancy in the Commission shall be filled in the manner in which the original appointment was made. (C) INITIAL APPOINTMENTS. The Comptroller General shall make initial appointments of members to the Commission not later than September 30, (4) COMPENSATION. While serving on the business of the Commission (including travel time), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of tile 5, United States Code, and while so serving away from home and the member s regular place of business, a member may be allowed travel expenses, as authorized by the Chairman of the Commission. Physicians serving as personnel of the Commission may be provided a physician comparability allowance by the Commission in the same manner as Government physicians may be provided such an allowance by an agency under section 5948 of title 5, United States Code, and for such purpose subsection (i) of such section shall apply to the Commission in the same manner as it applies to the Tennessee Valley Authority. For purposes of pay (other than pay of members of the Commission) and employment benefits, rights, and privileges, all personnel of the Commission shall be treated as if they were employees of the United States Senate. Personnel of the Commission shall not be treated as employees of the Government Accountability Office for any purpose. (5) CHAIRMAN, VICE CHAIRMAN. The Comptroller General shall designate a member of the Commission, at the time of appointment of the member, as Chairman and a member as Vice Chairman for that term of appointment, except that in the case of vacancy of the chairmanship or vice chairmanship, the Comptroller General may designate another member for the remainder of that member s term. (6) MEETINGS. The Commission shall meet at the call of the chairman, but no less frequently than on a quarterly basis. (d) DUTIES. (1) RECOGNITION, DISSEMINATION, AND COMMUNICATION. The Commission shall (A) recognize efforts of Federal, State, and local partnerships to develop and offer health care career pathways of proven effectiveness; (B) disseminate information on promising retention practices for health care professionals; and (C) communicate information on important policies and practices that affect the recruitment, education and training, and retention of the health care workforce. (2) REVIEW OF HEALTH CARE WORKFORCE AND ANNUAL REPORTS. In order to develop a fiscally sustainable integrated workforce that supports a high-quality, readily accessible health care delivery system that meets the needs of patients and populations, the Commission, in consultation with relevant Federal, State, and local agencies, shall (A) review current and projected health care workforce supply and demand, including the topics described in paragraph (3); (B) make recommendations to Congress and the Administration concerning national health care workforce priorities, goals, and policies; (C) by not later than October 1 of each year (beginning with 2011), submit a report to Congress and the Administration containing the results of such reviews and recommendations concerning related policies; and (D) by not later than April 1 of each year (beginning with 2011), submit a report to Congress and the Administration containing a review of, and recommendations on, at a minimum one high priority area as described in paragraph (4). (3) SPECIFIC TOPICS TO BE REVIEWED. The topics described in this paragraph include (A) current health care workforce supply and distribution, including demographics, skill sets, and demands,

17 15 with projected demands during the subsequent 10 and 25 year periods; (B) health care workforce education and training capacity, including the number of students who have completed education and training, including registered apprenticeships; the number of qualified faculty; the education and training infrastructure; and the education and training demands, with projected demands during the subsequent 10 and 25 year periods; (C) the education loan and grant programs in titles VII and VIII of the Public Health Service Act (42 U.S.C. 292 et seq. and 296 et seq.), with recommendations on whether such programs should become part of the Higher Education Act of 1965 (20 U.S.C et seq); (D) the implications of new and existing Federal policies which affect the health care workforce, including Medicare and Medicaid graduate medical education policies, titles VII and VIII of the Public Health Service Act (42 U.S.C. 292 et seq. and 296 et seq.), the National Health Service Corps (with recommendations for aligning such programs with national health workforce priorities and goals), and other health care workforce programs, including those supported through the Workforce Investment Act of 1998 (29 U.S.C et seq.), the Carl D. Perkins Career and Technical Education Act of 2006 (20 U.S.C et seq.), the Higher Education Act of 1965 (20 U.S.C et seq.), and any other Federal health care workforce programs; (E) the health care workforce needs of special populations, such as minorities, rural populations, medically underserved populations, gender specific needs, individuals with disabilities, and geriatric and pediatric populations with recommendations for new and existing Federal policies to meet the needs of these special populations; and (F) recommendations creating or revising national loan repayment programs and scholarship programs to require low-income, minority medical students to serve in their home communities, if designated as medical underserved community. (4) HIGH PRIORITY AREAS. (A) IN GENERAL. The initial high priority topics described in this paragraph include each of the following: (i) Integrated health care workforce planning that identifies health care professional skills needed and maximizes the skill sets of health care professionals across disciplines. (ii) An analysis of the nature, scopes of practice, and demands for health care workers in the enhanced information technology and management workplace. (iii) An analysis of how to align Medicare and Medicaid graduate medical education policies with national workforce goals. (iv) [As added by section 10501(a)(3)] An analysis of, and recommendations for, eliminating the barriers to entering and staying in primary care, including provider compensation. (v) The education and training capacity, projected demands, and integration with the health care delivery system of each of the following: (I) Nursing workforce capacity at all levels. (II) Oral health care workforce capacity at all levels. (III) Mental and behavioral health care workforce capacity at all levels. (IV) Allied health and public health care workforce capacity at all levels. (V) Emergency medical service workforce capacity, including the retention and recruitment of the volunteer workforce, at all levels. (VI) The geographic distribution of health care providers as compared to the identified health care workforce needs of States and regions. (B) FUTURE DETERMINATIONS. The Commission may require that additional topics be included under subparagraph (A). The appropriate committees of Congress may recommend to the Commission the inclusion of other topics for health care workforce development areas that require special attention. (5) GRANT PROGRAM. The Commission shall (A) review implementation progress reports on, and report to Congress about, the State Health Care Workforce Development Grant program established in section 5102; (B) in collaboration with the Department of Labor and in coordination with the Department of Education and other relevant Federal agencies, make recommendations to the fiscal and administrative agent under section 5102(b) for grant recipients under section 5102; (C) assess the implementation of the grants under such section; and (D) collect performance and report information, including identified models and best practices, on grants from the fiscal and administrative agent under such section and distribute this information to Congress, relevant Federal agencies, and to the public. (6) STUDY. The Commission shall study effective mechanisms for financing education and training for careers in health care, including public health and allied health. (7) RECOMMENDATIONS. The Commission shall submit recommendations to Congress, the Department of Labor, and the Department of Health and Human Services about improving safety, health, and worker protections in the workplace for the health care workforce. (8) ASSESSMENT. The Commission shall assess and receive reports from the National Center for Health Care Workforce Analysis established under section 761(b) of the Public Service Health Act (as amended by section 5103). (e) CONSULTATION WITH FEDERAL, STATE, AND LOCAL AGENCIES,

18 16 CONGRESS, AND OTHER ORGANIZATIONS. (1) IN GENERAL. The Commission shall consult with Federal agencies (including the Departments of Health and Human Services, Labor, Education, Commerce, Agriculture, Defense, and Veterans Affairs and the Environmental Protection Agency), Congress, the Medicare Payment Advisory Commission, the Medicaid and CHIP Payment and Access Commission, and, to the extent practicable, with State and local agencies, Indian tribes, voluntary health care organizations, professional societies, and other relevant public-private health care partnerships. (2) OBTAINING OFFICIAL DATA. The Commission, consistent with established privacy rules, may secure directly from any department or agency of the Executive Branch information necessary to enable the Commission to carry out this section. (3) DETAIL OF FEDERAL GOVERNMENT EMPLOYEES. An employee of the Federal Government may be detailed to the Commission without reimbursement. The detail of such an employee shall be without interruption or loss of civil service status. (f) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS. Subject to such review as the Comptroller General of the United States determines to be necessary to ensure the efficient administration of the Commission, the Commission may (1) employ and fix the compensation of an executive director that shall not exceed the rate of basic pay payable for level V of the Executive Schedule and such other personnel as may be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service); (2) seek such assistance and support as may be required in the performance of its duties from appropriate Federal departments and agencies; (3) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of the Commission (without regard to section 3709 of the Revised Statutes (41 U.S.C. 5)); (4) make advance, progress, and other payments which relate to the work of the Commission; (5) provide transportation and subsistence for persons serving without compensation; and (6) prescribe such rules and regulations as the Commission determines to be necessary with respect to the internal organization and operation of the Commission. (g) POWERS. (1) DATA COLLECTION. In order to carry out its functions under this section, the Commission shall (A) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section, including coordination with the Bureau of Labor Statistics; (B) carry out, or award grants or contracts for the carrying out of, original research and development, where existing information is inadequate, and (C) adopt procedures allowing interested parties to submit information for the Commission s use in making reports and recommendations. (2) ACCESS OF THE GOVERNMENT ACCOUNTABILITY OFFICE TO INFORMATION. The Comptroller General of the United States shall have unrestricted access to all deliberations, records, and data of the Commission, immediately upon request. (3) PERIODIC AUDIT. The Commission shall be subject to periodic audit by an independent public accountant under contract to the Commission. (h) AUTHORIZATION OF APPROPRIATIONS. (1) REQUEST FOR APPROPRIATIONS. The Commission shall submit requests for appropriations in the same manner as the Comptroller General of the United States submits requests for appropriations. Amounts so appropriated for the Commission shall be separate from amounts appropriated for the Comptroller General. (2) AUTHORIZATION. There are authorized to be appropriated such sums as may be necessary to carry out this section. (3) GIFTS AND SERVICES. The Commission may not accept gifts, bequeaths, or donations of property, but may accept and use donations of services for purposes of carrying out this section. (i) DEFINITIONS. In this section: (1) HEALTH CARE WORKFORCE. The term health care workforce includes all health care providers with direct patient care and support responsibilities, such as physicians, nurses, nurse practitioners, primary care providers, preventive medicine physicians, optometrists, ophthalmologists, physician assistants, pharmacists, dentists, dental hygienists, and other oral healthcare professionals, allied health professionals, doctors of chiropractic, community health workers, health care paraprofessionals, direct care workers, psychologists and other behavioral and mental health professionals (including substance abuse prevention and treatment providers), social workers, physical and occupational therapists, certified nurse midwives, podiatrists, the EMS workforce (including professional and volunteer ambulance personnel and firefighters who perform emergency medical services), licensed complementary and alternative medicine providers, integrative health practitioners, public health professionals, and any other health professional that the Comptroller General of the United States determines appropriate. 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