II 

113TH CONGRESS 

2D SESSION S. 2000 

To amend title XVIII of the Social Security Act to repeal the Medicare 

sustainable growth rate and improve Medicare payments for physicians 

and other professionals, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 6, 2014 

Mr. BAUCUS (for himself and Mr. HATCH) introduced the following bill; which 

was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to repeal 

the Medicare sustainable growth rate and improve Medicare payments for physicians and other professionals, 

and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘SGR Repeal and Medicare Provider Payment Moderniza6 tion Act of 2014’’. 

7 (b) TABLE OF CONTENTS.—The table of contents of 

8 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Repealing the sustainable growth rate (SGR) and improving Medicare 

payment for physicians’ services. 

Sec. 3. Priorities and funding for measure development. 

Sec. 4. Encouraging care management for individuals with chronic care needs. 

Sec. 5. Ensuring accurate valuation of services under the physician fee schedule. 

Sec. 6. Promoting evidence-based care. 

Sec. 7. Empowering beneficiary choices through access to information on physicians’ services. 

Sec. 8. Expanding availability of Medicare data. 

Sec. 9. Reducing administrative burden and other provisions. 

1 SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE 

2 (SGR) AND IMPROVING MEDICARE PAYMENT 

3 FOR PHYSICIANS’ SERVICES. 

4 (a) STABILIZING FEE UPDATES.— 

5 (1) REPEAL OF SGR PAYMENT METHOD6 OLOGY.—Section 1848 of the Social Security Act 

7 (42 U.S.C. 1395w–4) is amended— 

8 (A) in subsection (d)— 

9 (i) in paragraph (1)(A), by inserting 

10 ‘‘or a subsequent paragraph’’ after ‘‘para11 graph (4)’’; and 

12 (ii) in paragraph (4)— 

13 (I) in the heading, by inserting 

14 ‘‘AND ENDING WITH 2013’’ after 

15 ‘‘YEARS BEGINNING WITH 2001’’; and 

16 (II) in subparagraph (A), by in17 serting ‘‘and ending with 2013’’ after 

18 ‘‘a year beginning with 2001’’; and 

19 (B) in subsection (f)— 


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1 (i) in paragraph (1)(B), by inserting 

2 ‘‘through 2013’’ after ‘‘of each succeeding 

3 year’’; and 

4 (ii) in paragraph (2), in the matter 

5 preceding subparagraph (A), by inserting 

6 ‘‘and ending with 2013’’ after ‘‘beginning 

7 with 2000’’. 

8 (2) UPDATE OF RATES FOR APRIL THROUGH

9 DECEMBER OF 2014, 2015, AND SUBSEQUENT

10 YEARS.—Subsection (d) of section 1848 of the Social 

11 Security Act (42 U.S.C. 1395w–4) is amended by 

12 striking paragraph (15) and inserting the following 

13 new paragraphs: 

14 ‘‘(15) UPDATE FOR 2014 THROUGH 2018.—The 

15 update to the single conversion factor established in 

16 paragraph (1)(C) for 2014 and each subsequent 

17 year through 2018 shall be 0.5 percent. 

18 ‘‘(16) UPDATE FOR 2019 THROUGH 2023.—The 

19 update to the single conversion factor established in 

20 paragraph (1)(C) for 2019 and each subsequent 

21 year through 2023 shall be zero percent. 

22 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

23 YEARS.—The update to the single conversion factor 

24 established in paragraph (1)(C) for 2024 and each 

25 subsequent year shall be— 


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1 ‘‘(A) for items and services furnished by a 

2 qualifying APM participant (as defined in sec3 tion 1833(z)(2)) for such year, 1.0 percent; and 

4 ‘‘(B) for other items and services, 0.5 per5 cent.’’. 

6 (3) MEDPAC REPORTS.— 

7 (A) INITIAL REPORT.—Not later than July 

8 1, 2016, the Medicare Payment Advisory Com9 mission shall submit to Congress a report on 

10 the relationship between— 

11 (i) physician and other health profes12 sional utilization and expenditures (and the 

13 rate of increase of such utilization and ex14 penditures) of items and services for which 

15 payment is made under section 1848 of the 

16 Social Security Act (42 U.S.C. 1395w–4); 

17 and 

18 (ii) total utilization and expenditures 

19 (and the rate of increase of such utilization 

20 and expenditures) under parts A, B, and D 

21 of title XVIII of such Act. 

22 Such report shall include a methodology to de23 scribe such relationship and the impact of 

24 changes in such physician and other health pro25 fessional practice and service ordering patterns 


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1 on total utilization and expenditures under 

2 parts A, B, and D of such title. 

3 (B) FINAL REPORT.—Not later than July 

4 1, 2020, the Medicare Payment Advisory Com5 mission shall submit to Congress a report on 

6 the relationship described in subparagraph (A), 

7 including the results determined from applying 

8 the methodology included in the report sub9 mitted under such subparagraph. 

10 (C) REPORT ON UPDATE TO PHYSICIANS’ 

11 SERVICES UNDER MEDICARE.—Not later than 

12 July 1, 2018, the Medicare Payment Advisory 

13 Commission shall submit to Congress a report 

14 on— 

15 (i) the payment update for profes16 sional services applied under the Medicare 

17 program under title XVIII of the Social 

18 Security Act for the period of years 2014 

19 through 2018; 

20 (ii) the effect of such update on the 

21 efficiency, economy, and quality of care 

22 provided under such program; 

23 (iii) the effect of such update on en24 suring a sufficient number of providers to 


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1 maintain access to care by Medicare bene2 ficiaries; and 

3 (iv) recommendations for any future 

4 payment updates for professional services 

5 under such program to ensure adequate 

6 access to care is maintained for Medicare 

7 beneficiaries. 

8 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

9 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN10 CENTIVE PAYMENT SYSTEM.— 

11 (1) EHR MEANINGFUL USE INCENTIVE PRO12 GRAM.— 

13 (A) SUNSETTING SEPARATE MEANINGFUL

14 USE PAYMENT ADJUSTMENTS.—Section 

15 1848(a)(7)(A) of the Social Security Act (42 

16 U.S.C. 1395w–4(a)(7)(A)) is amended— 

17 (i) in clause (i), by striking ‘‘or any 

18 subsequent payment year’’ and inserting 

19 ‘‘or 2017’’; 

20 (ii) in clause (ii)— 

21 (I) in the matter preceding sub22 clause (I), by striking ‘‘Subject to 

23 clause (iii), for’’ and inserting ‘‘For’’; 

24 (II) in subclause (I), by adding 

25 at the end ‘‘and’’; 


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1 (III) in subclause (II), by strik2 ing ‘‘; and’’ and inserting a period; 

3 and 

4 (IV) by striking subclause (III); 

5 and 

6 (iii) by striking clause (iii). 

7 (B) CONTINUATION OF MEANINGFUL USE

8 DETERMINATIONS FOR MIPS.—Section 

9 1848(o)(2) of the Social Security Act (42 

10 U.S.C. 1395w–4(o)(2)) is amended— 

11 (i) in subparagraph (A), in the matter 

12 preceding clause (i)— 

13 (I) by striking ‘‘For purposes of 

14 paragraph (1), an’’ and inserting 

15 ‘‘An’’; and 

16 (II) by inserting ‘‘, or pursuant 

17 to subparagraph (D) for purposes of 

18 subsection (q), for a performance pe19 riod under such subsection for a year’’ 

20 after ‘‘under such subsection for a 

21 year’’; and 

22 (ii) by adding at the end the following 

23 new subparagraph: 

24 ‘‘(D) CONTINUED APPLICATION FOR PUR25 POSES OF MIPS.—With respect to 2018 and 


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1 each subsequent payment year, the Secretary 

2 shall, for purposes of subsection (q) and in ac3 cordance with paragraph (1)(F) of such sub4 section, determine whether an eligible profes5 sional who is a MIPS eligible professional (as 

6 defined in subsection (q)(1)(C)) for such year is 

7 a meaningful EHR user under this paragraph 

8 for the performance period under subsection (q) 

9 for such year.’’. 

10 (2) QUALITY REPORTING.— 

11 (A) SUNSETTING SEPARATE QUALITY RE12 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

13 of the Social Security Act (42 U.S.C. 1395w– 

14 4(a)(8)(A)) is amended— 

15 (i) in clause (i), by striking ‘‘or any 

16 subsequent year’’ and inserting ‘‘or 2017’’; 

17 and 

18 (ii) in clause (ii)(II), by striking ‘‘and 

19 each subsequent year’’. 

20 (B) CONTINUATION OF QUALITY MEAS21 URES AND PROCESSES FOR MIPS.—Section 

22 1848 of the Social Security Act (42 U.S.C. 

23 1395w–4) is amended— 

24 (i) in subsection (k), by adding at the 

25 end the following new paragraph: 


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1 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

2 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN3 TEERING TO REPORT.—The Secretary shall, in ac4 cordance with subsection (q)(1)(F), carry out the 

5 provisions of this subsection— 

6 ‘‘(A) for purposes of subsection (q); and 

7 ‘‘(B) for eligible professionals who are not 

8 MIPS eligible professionals (as defined in sub9 section (q)(1)(C)) for the year involved.’’; and 

10 (ii) in subsection (m)— 

11 (I) by redesignating paragraph 

12 (7) added by section 10327(a) of Pub13 lic Law 111–148 as paragraph (8); 

14 and 

15 (II) by adding at the end the fol16 lowing new paragraph: 

17 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

18 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN19 TEERING TO REPORT.—The Secretary shall, in ac20 cordance with subsection (q)(1)(F), carry out the 

21 processes under this subsection— 

22 ‘‘(A) for purposes of subsection (q); and 

23 ‘‘(B) for eligible professionals who are not 

24 MIPS eligible professionals (as defined in sub25 section (q)(1)(C)) for the year involved.’’. 


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1 (3) VALUE-BASED PAYMENTS.— 

2 (A) SUNSETTING SEPARATE VALUE-BASED

3 PAYMENTS.—Clause (iii) of section 

4 1848(p)(4)(B) of the Social Security Act (42 

5 U.S.C. 1395w–4(p)(4)(B)) is amended to read 

6 as follows: 

7 ‘‘(iii) APPLICATION.—The Secretary 

8 shall apply the payment modifier estab9 lished under this subsection for items and 

10 services furnished on or after January 1, 

11 2015, but before January 1, 2018, with re12 spect to specific physicians and groups of 

13 physicians the Secretary determines appro14 priate. Such payment modifier shall not be 

15 applied for items and services furnished on 

16 or after January 1, 2018.’’. 

17 (B) CONTINUATION OF VALUE-BASED PAY18 MENT MODIFIER MEASURES FOR MIPS.—Section 

19 1848(p) of the Social Security Act (42 U.S.C. 

20 1395w–4(p)) is amended— 

21 (i) in paragraph (2), by adding at the 

22 end the following new subparagraph: 

23 ‘‘(C) CONTINUED APPLICATION FOR PUR24 POSES OF MIPS.—The Secretary shall, in ac25 cordance with subsection (q)(1)(F), carry out 


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1 subparagraph (B) for purposes of subsection 

2 (q).’’; and 

3 (ii) in paragraph (3), by adding at the 

4 end the following: ‘‘With respect to 2018 

5 and each subsequent year, the Secretary 

6 shall, in accordance with subsection 

7 (q)(1)(F), carry out this paragraph for 

8 purposes of subsection (q).’’. 

9 (c) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 

10 (1) IN GENERAL.—Section 1848 of the Social 

11 Security Act (42 U.S.C. 1395w–4) is amended by 

12 adding at the end the following new subsection: 

13 ‘‘(q) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 

14 ‘‘(1) ESTABLISHMENT.— 

15 ‘‘(A) IN GENERAL.—Subject to the suc16 ceeding provisions of this subsection, the Sec17 retary shall establish an eligible professional 

18 Merit-based Incentive Payment System (in this 

19 subsection referred to as the ‘MIPS’) under 

20 which the Secretary shall— 

21 ‘‘(i) develop a methodology for assess22 ing the total performance of each MIPS el23 igible professional according to perform24 ance standards under paragraph (3) for a 


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1 performance period (as established under 

2 paragraph (4)) for a year; 

3 ‘‘(ii) using such methodology, provide 

4 for a composite performance score in ac5 cordance with paragraph (5) for each such 

6 professional for each performance period; 

7 and 

8 ‘‘(iii) use such composite performance 

9 score of the MIPS eligible professional for 

10 a performance period for a year to deter11 mine and apply a MIPS adjustment factor 

12 (and, as applicable, an additional MIPS 

13 adjustment factor) under paragraph (6) to 

14 the professional for the year. 

15 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

16 MIPS shall apply to payments for items and 

17 services furnished on or after January 1, 2018. 

18 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE19 FINED.— 

20 ‘‘(i) IN GENERAL.—For purposes of 

21 this subsection, subject to clauses (ii) and 

22 (iv), the term ‘MIPS eligible professional’ 

23 means— 

24 ‘‘(I) for the first and second 

25 years for which the MIPS applies to 


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1 payments (and for the performance 

2 period for such first and second year), 

3 a physician (as defined in section 

4 1861(r)), a physician assistant, nurse 

5 practitioner, and clinical nurse spe6 cialist (as such terms are defined in 

7 section 1861(aa)(5)), and a certified 

8 registered nurse anesthetist (as de9 fined in section 1861(bb)(2)) and a 

10 group that includes such profes11 sionals; and 

12 ‘‘(II) for the third year for which 

13 the MIPS applies to payments (and 

14 for the performance period for such 

15 third year) and for each succeeding 

16 year (and for the performance period 

17 for each such year), the professionals 

18 described in subclause (I) and such 

19 other eligible professionals (as defined 

20 in subsection (k)(3)(B)) as specified 

21 by the Secretary and a group that in22 cludes such professionals. 

23 ‘‘(ii) EXCLUSIONS.—For purposes of 

24 clause (i), the term ‘MIPS eligible profes25 sional’ does not include, with respect to a 


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1 year, an eligible professional (as defined in 

2 subsection (k)(3)(B)) who— 

3 ‘‘(I) is a qualifying APM partici4 pant (as defined in section 

5 1833(z)(2)); 

6 ‘‘(II) subject to clause (vii), is a 

7 partial qualifying APM participant (as 

8 defined in clause (iii)) for the most re9 cent period for which data are avail10 able and who, for the performance pe11 riod with respect to such year, does 

12 not report on applicable measures and 

13 activities described in paragraph 

14 (2)(B) that are required to be re15 ported by such a professional under 

16 the MIPS; or 

17 ‘‘(III) for the performance period 

18 with respect to such year, does not ex19 ceed the low-volume threshold meas20 urement selected under clause (iv). 

21 ‘‘(iii) PARTIAL QUALIFYING APM PAR22 TICIPANT.—For purposes of this subpara23 graph, the term ‘partial qualifying APM 

24 participant’ means, with respect to a year, 

25 an eligible professional for whom the SecVerDate Mar 15 2010 02:53 Feb 08, 2014 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S2000.IS S2000

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1 retary determines the minimum payment 

2 percentage (or percentages), as applicable, 

3 described in paragraph (2) of section 

4 1833(z) for such year have not been satis5 fied, but who would be considered a quali6 fying APM participant (as defined in such 

7 paragraph) for such year if— 

8 ‘‘(I) with respect to 2018 and 

9 2019, the reference in subparagraph 

10 (A) of such paragraph to 25 percent 

11 was instead a reference to 20 percent; 

12 ‘‘(II) with respect to 2020 and 

13 2021— 

14 ‘‘(aa) the reference in sub15 paragraph (B)(i) of such para16 graph to 50 percent was instead 

17 a reference to 40 percent; and 

18 ‘‘(bb) the references in sub19 paragraph (B)(ii) of such para20 graph to 50 percent and 25 per21 cent of such paragraph were in22 stead references to 40 percent 

23 and 20 percent, respectively; and 

24 ‘‘(III) with respect to 2022 and 

25 subsequent years— 


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1 ‘‘(aa) the reference in sub2 paragraph (C)(i) of such para3 graph to 75 percent was instead 

4 a reference to 50 percent; and 

5 ‘‘(bb) the references in sub6 paragraph (C)(ii) of such para7 graph to 75 percent and 25 per8 cent of such paragraph were in9 stead references to 50 percent 

10 and 20 percent, respectively. 

11 ‘‘(iv) SELECTION OF LOW-VOLUME

12 THRESHOLD MEASUREMENT.—The Sec13 retary shall select a low-volume threshold 

14 to apply for purposes of clause (ii)(III), 

15 which may include one or more or a com16 bination of the following: 

17 ‘‘(I) The minimum number (as 

18 determined by the Secretary) of indi19 viduals enrolled under this part who 

20 are treated by the eligible professional 

21 for the performance period involved. 

22 ‘‘(II) The minimum number (as 

23 determined by the Secretary) of items 

24 and services furnished to individuals 


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1 enrolled under this part by such pro2 fessional for such performance period. 

3 ‘‘(III) The minimum amount (as 

4 determined by the Secretary) of al5 lowed charges billed by such profes6 sional under this part for such per7 formance period. 

8 ‘‘(v) TREATMENT OF NEW MEDICARE

9 ENROLLED ELIGIBLE PROFESSIONALS.—In 

10 the case of a professional who first be11 comes a Medicare enrolled eligible profes12 sional during the performance period for a 

13 year (and had not previously submitted 

14 claims under this title such as a person, an 

15 entity, or a part of a physician group or 

16 under a different billing number or tax 

17 identifier), such professional shall not be 

18 treated under this subsection as a MIPS 

19 eligible professional until the subsequent 

20 year and performance period for such sub21 sequent year. 

22 ‘‘(vi) CLARIFICATION.—In the case of 

23 items and services furnished during a year 

24 by an individual who is not a MIPS eligible 

25 professional (including pursuant to clauses 


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1 (ii) and (v)) with respect to a year, in no 

2 case shall a MIPS adjustment factor (or 

3 additional MIPS adjustment factor) under 

4 paragraph (6) apply to such individual for 

5 such year. 

6 ‘‘(vii) PARTIAL QUALIFYING APM PAR7 TICIPANT CLARIFICATIONS.— 

8 ‘‘(I) TREATMENT AS MIPS ELIGI9 BLE PROFESSIONAL.—In the case of 

10 an eligible professional who is a par11 tial qualifying APM participant, with 

12 respect to a year, and who for the 

13 performance period for such year re14 ports on applicable measures and ac15 tivities described in paragraph (2)(B) 

16 that are required to be reported by 

17 such a professional under the MIPS, 

18 such eligible professional is considered 

19 to be a MIPS eligible professional 

20 with respect to such year. 

21 ‘‘(II) NOT ELIGIBLE FOR QUALI22 FYING APM PARTICIPANT PAY23 MENTS.—In no case shall an eligible 

24 professional who is a partial quali25 fying APM participant, with respect 


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1 to a year, be considered a qualifying 

2 APM participant (as defined in para3 graph (2) of section 1833(z)) for such 

4 year or be eligible for the additional 

5 payment under paragraph (1) of such 

6 section for such year. 

7 ‘‘(D) APPLICATION TO GROUP PRAC8 TICES.— 

9 ‘‘(i) IN GENERAL.—Under the MIPS: 

10 ‘‘(I) QUALITY PERFORMANCE

11 CATEGORY.—The Secretary shall es12 tablish and apply a process that in13 cludes features of the provisions of 

14 subsection (m)(3)(C) for MIPS eligi15 ble professionals in a group practice 

16 with respect to assessing performance 

17 of such group with respect to the per18 formance category described in clause 

19 (i) of paragraph (2)(A). 

20 ‘‘(II) OTHER PERFORMANCE CAT21 EGORIES.—The Secretary may estab22 lish and apply a process that includes 

23 features of the provisions of sub24 section (m)(3)(C) for MIPS eligible 

25 professionals in a group practice with 


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1 respect to assessing the performance 

2 of such group with respect to the per3 formance categories described in 

4 clauses (ii) through (iv) of such para5 graph. 

6 ‘‘(ii) ENSURING COMPREHENSIVENESS

7 OF GROUP PRACTICE ASSESSMENT.—The 

8 process established under clause (i) shall to 

9 the extent practicable reflect the range of 

10 items and services furnished by the MIPS 

11 eligible professionals in the group practice 

12 involved. 

13 ‘‘(iii) CLARIFICATION.—MIPS eligible 

14 professionals electing to be a virtual group 

15 under paragraph (5)(I) shall not be consid16 ered MIPS eligible professionals in a group 

17 practice for purposes of applying this sub18 paragraph. 

19 ‘‘(E) USE OF REGISTRIES.—Under the 

20 MIPS, the Secretary shall encourage the use of 

21 qualified clinical data registries pursuant to 

22 subsection (m)(3)(E) in carrying out this sub23 section. 

24 ‘‘(F) APPLICATION OF CERTAIN PROVI25 SIONS.—In applying a provision of subsection 


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1 (k), (m), (o), or (p) for purposes of this sub2 section, the Secretary shall— 

3 ‘‘(i) adjust the application of such 

4 provision to ensure the provision is con5 sistent with the provisions of this sub6 section; and 

7 ‘‘(ii) not apply such provision to the 

8 extent that the provision is duplicative with 

9 a provision of this subsection. 

10 ‘‘(G) ACCOUNTING FOR RISK FACTORS.— 

11 ‘‘(i) RISK FACTORS.—Taking into ac12 count the relevant studies conducted and 

13 recommendations made in reports under 

14 section 2(f)(1) of the SGR Repeal and 

15 Medicare Provider Payment Modernization 

16 Act of 2014, the Secretary, on an ongoing 

17 basis, shall estimate how an individual’s 

18 health status and other risk factors affect 

19 quality and resource use outcome measures 

20 and, as feasible, shall incorporate informa21 tion from quality and resource use outcome 

22 measurement (including care episode and 

23 patient condition groups) into the MIPS. 

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1 ing into account the studies conducted and 

2 recommendations made in reports under 

3 section 2(f)(1) of the SGR Repeal and 

4 Medicare Provider Payment Modernization 

5 Act of 2014 and other information as ap6 propriate, the Secretary shall account for 

7 identified factors with an effect on quality 

8 and resource use outcome measures when 

9 determining payment adjustments, com10 posite performance scores, scores for per11 formance categories, or scores for meas12 ures or activities under the MIPS. 

13 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER14 FORMANCE CATEGORIES.— 

15 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

16 the MIPS, the Secretary shall use the following 

17 performance categories (each of which is re18 ferred to in this subsection as a performance 

19 category) in determining the composite per20 formance score under paragraph (5): 

21 ‘‘(i) Quality. 

22 ‘‘(ii) Resource use. 

23 ‘‘(iii) Clinical practice improvement 

24 activities. 


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1 ‘‘(iv) Meaningful use of certified EHR 

2 technology. 

3 ‘‘(B) MEASURES AND ACTIVITIES SPECI4 FIED FOR EACH CATEGORY.—For purposes of 

5 paragraph (3)(A) and subject to subparagraph 

6 (C), measures and activities specified for a per7 formance period (as established under para8 graph (4)) for a year are as follows: 

9 ‘‘(i) QUALITY.—For the performance 

10 category described in subparagraph (A)(i), 

11 the quality measures included in the final 

12 measures list published under subpara13 graph (D)(i) for such year and the list of 

14 quality measures described in subpara15 graph (D)(vi) used by qualified clinical 

16 data registries under subsection (m)(3)(E). 

17 ‘‘(ii) RESOURCE USE.—For the per18 formance category described in subpara19 graph (A)(ii), the measurement of resource 

20 use for such period under subsection 

21 (p)(3), using the methodology under sub22 section (r) as appropriate, and, as feasible 

23 and applicable, accounting for the cost of 

24 drugs under part D. 


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1 ‘‘(iii) CLINICAL PRACTICE IMPROVE2 MENT ACTIVITIES.—For the performance 

3 category described in subparagraph 

4 (A)(iii), clinical practice improvement ac5 tivities (as defined in subparagraph 

6 (C)(v)(III)) under subcategories specified 

7 by the Secretary for such period, which 

8 shall include at least the following: 

9 ‘‘(I) The subcategory of expanded 

10 practice access, which shall include ac11 tivities such as same day appoint12 ments for urgent needs and after 

13 hours access to clinician advice. 

14 ‘‘(II) The subcategory of popu15 lation management, which shall in16 clude activities such as monitoring 

17 health conditions of individuals to pro18 vide timely health care interventions 

19 or participation in a qualified clinical 

20 data registry. 

21 ‘‘(III) The subcategory of care 

22 coordination, which shall include ac23 tivities such as timely communication 

24 of test results, timely exchange of 

25 clinical information to patients and 


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1 other providers, and use of remote 

2 monitoring or telehealth. 

3 ‘‘(IV) The subcategory of bene4 ficiary engagement, which shall in5 clude activities such as the establish6 ment of care plans for individuals 

7 with complex care needs, beneficiary 

8 self-management assessment and 

9 training, and using shared decision10 making mechanisms. 

11 ‘‘(V) The subcategory of patient 

12 safety and practice assessment, such 

13 as through use of clinical or surgical 

14 checklists and practice assessments 

15 related to maintaining certification. 

16 ‘‘(VI) The subcategory of partici17 pation in an alternative payment 

18 model (as defined in section 

19 1833(z)(3)(C)). 

20 In establishing activities under this clause, 

21 the Secretary shall give consideration to 

22 the circumstances of small practices (con23 sisting of 15 or fewer professionals) and 

24 practices located in rural areas and in 

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1 ignated under section 332(a)(1)(A) of the 

2 Public Health Service Act). 

3 ‘‘(iv) MEANINGFUL EHR USE.—For 

4 the performance category described in sub5 paragraph (A)(iv), the requirements estab6 lished for such period under subsection 

7 (o)(2) for determining whether an eligible 

8 professional is a meaningful EHR user. 

9 ‘‘(C) ADDITIONAL PROVISIONS.— 

10 ‘‘(i) EMPHASIZING OUTCOME MEAS11 URES UNDER THE QUALITY PERFORMANCE

12 CATEGORY.—In applying subparagraph 

13 (B)(i), the Secretary shall, as feasible, em14 phasize the application of outcome meas15 ures. 

16 ‘‘(ii) APPLICATION OF ADDITIONAL

17 SYSTEM MEASURES.—The Secretary may 

18 use measures used for a payment system 

19 other than for physicians, such as meas20 ures for inpatient hospitals, for purposes of 

21 the performance categories described in 

22 clauses (i) and (ii) of subparagraph (A). 

23 For purposes of the previous sentence, the 

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1 pital outpatient departments, except in the 

2 case of emergency physicians. 

3 ‘‘(iii) GLOBAL AND POPULATION4 BASED MEASURES.—The Secretary may 

5 use global measures, such as global out6 come measures, and population-based 

7 measures for purposes of the performance 

8 category described in subparagraph (A)(i). 

9 ‘‘(iv) APPLICATION OF MEASURES AND

10 ACTIVITIES TO NON-PATIENT-FACING PRO11 FESSIONALS.—In carrying out this para12 graph, with respect to measures and activi13 ties specified in subparagraph (B) for per14 formance categories described in subpara15 graph (A), the Secretary— 

16 ‘‘(I) shall give consideration to 

17 the circumstances of professional 

18 types (or subcategories of those types 

19 determined by practice characteris20 tics) who typically furnish services 

21 that do not involve face-to-face inter22 action with a patient; and 

23 ‘‘(II) may, to the extent feasible 

24 and appropriate, take into account 

25 such circumstances and apply under 


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1 this subsection with respect to MIPS 

2 eligible professionals of such profes3 sional types or subcategories, alter4 native measures or activities that ful5 fill the goals of the applicable per6 formance category. 

7 In carrying out the previous sentence, the 

8 Secretary shall consult with professionals 

9 of such professional types or subcategories. 

10 ‘‘(v) CLINICAL PRACTICE IMPROVE11 MENT ACTIVITIES.— 

12 ‘‘(I) REQUEST FOR INFORMA13 TION.—In initially applying subpara14 graph (B)(iii), the Secretary shall use 

15 a request for information to solicit 

16 recommendations from stakeholders to 

17 identify activities described in such 

18 subparagraph and specifying criteria 

19 for such activities. 

20 ‘‘(II) CONTRACT AUTHORITY FOR

21 CLINICAL PRACTICE IMPROVEMENT

22 ACTIVITIES PERFORMANCE CAT23 EGORY.—In applying subparagraph 

24 (B)(iii), the Secretary may contract 


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1 with entities to assist the Secretary 

2 in— 

3 ‘‘(aa) identifying activities 

4 described in subparagraph 

5 (B)(iii); 

6 ‘‘(bb) specifying criteria for 

7 such activities; and 

8 ‘‘(cc) determining whether a 

9 MIPS eligible professional meets 

10 such criteria. 

11 ‘‘(III) CLINICAL PRACTICE IM12 PROVEMENT ACTIVITIES DEFINED.— 

13 For purposes of this subsection, the 

14 term ‘clinical practice improvement 

15 activity’ means an activity that rel16 evant eligible professional organiza17 tions and other relevant stakeholders 

18 identify as improving clinical practice 

19 or care delivery and that the Sec20 retary determines, when effectively ex21 ecuted, is likely to result in improved 

22 outcomes. 

23 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

24 AVAILABLE FOR MIPS ASSESSMENT.— 


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1 ‘‘(i) IN GENERAL.—Under the MIPS, 

2 the Secretary, through notice and comment 

3 rulemaking and subject to the succeeding 

4 clauses of this subparagraph, shall, with 

5 respect to the performance period for a 

6 year, establish an annual final list of qual7 ity measures from which MIPS eligible 

8 professionals may choose for purposes of 

9 assessment under this subsection for such 

10 performance period. Pursuant to the pre11 vious sentence, the Secretary shall— 

12 ‘‘(I) not later than November 1 

13 of the year prior to the first day of 

14 the first performance period under the 

15 MIPS, establish and publish in the 

16 Federal Register a final list of quality 

17 measures; and 

18 ‘‘(II) not later than November 1 

19 of the year prior to the first day of 

20 each subsequent performance period, 

21 update the final list of quality meas22 ures from the previous year (and pub23 lish such updated final list in the Fed24 eral Register), by— 


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1 ‘‘(aa) removing from such 

2 list, as appropriate, quality meas3 ures, which may include the re4 moval of measures that are no 

5 longer meaningful (such as meas6 ures that are topped out); 

7 ‘‘(bb) adding to such list, as 

8 appropriate, new quality meas9 ures; and 

10 ‘‘(cc) determining whether 

11 or not quality measures on such 

12 list that have undergone sub13 stantive changes should be in14 cluded in the updated list. 

15 ‘‘(ii) CALL FOR QUALITY MEAS16 URES.— 

17 ‘‘(I) IN GENERAL.—Eligible pro18 fessional organizations and other rel19 evant stakeholders shall be requested 

20 to identify and submit quality meas21 ures to be considered for selection 

22 under this subparagraph in the an23 nual list of quality measures published 

24 under clause (i) and to identify and 

25 submit updates to the measures on 


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1 such list. For purposes of the previous 

2 sentence, measures may be submitted 

3 regardless of whether such measures 

4 were previously published in a pro5 posed rule or endorsed by an entity 

6 with a contract under section 1890(a). 

7 ‘‘(II) ELIGIBLE PROFESSIONAL

8 ORGANIZATION DEFINED.—In this 

9 subparagraph, the term ‘eligible pro10 fessional organization’ means a pro11 fessional organization as defined by 

12 nationally recognized multispecialty 

13 boards of certification or equivalent 

14 certification boards. 

15 ‘‘(iii) REQUIREMENTS.—In selecting 

16 quality measures for inclusion in the an17 nual final list under clause (i), the Sec18 retary shall— 

19 ‘‘(I) provide that, to the extent 

20 practicable, all quality domains (as 

21 defined in subsection (s)(1)(B)) are 

22 addressed by such measures; and 

23 ‘‘(II) ensure that such selection 

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1 lection of measures under subsections 

2 (k), (m), and (p)(2). 

3 ‘‘(iv) PEER REVIEW.—Before includ4 ing a new measure or a measure described 

5 in clause (i)(II)(cc) in the final list of 

6 measures published under clause (i) for a 

7 year, the Secretary shall submit for publi8 cation in applicable specialty-appropriate 

9 peer-reviewed journals such measure and 

10 the method for developing and selecting 

11 such measure, including clinical and other 

12 data supporting such measure. 

13 ‘‘(v) MEASURES FOR INCLUSION.— 

14 The final list of quality measures published 

15 under clause (i) shall include, as applica16 ble, measures under subsections (k), (m), 

17 and (p)(2), including quality measures 

18 from among— 

19 ‘‘(I) measures endorsed by a con20 sensus-based entity; 

21 ‘‘(II) measures developed under 

22 subsection (s); and 

23 ‘‘(III) measures submitted under 

24 clause (ii)(I). 


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1 Any measure selected for inclusion in such 

2 list that is not endorsed by a consensus3 based entity shall have a focus that is evi4 dence-based. 

5 ‘‘(vi) EXCEPTION FOR QUALIFIED

6 CLINICAL DATA REGISTRY MEASURES.— 

7 Measures used by a qualified clinical data 

8 registry under subsection (m)(3)(E) shall 

9 not be subject to the requirements under 

10 clauses (i), (iv), and (v). The Secretary 

11 shall publish the list of measures used by 

12 such qualified clinical data registries on 

13 the Internet website of the Centers for 

14 Medicare & Medicaid Services. 

15 ‘‘(vii) EXCEPTION FOR EXISTING

16 QUALITY MEASURES.—Any quality meas17 ure specified by the Secretary under sub18 section (k) or (m), including under sub19 section (m)(3)(E), and any measure of 

20 quality of care established under sub21 section (p)(2) for the reporting period 

22 under the respective subsection beginning 

23 before the first performance period under 

24 the MIPS— 


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1 ‘‘(I) shall not be subject to the 

2 requirements under clause (i) (except 

3 under items (aa) and (cc) of subclause 

4 (II) of such clause) or to the require5 ment under clause (iv); and 

6 ‘‘(II) shall be included in the 

7 final list of quality measures pub8 lished under clause (i) unless removed 

9 under clause (i)(II)(aa). 

10 ‘‘(viii) CONSULTATION WITH REL11 EVANT ELIGIBLE PROFESSIONAL ORGANI12 ZATIONS AND OTHER RELEVANT STAKE13 HOLDERS.—Relevant eligible professional 

14 organizations and other relevant stake15 holders, including State and national med16 ical societies, shall be consulted in carrying 

17 out this subparagraph. 

18 ‘‘(ix) OPTIONAL APPLICATION.—The 

19 process under section 1890A is not re20 quired to apply to the selection of meas21 ures under this subparagraph. 

22 ‘‘(3) PERFORMANCE STANDARDS.— 

23 ‘‘(A) ESTABLISHMENT.—Under the MIPS, 

24 the Secretary shall establish performance stand25 ards with respect to measures and activities 


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1 specified under paragraph (2)(B) for a perform2 ance period (as established under paragraph 

3 (4)) for a year. 

4 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

5 STANDARDS.—In establishing such performance 

6 standards with respect to measures and activi7 ties specified under paragraph (2)(B), the Sec8 retary shall consider the following: 

9 ‘‘(i) Historical performance standards. 

10 ‘‘(ii) Improvement. 

11 ‘‘(iii) The opportunity for continued 

12 improvement. 

13 ‘‘(4) PERFORMANCE PERIOD.—The Secretary 

14 shall establish a performance period (or periods) for 

15 a year (beginning with the year described in para16 graph (1)(B)). Such performance period (or periods) 

17 shall begin and end prior to the beginning of such 

18 year and be as close as possible to such year. In this 

19 subsection, such performance period (or periods) for 

20 a year shall be referred to as the performance period 

21 for the year. 

22 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

23 ‘‘(A) IN GENERAL.—Subject to the suc24 ceeding provisions of this paragraph and taking 

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1 graph (1)(G), the Secretary shall develop a 

2 methodology for assessing the total performance 

3 of each MIPS eligible professional according to 

4 performance standards under paragraph (3) 

5 with respect to applicable measures and activi6 ties specified in paragraph (2)(B) with respect 

7 to each performance category applicable to such 

8 professional for a performance period (as estab9 lished under paragraph (4)) for a year. Using 

10 such methodology, the Secretary shall provide 

11 for a composite assessment (using a scoring 

12 scale of 0 to 100) for each such professional for 

13 the performance period for such year. In this 

14 subsection such a composite assessment for 

15 such a professional with respect to a perform16 ance period shall be referred to as the ‘com17 posite performance score’ for such professional 

18 for such performance period. 

19 ‘‘(B) INCENTIVE TO REPORT; ENCOUR20 AGING USE OF CERTIFIED EHR TECHNOLOGY

21 FOR REPORTING QUALITY MEASURES.— 

22 ‘‘(i) INCENTIVE TO REPORT.—Under 

23 the methodology established under sub24 paragraph (A), the Secretary shall provide 

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1 sional who fails to report on an applicable 

2 measure or activity that is required to be 

3 reported by the professional, the profes4 sional shall be treated as achieving the 

5 lowest potential score applicable to such 

6 measure or activity. 

7 ‘‘(ii) ENCOURAGING USE OF CER8 TIFIED EHR TECHNOLOGY AND QUALIFIED

9 CLINICAL DATA REGISTRIES FOR REPORT10 ING QUALITY MEASURES.—Under the 

11 methodology established under subpara12 graph (A), the Secretary shall— 

13 ‘‘(I) encourage MIPS eligible 

14 professionals to report on applicable 

15 measures with respect to the perform16 ance category described in paragraph 

17 (2)(A)(i) through the use of certified 

18 EHR technology and qualified clinical 

19 data registries; and 

20 ‘‘(II) with respect to a perform21 ance period, with respect to a year, 

22 for which a MIPS eligible professional 

23 reports such measures through the 

24 use of such EHR technology, treat 

25 such professional as satisfying the 


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1 clinical quality measures reporting re2 quirement described in subsection 

3 (o)(2)(A)(iii) for such year. 

4 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

5 ACTIVITIES PERFORMANCE SCORE.— 

6 ‘‘(i) RULE FOR ACCREDITATION.—A 

7 MIPS eligible professional who is in a 

8 practice that is certified as a patient-cen9 tered medical home or comparable spe10 cialty practice pursuant to subsection 

11 (b)(8)(B)(i) with respect to a performance 

12 period shall be given the highest potential 

13 score for the performance category de14 scribed in paragraph (2)(A)(iii) for such 

15 period. 

16 ‘‘(ii) APM PARTICIPATION.—Partici17 pation by a MIPS eligible professional in 

18 an alternative payment model (as defined 

19 in section 1833(z)(3)(C)) with respect to a 

20 performance period shall earn such eligible 

21 professional a minimum score of one-half 

22 of the highest potential score for the per23 formance category described in paragraph 

24 (2)(A)(iii) for such performance period. 


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1 ‘‘(iii) SUBCATEGORIES.—A MIPS eli2 gible professional shall not be required to 

3 perform activities in each subcategory 

4 under paragraph (2)(B)(iii) or participate 

5 in an alternative payment model in order 

6 to achieve the highest potential score for 

7 the performance category described in 

8 paragraph (2)(A)(iii). 

9 ‘‘(D) ACHIEVEMENT AND IMPROVE10 MENT.— 

11 ‘‘(i) TAKING INTO ACCOUNT IMPROVE12 MENT.—Beginning with the second year to 

13 which the MIPS applies, in addition to the 

14 achievement of a MIPS eligible profes15 sional, if data sufficient to measure im16 provement is available, the methodology 

17 developed under subparagraph (A)— 

18 ‘‘(I) in the case of the perform19 ance score for the performance cat20 egory described in clauses (i) and (ii) 

21 of paragraph (2)(A), shall take into 

22 account the improvement of the pro23 fessional; and 

24 ‘‘(II) in the case of performance 

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1 egories, may take into account the im2 provement of the professional. 

3 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

4 ACHIEVEMENT.—Beginning with the 

5 fourth year to which the MIPS applies, 

6 under the methodology developed under 

7 subparagraph (A), the Secretary may as8 sign a higher scoring weight under sub9 paragraph (F) with respect to the achieve10 ment of a MIPS eligible professional than 

11 with respect to any improvement of such 

12 professional applied under clause (i) with 

13 respect to a measure, activity, or category 

14 described in paragraph (2). 

15 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

16 CATEGORIES.— 

17 ‘‘(i) IN GENERAL.—Under the meth18 odology developed under subparagraph (A), 

19 subject to subparagraph (F)(i) and clauses 

20 (ii) and (iii), the composite performance 

21 score shall be determined as follows: 

22 ‘‘(I) QUALITY.— 

23 ‘‘(aa) IN GENERAL.—Sub24 ject to item (bb), thirty percent 

25 of such score shall be based on 


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1 performance with respect to the 

2 category described in clause (i) of 

3 paragraph (2)(A). In applying 

4 the previous sentence, the Sec5 retary shall, as feasible, encour6 age the application of outcome 

7 measures within such category. 

8 ‘‘(bb) FIRST 2 YEARS.—For 

9 the first and second years for 

10 which the MIPS applies to pay11 ments, the percentage applicable 

12 under item (aa) shall be in13 creased in a manner such that 

14 the total percentage points of the 

15 increase under this item for the 

16 respective year equals the total 

17 number of percentage points by 

18 which the percentage applied 

19 under subclause (II)(bb) for the 

20 respective year is less than 30 

21 percent. 

22 ‘‘(II) RESOURCE USE.— 

23 ‘‘(aa) IN GENERAL.—Sub24 ject to item (bb), thirty percent 

25 of such score shall be based on 


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1 performance with respect to the 

2 category described in clause (ii) 

3 of paragraph (2)(A). 

4 ‘‘(bb) FIRST 2 YEARS.—For 

5 the first year for which the MIPS 

6 applies to payments, not more 

7 than 10 percent of such score 

8 shall be based on performance 

9 with respect to the category de10 scribed in clause (ii) of para11 graph (2)(A). For the second 

12 year for which the MIPS applies 

13 to payments, not more than 15 

14 percent of such score shall be 

15 based on performance with re16 spect to the category described in 

17 clause (ii) of paragraph (2)(A). 

18 ‘‘(III) CLINICAL PRACTICE IM19 PROVEMENT ACTIVITIES.—Fifteen 

20 percent of such score shall be based 

21 on performance with respect to the 

22 category described in clause (iii) of 

23 paragraph (2)(A). 

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1 five percent of such score shall be 

2 based on performance with respect to 

3 the category described in clause (iv) of 

4 paragraph (2)(A). 

5 ‘‘(ii) AUTHORITY TO ADJUST PER6 CENTAGES IN CASE OF HIGH EHR MEAN7 INGFUL USE ADOPTION.—In any year in 

8 which the Secretary estimates that the pro9 portion of eligible professionals (as defined 

10 in subsection (o)(5)) who are meaningful 

11 EHR users (as determined under sub12 section (o)(2)) is 75 percent or greater, the 

13 Secretary may reduce the percent applica14 ble under clause (i)(IV), but not below 15 

15 percent. If the Secretary makes such re16 duction for a year, subject to subclauses 

17 (I)(bb) and (II)(bb) of clause (i), the per18 centages applicable under one or more of 

19 subclauses (I), (II), and (III) of clause (i) 

20 for such year shall be increased in a man21 ner such that the total percentage points 

22 of the increase under this clause for such 

23 year equals the total number of percentage 

24 points reduced under the preceding sen25 tence for such year. 


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1 ‘‘(F) CERTAIN FLEXIBILITY FOR

2 WEIGHTING PERFORMANCE CATEGORIES, MEAS3 URES, AND ACTIVITIES.—Under the method4 ology under subparagraph (A), if there are not 

5 sufficient measures and clinical practice im6 provement activities applicable and available to 

7 each type of eligible professional involved, the 

8 Secretary shall assign different scoring weights 

9 (including a weight of 0)— 

10 ‘‘(i) which may vary from the scoring 

11 weights specified in subparagraph (E), for 

12 each performance category based on the 

13 extent to which the category is applicable 

14 to the type of eligible professional involved; 

15 and 

16 ‘‘(ii) for each measure and activity 

17 specified under paragraph (2)(B) with re18 spect to each such category based on the 

19 extent to which the measure or activity is 

20 applicable and available to the type of eli21 gible professional involved. 

22 ‘‘(G) RESOURCE USE.—Analysis of the 

23 performance category described in paragraph 

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1 ology described in subsection (r)(5), as appro2 priate. 

3 ‘‘(H) INCLUSION OF QUALITY MEASURE

4 DATA FROM OTHER PAYERS.—In applying sub5 sections (k), (m), and (p) with respect to meas6 ures described in paragraph (2)(B)(i), analysis 

7 of the performance category described in para8 graph (2)(A)(i) may include data submitted by 

9 MIPS eligible professionals with respect to 

10 items and services furnished to individuals who 

11 are not individuals entitled to benefits under 

12 part A or enrolled under part B. 

13 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

14 FOR CERTAIN ASSESSMENT PURPOSES.— 

15 ‘‘(i) IN GENERAL.—In the case of 

16 MIPS eligible professionals electing to be a 

17 virtual group under clause (ii) with respect 

18 to a performance period for a year, for 

19 purposes of applying the methodology 

20 under subparagraph (A)— 

21 ‘‘(I) the assessment of perform22 ance provided under such methodology 

23 with respect to the performance cat24 egories described in clauses (i) and 

25 (ii) of paragraph (2)(A) that is to be 


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1 applied to each such professional in 

2 such group for such performance pe3 riod shall be with respect to the com4 bined performance of all such profes5 sionals in such group for such period; 

6 and 

7 ‘‘(II) the composite score pro8 vided under this paragraph for such 

9 performance period with respect to 

10 each such performance category for 

11 each such MIPS eligible professional 

12 in such virtual group shall be based 

13 on the assessment of the combined 

14 performance under subclause (I) for 

15 the performance category and per16 formance period. 

17 ‘‘(ii) ELECTION OF PRACTICES TO BE

18 A VIRTUAL GROUP.—The Secretary shall, 

19 in accordance with clause (iii), establish 

20 and have in place a process to allow an in21 dividual MIPS eligible professional or a 

22 group practice consisting of not more than 

23 10 MIPS eligible professionals to elect, 

24 with respect to a performance period for a 

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1 fessional or all such MIPS eligible profes2 sionals in such group practice, respectively, 

3 to be a virtual group under this subpara4 graph with at least one other such indi5 vidual MIPS eligible professional or group 

6 practice making such an election. Such a 

7 virtual group may be based on geographic 

8 areas or on provider specialties defined by 

9 nationally recognized multispecialty boards 

10 of certification or equivalent certification 

11 boards and such other eligible professional 

12 groupings in order to capture classifica13 tions of providers across eligible profes14 sional organizations and other practice 

15 areas or categories. 

16 ‘‘(iii) REQUIREMENTS.—The process 

17 under clause (ii)— 

18 ‘‘(I) shall provide that an election 

19 under such clause, with respect to a 

20 performance period, shall be made be21 fore or during the beginning of such 

22 performance period and may not be 

23 changed during such performance pe24 riod; 


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1 ‘‘(II) shall provide that a practice 

2 described in such clause, and each 

3 MIPS eligible professional in such 

4 practice, may elect to be in no more 

5 than one virtual group for a perform6 ance period; and 

7 ‘‘(III) may provide that a virtual 

8 group may be combined at the tax 

9 identification number level. 

10 ‘‘(6) MIPS PAYMENTS.— 

11 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak12 ing into account paragraph (1)(G), the Sec13 retary shall specify a MIPS adjustment factor 

14 for each MIPS eligible professional for a year. 

15 Such MIPS adjustment factor for a MIPS eligi16 ble professional for a year shall be in the form 

17 of a percent and shall be determined— 

18 ‘‘(i) by comparing the composite per19 formance score of the eligible professional 

20 for such year to the performance threshold 

21 established under subparagraph (D)(i) for 

22 such year; 

23 ‘‘(ii) in a manner such that the ad24 justment factors specified under this sub25 paragraph for a year result in differential 


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1 payments under this paragraph reflecting 

2 that— 

3 ‘‘(I) MIPS eligible professionals 

4 with composite performance scores for 

5 such year at or above such perform6 ance threshold for such year receive 

7 zero or positive incentive payment ad8 justment factors for such year in ac9 cordance with clause (iii), with such 

10 professionals having higher composite 

11 performance scores receiving higher 

12 adjustment factors; and 

13 ‘‘(II) MIPS eligible professionals 

14 with composite performance scores for 

15 such year below such performance 

16 threshold for such year receive nega17 tive payment adjustment factors for 

18 such year in accordance with clause 

19 (iv), with such professionals having 

20 lower composite performance scores 

21 receiving lower adjustment factors; 

22 ‘‘(iii) in a manner such that MIPS eli23 gible professionals with composite scores 

24 described in clause (ii)(I) for such year, 

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1 graph (F), receive a zero or positive ad2 justment factor on a linear sliding scale 

3 such that an adjustment factor of 0 per4 cent is assigned for a score at the perform5 ance threshold and an adjustment factor of 

6 the applicable percent specified in subpara7 graph (B) is assigned for a score of 100; 

8 and 

9 ‘‘(iv) in a manner such that— 

10 ‘‘(I) subject to subclause (II), 

11 MIPS eligible professionals with com12 posite performance scores described in 

13 clause (ii)(II) for such year receive a 

14 negative payment adjustment factor 

15 on a linear sliding scale such that an 

16 adjustment factor of 0 percent is as17 signed for a score at the performance 

18 threshold and an adjustment factor of 

19 the negative of the applicable percent 

20 specified in subparagraph (B) is as21 signed for a score of 0; and 

22 ‘‘(II) MIPS eligible professionals 

23 with composite performance scores 

24 that are equal to or greater than 0, 

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1 formance threshold specified under 

2 subparagraph (D)(i) for such year, re3 ceive a negative payment adjustment 

4 factor that is equal to the negative of 

5 the applicable percent specified in 

6 subparagraph (B) for such year. 

7 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

8 For purposes of this paragraph, the term ‘ap9 plicable percent’ means— 

10 ‘‘(i) for 2018, 4 percent; 

11 ‘‘(ii) for 2019, 5 percent; 

12 ‘‘(iii) for 2020, 7 percent; and 

13 ‘‘(iv) for 2021 and subsequent years, 

14 9 percent. 

15 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC16 TORS FOR EXCEPTIONAL PERFORMANCE.— 

17 ‘‘(i) IN GENERAL.—In the case of a 

18 MIPS eligible professional with a com19 posite performance score for a year at or 

20 above the additional performance threshold 

21 under subparagraph (D)(ii) for such year, 

22 in addition to the MIPS adjustment factor 

23 under subparagraph (A) for the eligible 

24 professional for such year, subject to the 

25 availability of funds under clause (ii), the 


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1 Secretary shall specify an additional posi2 tive MIPS adjustment factor for such pro3 fessional and year. Such additional MIPS 

4 adjustment factors shall be determined by 

5 the Secretary in a manner such that pro6 fessionals having higher composite per7 formance scores above the additional per8 formance threshold receive higher addi9 tional MIPS adjustment factors. 

10 ‘‘(ii) ADDITIONAL FUNDING POOL.— 

11 For 2018 and each subsequent year 

12 through 2023, there is appropriated from 

13 the Federal Supplementary Medical Insur14 ance Trust Fund $500,000,000 for MIPS 

15 payments under this paragraph resulting 

16 from the application of the additional 

17 MIPS adjustment factors under clause (i). 

18 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

19 THRESHOLDS.— 

20 ‘‘(i) PERFORMANCE THRESHOLD.— 

21 For each year of the MIPS, the Secretary 

22 shall compute a performance threshold 

23 with respect to which the composite per24 formance score of MIPS eligible profes25 sionals shall be compared for purposes of 


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1 determining adjustment factors under sub2 paragraph (A) that are positive, negative, 

3 and zero. Such performance threshold for 

4 a year shall be the mean or median (as se5 lected by the Secretary) of the composite 

6 performance scores for all MIPS eligible 

7 professionals with respect to a prior period 

8 specified by the Secretary. The Secretary 

9 may reassess the selection under the pre10 vious sentence every 3 years. 

11 ‘‘(ii) ADDITIONAL PERFORMANCE

12 THRESHOLD FOR EXCEPTIONAL PERFORM13 ANCE.—In addition to the performance 

14 threshold under clause (i), for each year of 

15 the MIPS, the Secretary shall compute an 

16 additional performance threshold for pur17 poses of determining the additional MIPS 

18 adjustment factors under subparagraph 

19 (C)(i). For each such year, the Secretary 

20 shall apply either of the following methods 

21 for computing such additional performance 

22 threshold for such a year: 

23 ‘‘(I) The threshold shall be the 

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1 posite performance scores above the 

2 performance threshold with respect to 

3 the prior period described in clause 

4 (i). 

5 ‘‘(II) The threshold shall be the 

6 score that is equal to the 25th per7 centile of the actual composite per8 formance scores for MIPS eligible 

9 professionals with composite perform10 ance scores at or above the perform11 ance threshold with respect to the 

12 prior period described in clause (i). 

13 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

14 YEARS.—With respect to each of the first 

15 two years to which the MIPS applies, the 

16 Secretary shall, prior to the performance 

17 period for such years, establish a perform18 ance threshold for purposes of determining 

19 MIPS adjustment factors under subpara20 graph (A) and a threshold for purposes of 

21 determining additional MIPS adjustment 

22 factors under subparagraph (C)(i). Each 

23 such performance threshold shall— 

24 ‘‘(I) be based on a period prior to 

25 such performance periods; and 


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1 ‘‘(II) take into account— 

2 ‘‘(aa) data available with re3 spect to performance on meas4 ures and activities that may be 

5 used under the performance cat6 egories under subparagraph 

7 (2)(B); and 

8 ‘‘(bb) other factors deter9 mined appropriate by the Sec10 retary. 

11 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

12 FACTORS.—In the case of items and services 

13 furnished by a MIPS eligible professional dur14 ing a year (beginning with 2018), the amount 

15 otherwise paid under this part with respect to 

16 such items and services and MIPS eligible pro17 fessional for such year, shall be multiplied by— 

18 ‘‘(i) 1, plus 

19 ‘‘(ii) the sum of— 

20 ‘‘(I) the MIPS adjustment factor 

21 determined under subparagraph (A) 

22 divided by 100, and 

23 ‘‘(II) as applicable, the additional 

24 MIPS adjustment factor determined 


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1 under subparagraph (C)(i) divided by 

2 100. 

3 ‘‘(F) AGGREGATE APPLICATION OF MIPS

4 ADJUSTMENT FACTORS.— 

5 ‘‘(i) APPLICATION OF SCALING FAC6 TOR.— 

7 ‘‘(I) IN GENERAL.—With respect 

8 to positive MIPS adjustment factors 

9 under subparagraph (A)(ii)(I) for eli10 gible professionals whose composite 

11 performance score is above the per12 formance threshold under subpara13 graph (D)(i) for such year, subject to 

14 subclause (II), the Secretary shall in15 crease or decrease such adjustment 

16 factors by a scaling factor in order to 

17 ensure that the budget neutrality re18 quirement of clause (ii) is met. 

19 ‘‘(II) SCALING FACTOR LIMIT.— 

20 In no case may be the scaling factor 

21 applied under this clause exceed 3.0. 

22 ‘‘(ii) BUDGET NEUTRALITY REQUIRE23 MENT.— 

24 ‘‘(I) IN GENERAL.—Subject to 

25 clause (iii), the Secretary shall ensure 


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1 that the estimated amount described 

2 in subclause (II) for a year is equal to 

3 the estimated amount described in 

4 subclause (III) for such year. 

5 ‘‘(II) AGGREGATE INCREASES.— 

6 The amount described in this sub7 clause is the estimated increase in the 

8 aggregate allowed charges resulting 

9 from the application of positive MIPS 

10 adjustment factors under subpara11 graph (A) (after application of the 

12 scaling factor described in clause (i)) 

13 to MIPS eligible professionals whose 

14 composite performance score for a 

15 year is above the performance thresh16 old under subparagraph (D)(i) for 

17 such year. 

18 ‘‘(III) AGGREGATE DE19 CREASES.—The amount described in 

20 this subclause is the estimated de21 crease in the aggregate allowed 

22 charges resulting from the application 

23 of negative MIPS adjustment factors 

24 under subparagraph (A) to MIPS eli25 gible professionals whose composite 


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1 performance score for a year is below 

2 the performance threshold under sub3 paragraph (D)(i) for such year. 

4 ‘‘(iii) EXCEPTIONS.— 

5 ‘‘(I) In the case that all MIPS el6 igible professionals receive composite 

7 performance scores for a year that are 

8 below the performance threshold 

9 under subparagraph (D)(i) for such 

10 year, the negative MIPS adjustment 

11 factors under subparagraph (A) shall 

12 apply with respect to such MIPS eligi13 ble professionals and the budget neu14 trality requirement of clause (ii) shall 

15 not apply for such year. 

16 ‘‘(II) In the case that, with re17 spect to a year, the application of 

18 clause (i) results in a scaling factor 

19 equal to the maximum scaling factor 

20 specified in clause (i)(II), such scaling 

21 factor shall apply and the budget neu22 trality requirement of clause (ii) shall 

23 not apply for such year. 

24 ‘‘(iv) ADDITIONAL INCENTIVE PAY25 MENT ADJUSTMENTS.—In specifying the 


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1 MIPS additional adjustment factors under 

2 subparagraph (C)(i) for each applicable 

3 MIPS eligible professional for a year, the 

4 Secretary shall ensure that the estimated 

5 increase in payments under this part re6 sulting from the application of such addi7 tional adjustment factors for MIPS eligible 

8 professionals in a year shall be equal (as 

9 estimated by the Secretary) to the addi10 tional funding pool amount for such year 

11 under subparagraph (C)(ii). 

12 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST13 MENTS.—Under the MIPS, the Secretary shall, not 

14 later than 30 days prior to January 1 of the year 

15 involved, make available to MIPS eligible profes16 sionals the MIPS adjustment factor (and, as appli17 cable, the additional MIPS adjustment factor) under 

18 paragraph (6) applicable to the eligible professional 

19 for items and services furnished by the professional 

20 for such year. The Secretary may include such infor21 mation in the confidential feedback under paragraph 

22 (12). 

23 ‘‘(8) NO EFFECT IN SUBSEQUENT YEARS.—The 

24 MIPS adjustment factors and additional MIPS ad25 justment factors under paragraph (6) shall apply 


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1 only with respect to the year involved, and the Sec2 retary shall not take into account such adjustment 

3 factors in making payments to a MIPS eligible pro4 fessional under this part in a subsequent year. 

5 ‘‘(9) PUBLIC REPORTING.— 

6 ‘‘(A) IN GENERAL.—The Secretary shall, 

7 in an easily understandable format, make avail8 able on the Physician Compare Internet website 

9 of the Centers for Medicare & Medicaid Serv10 ices the following: 

11 ‘‘(i) Information regarding the per12 formance of MIPS eligible professionals 

13 under the MIPS, which— 

14 ‘‘(I) shall include the composite 

15 score for each such MIPS eligible pro16 fessional and the performance of each 

17 such MIPS eligible professional with 

18 respect to each performance category; 

19 and 

20 ‘‘(II) may include the perform21 ance of each such MIPS eligible pro22 fessional with respect to each measure 

23 or activity specified in paragraph 

24 (2)(B). 


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1 ‘‘(ii) The names of eligible profes2 sionals in eligible alternative payment mod3 els (as defined in section 1833(z)(3)(D)) 

4 and, to the extent feasible, the names of 

5 such eligible alternative payment models 

6 and performance of such models. 

7 ‘‘(B) DISCLOSURE.—The information 

8 made available under this paragraph shall indi9 cate, where appropriate, that publicized infor10 mation may not be representative of the eligible 

11 professional’s entire patient population, the va12 riety of services furnished by the eligible profes13 sional, or the health conditions of individuals 

14 treated. 

15 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB16 MIT CORRECTIONS.—The Secretary shall pro17 vide for an opportunity for a professional de18 scribed in subparagraph (A) to review, and sub19 mit corrections for, the information to be made 

20 public with respect to the professional under 

21 such subparagraph prior to such information 

22 being made public. 

23 ‘‘(D) AGGREGATE INFORMATION.—The 

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1 mation on the MIPS, including the range of 

2 composite scores for all MIPS eligible profes3 sionals and the range of the performance of all 

4 MIPS eligible professionals with respect to each 

5 performance category. 

6 ‘‘(10) CONSULTATION.—The Secretary shall 

7 consult with stakeholders in carrying out the MIPS, 

8 including for the identification of measures and ac9 tivities under paragraph (2)(B) and the methodolo10 gies developed under paragraphs (5)(A) and (6) and 

11 regarding the use of qualified clinical data registries. 

12 Such consultation shall include the use of a request 

13 for information or other mechanisms determined ap14 propriate. 

15 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC16 TICES AND PRACTICES IN HEALTH PROFESSIONAL

17 SHORTAGE AREAS.— 

18 ‘‘(A) IN GENERAL.—The Secretary shall 

19 enter into contracts or agreements with appro20 priate entities (such as quality improvement or21 ganizations, regional extension centers (as de22 scribed in section 3012(c) of the Public Health 

23 Service Act), or regional health collaboratives) 

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1 fessionals (with priority given to such practices 

2 located in rural areas, health professional short3 age areas (as designated under in section 

4 332(a)(1)(A) of such Act), and medically under5 served areas, and practices with low composite 

6 scores) with respect to— 

7 ‘‘(i) the performance categories de8 scribed in clauses (i) through (iv) of para9 graph (2)(A); or 

10 ‘‘(ii) how to transition to the imple11 mentation of and participation in an alter12 native payment model as described in sec13 tion 1833(z)(3)(C). 

14 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 

15 ‘‘(i) IN GENERAL.—For purposes of 

16 implementing subparagraph (A), the Sec17 retary shall provide for the transfer from 

18 the Federal Supplementary Medical Insur19 ance Trust Fund established under section 

20 1841 to the Centers for Medicare & Med21 icaid Services Program Management Ac22 count of $40,000,000 for each of fiscal 

23 years 2015 through 2019. Amounts trans24 ferred under this subparagraph for a fiscal 

25 year shall be available until expended. 


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1 ‘‘(ii) TECHNICAL ASSISTANCE.—Of 

2 the amounts transferred pursuant to clause 

3 (i) for each of fiscal years 2015 through 

4 2019, not less than $10,000,000 shall be 

5 made available for each such year for tech6 nical assistance to small practices in health 

7 professional shortage areas (as so des8 ignated) and medically underserved areas. 

9 ‘‘(12) FEEDBACK AND INFORMATION TO IM10 PROVE PERFORMANCE.— 

11 ‘‘(A) PERFORMANCE FEEDBACK.— 

12 ‘‘(i) IN GENERAL.—Beginning July 1, 

13 2016, the Secretary— 

14 ‘‘(I) shall make available timely 

15 (such as quarterly) confidential feed16 back to MIPS eligible professionals on 

17 the performance of such professionals 

18 with respect to the performance cat19 egories under clauses (i) and (ii) of 

20 paragraph (2)(A); and 

21 ‘‘(II) may make available con22 fidential feedback to each such profes23 sional on the performance of such 

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1 formance categories under clauses (iii) 

2 and (iv) of such paragraph. 

3 ‘‘(ii) MECHANISMS.—The Secretary 

4 may use one or more mechanisms to make 

5 feedback available under clause (i), which 

6 may include use of a web-based portal or 

7 other mechanisms determined appropriate 

8 by the Secretary. With respect to the per9 formance category described in paragraph 

10 (2)(A)(i), feedback under this subpara11 graph shall, to the extent an eligible pro12 fessional chooses to participate in a data 

13 registry for purposes of this subsection (in14 cluding registries under subsections (k) 

15 and (m)), be provided based on perform16 ance on quality measures reported through 

17 the use of such registries. With respect to 

18 any other performance category described 

19 in paragraph (2)(A), the Secretary shall 

20 encourage provision of feedback through 

21 qualified clinical data registries as de22 scribed in subsection (m)(3)(E)). 

23 ‘‘(iii) USE OF DATA.—For purposes of 

24 clause (i), the Secretary may use data, 

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1 sional, from periods prior to the current 

2 performance period and may use rolling 

3 periods in order to make illustrative cal4 culations about the performance of such 

5 professional. 

6 ‘‘(iv) DISCLOSURE EXEMPTION.— 

7 Feedback made available under this sub8 paragraph shall be exempt from disclosure 

9 under section 552 of title 5, United States 

10 Code. 

11 ‘‘(v) RECEIPT OF INFORMATION.— 

12 The Secretary may use the mechanisms es13 tablished under clause (ii) to receive infor14 mation from professionals, such as infor15 mation with respect to this subsection. 

16 ‘‘(B) ADDITIONAL INFORMATION.— 

17 ‘‘(i) IN GENERAL.—Beginning July 1, 

18 2017, the Secretary shall make available to 

19 each MIPS eligible professional informa20 tion, with respect to individuals who are 

21 patients of such MIPS eligible professional, 

22 about items and services for which pay23 ment is made under this title that are fur24 nished to such individuals by other sup25 pliers and providers of services, which may 


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1 include information described in clause (ii). 

2 Such information may be made available 

3 under the previous sentence to such MIPS 

4 eligible professionals by mechanisms deter5 mined appropriate by the Secretary, which 

6 may include use of a web-based portal. 

7 Such information may be made available in 

8 accordance with the same or similar terms 

9 as data are made available to accountable 

10 care organizations participating in the 

11 shared savings program under section 

12 1899, including a beneficiary opt-out. 

13 ‘‘(ii) TYPE OF INFORMATION.—For 

14 purposes of clause (i), the information de15 scribed in this clause, is the following: 

16 ‘‘(I) With respect to selected 

17 items and services (as determined ap18 propriate by the Secretary) for which 

19 payment is made under this title and 

20 that are furnished to individuals, who 

21 are patients of a MIPS eligible profes22 sional, by another supplier or provider 

23 of services during the most recent pe24 riod for which data are available (such 

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1 riod), such as the name of such pro2 viders furnishing such items and serv3 ices to such patients during such pe4 riod, the types of such items and serv5 ices so furnished, and the dates such 

6 items and services were so furnished. 

7 ‘‘(II) Historical data, such as 

8 averages and other measures of the 

9 distribution if appropriate, of the 

10 total, and components of, allowed 

11 charges (and other figures as deter12 mined appropriate by the Secretary). 

13 ‘‘(13) REVIEW.— 

14 ‘‘(A) TARGETED REVIEW.—The Secretary 

15 shall establish a process under which a MIPS 

16 eligible professional may seek an informal re17 view of the calculation of the MIPS adjustment 

18 factor applicable to such eligible professional 

19 under this subsection for a year. The results of 

20 a review conducted pursuant to the previous 

21 sentence shall not be taken into account for 

22 purposes of paragraph (6) with respect to a 

23 year (other than with respect to the calculation 

24 of such eligible professional’s MIPS adjustment 

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1 ment factor for such year) after the factors de2 termined in subparagraph (A) and subpara3 graph (C) of such paragraph have been deter4 mined for such year. 

5 ‘‘(B) LIMITATION.—Except as provided for 

6 in subparagraph (A), there shall be no adminis7 trative or judicial review under section 1869, 

8 section 1878, or otherwise of the following: 

9 ‘‘(i) The methodology used to deter10 mine the amount of the MIPS adjustment 

11 factor under paragraph (6)(A) and the 

12 amount of the additional MIPS adjustment 

13 factor under paragraph (6)(C)(i) and the 

14 determination of such amounts. 

15 ‘‘(ii) The establishment of the per16 formance standards under paragraph (3) 

17 and the performance period under para18 graph (4). 

19 ‘‘(iii) The identification of measures 

20 and activities specified under paragraph 

21 (2)(B) and information made public or 

22 posted on the Physician Compare Internet 

23 website of the Centers for Medicare & 

24 Medicaid Services under paragraph (9). 


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1 ‘‘(iv) The methodology developed 

2 under paragraph (5) that is used to cal3 culate performance scores and the calcula4 tion of such scores, including the weighting 

5 of measures and activities under such 

6 methodology.’’. 

7 (2) GAO REPORTS.— 

8 (A) EVALUATION OF ELIGIBLE PROFES9 SIONAL MIPS.—Not later than October 1, 2019, 

10 and October 1, 2022, the Comptroller General 

11 of the United States shall submit to Congress 

12 a report evaluating the eligible professional 

13 Merit-based Incentive Payment System under 

14 subsection (q) of section 1848 of the Social Se15 curity Act (42 U.S.C. 1395w–4), as added by 

16 paragraph (1). Such report shall— 

17 (i) examine the distribution of the 

18 composite performance scores and MIPS 

19 adjustment factors (and additional MIPS 

20 adjustment factors) for MIPS eligible pro21 fessionals (as defined in subsection 

22 (q)(1)(c) of such section) under such pro23 gram, and patterns relating to such scores 

24 and adjustment factors, including based on 


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1 type of provider, practice size, geographic 

2 location, and patient mix; 

3 (ii) provide recommendations for im4 proving such program; 

5 (iii) evaluate the impact of technical 

6 assistance funding under section 

7 1848(q)(11) of the Social Security Act, as 

8 added by paragraph (1), on the ability of 

9 professionals to improve within such pro10 gram or successfully transition to an alter11 native payment model (as defined in sec12 tion 1833(z)(3) of the Social Security Act, 

13 as added by subsection (e)), with priority 

14 for such evaluation given to practices lo15 cated in rural areas, health professional 

16 shortage areas (as designated in section 

17 332(a)(1)(a) of the Public Health Service 

18 Act), and medically underserved areas; and 

19 (iv) provide recommendations for opti20 mizing the use of such technical assistance 

21 funds. 

22 (B) STUDY TO EXAMINE ALIGNMENT OF

23 QUALITY MEASURES USED IN PUBLIC AND PRI24 VATE PROGRAMS.— 


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1 (i) IN GENERAL.—Not later than 18 

2 months after the date of the enactment of 

3 this Act, the Comptroller General of the 

4 United States shall submit to Congress a 

5 report that— 

6 (I) compares the similarities and 

7 differences in the use of quality meas8 ures under the original Medicare fee9 for-service program under parts A and 

10 B of title XVIII of the Social Security 

11 Act, the Medicare Advantage program 

12 under part C of such title, selected 

13 State Medicaid programs under title 

14 XIX of such Act, and private payer 

15 arrangements; and 

16 (II) makes recommendations on 

17 how to reduce the administrative bur18 den involved in applying such quality 

19 measures. 

20 (ii) REQUIREMENTS.—The report 

21 under clause (i) shall— 

22 (I) consider those measures ap23 plicable to individuals entitled to, or 

24 enrolled for, benefits under such part 


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1 A, or enrolled under such part B and 

2 individuals under the age of 65; and 

3 (II) focus on those measures that 

4 comprise the most significant compo5 nent of the quality performance cat6 egory of the eligible professional 

7 MIPS incentive program under sub8 section (q) of section 1848 of the So9 cial Security Act (42 U.S.C. 1395w– 

10 4), as added by paragraph (1). 

11 (C) STUDY ON ROLE OF INDEPENDENT

12 RISK MANAGERS.—Not later than January 1, 

13 2016, the Comptroller General of the United 

14 States shall submit to Congress a report exam15 ining whether entities that pool financial risk 

16 for physician practices, such as independent 

17 risk managers, can play a role in supporting 

18 physician practices, particularly small physician 

19 practices, in assuming financial risk for the 

20 treatment of patients. Such report shall exam21 ine barriers that small physician practices cur22 rently face in assuming financial risk for treat23 ing patients, the types of risk management enti24 ties that could assist physician practices in par25 ticipating in two-sided risk payment models, 


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1 and how such entities could assist with risk 

2 management and with quality improvement ac3 tivities. Such report shall also include an anal4 ysis of any existing legal barriers to such ar5 rangements. 

6 (D) STUDY TO EXAMINE RURAL AND

7 HEALTH PROFESSIONAL SHORTAGE AREA AL8 TERNATIVE PAYMENT MODELS.—Not later than 

9 October 1, 2020, and October 1, 2022, the 

10 Comptroller General of the United States shall 

11 submit to Congress a report that examines the 

12 transition of professionals in rural areas, health 

13 professional shortage areas (as designated in 

14 section 332(a)(1)(A) of the Public Health Serv15 ice Act), or medically underserved areas to an 

16 alternative payment model (as defined in sec17 tion 1833(z)(3) of the Social Security Act, as 

18 added by subsection (e)). Such report shall 

19 make recommendations for removing adminis20 trative barriers to practices, including small 

21 practices consisting of 15 or fewer profes22 sionals, in rural areas, health professional 

23 shortage areas, and medically underserved areas 

24 to participation in such models. 


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1 (3) FUNDING FOR IMPLEMENTATION.—For 

2 purposes of implementing the provisions of and the 

3 amendments made by this section, the Secretary of 

4 Health and Human Services shall provide for the 

5 transfer of $80,000,000 from the Supplementary 

6 Medical Insurance Trust Fund established under 

7 section 1841 of the Social Security Act (42 U.S.C. 

8 1395t) to the Centers for Medicare & Medicaid Pro9 gram Management Account for each of the fiscal 

10 years 2014 through 2018. Amounts transferred 

11 under this paragraph shall be available until ex12 pended. 

13 (d) IMPROVING QUALITY REPORTING FOR COM14 POSITE SCORES.— 

15 (1) CHANGES FOR GROUP REPORTING OP16 TION.— 

17 (A) IN GENERAL.—Section 

18 1848(m)(3)(C)(ii) of the Social Security Act 

19 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

20 by inserting ‘‘and, for 2015 and subsequent 

21 years, may provide’’ after ‘‘shall provide’’. 

22 (B) CLARIFICATION OF QUALIFIED CLIN23 ICAL DATA REGISTRY REPORTING TO GROUP

24 PRACTICES.—Section 1848(m)(3)(D) of the So25 cial Security Act (42 U.S.C. 1395w– 


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1 4(m)(3)(D)) is amended by inserting ‘‘and, for 

2 2015 and subsequent years, subparagraph (A) 

3 or (C)’’ after ‘‘subparagraph (A)’’. 

4 (2) CHANGES FOR MULTIPLE REPORTING PERI5 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC6 TORY REPORTING.—Section 1848(m)(5)(F) of the 

7 Social Security Act (42 U.S.C. 1395w–4(m)(5)(F)) 

8 is amended— 

9 (A) by striking ‘‘and subsequent years’’ 

10 and inserting ‘‘through reporting periods occur11 ring in 2014’’; and 

12 (B) by inserting ‘‘and, for reporting peri13 ods occurring in 2015 and subsequent years, 

14 the Secretary may establish’’ following ‘‘shall 

15 establish’’. 

16 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

17 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

18 1848(n) of the Social Security Act (42 U.S.C. 

19 1395w–4(n)) is amended by adding at the end the 

20 following new paragraph: 

21 ‘‘(11) REPORTS ENDING WITH 2016.—Reports 

22 under the Program shall not be provided after De23 cember 31, 2016. See subsection (q)(12) for reports 

24 under the eligible professionals Merit-based Incentive 

25 Payment System.’’. 


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1 (4) COORDINATION WITH SATISFYING MEANING2 FUL EHR USE CLINICAL QUALITY MEASURE REPORT3 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

4 the Social Security Act (42 U.S.C. 1395w– 

5 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub6 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara7 graph (B)(ii)’’. 

8 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

9 (1) INCREASING TRANSPARENCY OF PHYSICIAN

10 FOCUSED PAYMENT MODELS.—Section 1868 of the 

11 Social Security Act (42 U.S.C. 1395ee) is amended 

12 by adding at the end the following new subsection: 

13 ‘‘(c) PHYSICIAN FOCUSED PAYMENT MODELS.— 

14 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 

15 ‘‘(A) ESTABLISHMENT.—There is estab16 lished an ad hoc committee to be known as the 

17 ‘Payment Model Technical Advisory Committee’ 

18 (referred to in this subsection as the ‘Com19 mittee’). 

20 ‘‘(B) MEMBERSHIP.— 

21 ‘‘(i) NUMBER AND APPOINTMENT.— 

22 The Committee shall be composed of 11 

23 members appointed by the Comptroller 

24 General of the United States. 


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1 ‘‘(ii) QUALIFICATIONS.—The member2 ship of the Committee shall include indi3 viduals with national recognition for their 

4 expertise in payment models and related 

5 delivery of care. No more than 5 members 

6 of the Committee shall be providers of 

7 services or suppliers, or representatives of 

8 providers of services or suppliers. 

9 ‘‘(iii) PROHIBITION ON FEDERAL EM10 PLOYMENT.—A member of the Committee 

11 shall not be an employee of the Federal 

12 Government. 

13 ‘‘(iv) ETHICS DISCLOSURE.—The 

14 Comptroller General shall establish a sys15 tem for public disclosure by members of 

16 the Committee of financial and other po17 tential conflicts of interest relating to such 

18 members. Members of the Committee shall 

19 be treated as employees of Congress for 

20 purposes of applying title I of the Ethics 

21 in Government Act of 1978 (Public Law 

22 95–521). 

23 ‘‘(v) DATE OF INITIAL APPOINT24 MENTS.—The initial appointments of mem25 bers of the Committee shall be made by 


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1 not later than 180 days after the date of 

2 enactment of this subsection. 

3 ‘‘(C) TERM; VACANCIES.— 

4 ‘‘(i) TERM.—The terms of members of 

5 the Committee shall be for 3 years except 

6 that the Comptroller General shall des7 ignate staggered terms for the members 

8 first appointed. 

9 ‘‘(ii) VACANCIES.—Any member ap10 pointed to fill a vacancy occurring before 

11 the expiration of the term for which the 

12 member’s predecessor was appointed shall 

13 be appointed only for the remainder of that 

14 term. A member may serve after the expi15 ration of that member’s term until a suc16 cessor has taken office. A vacancy in the 

17 Committee shall be filled in the manner in 

18 which the original appointment was made. 

19 ‘‘(D) DUTIES.—The Committee shall meet, 

20 as needed, to provide comments and rec21 ommendations to the Secretary, as described in 

22 paragraph (2)(C), on physician-focused pay23 ment models. 

24 ‘‘(E) COMPENSATION OF MEMBERS.— 


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1 ‘‘(i) IN GENERAL.—Except as pro2 vided in clause (ii), a member of the Com3 mittee shall serve without compensation. 

4 ‘‘(ii) TRAVEL EXPENSES.—A member 

5 of the Committee shall be allowed travel 

6 expenses, including per diem in lieu of sub7 sistence, at rates authorized for an em8 ployee of an agency under subchapter I of 

9 chapter 57 of title 5, United States Code, 

10 while away from the home or regular place 

11 of business of the member in the perform12 ance of the duties of the Committee. 

13 ‘‘(F) OPERATIONAL AND TECHNICAL SUP14 PORT.— 

15 ‘‘(i) IN GENERAL.—The Assistant 

16 Secretary for Planning and Evaluation 

17 shall provide technical and operational sup18 port for the Committee, which may be by 

19 use of a contractor. The Office of the Ac20 tuary of the Centers for Medicare & Med21 icaid Services shall provide to the Com22 mittee actuarial assistance as needed. 

23 ‘‘(ii) FUNDING.—The Secretary shall 

24 provide for the transfer, from the Federal 

25 Supplementary Medical Insurance Trust 


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1 Fund under section 1841, such amounts as 

2 are necessary to carry out clause (i) (not 

3 to exceed $5,000,000) for fiscal year 2014 

4 and each subsequent fiscal year. Any 

5 amounts transferred under the preceding 

6 sentence for a fiscal year shall remain 

7 available until expended. 

8 ‘‘(G) APPLICATION.—Section 14 of the 

9 Federal Advisory Committee Act (5 U.S.C. 

10 App.) shall not apply to the Committee. 

11 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

12 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

13 MODELS.— 

14 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN15 FOCUSED PAYMENT MODELS.— 

16 ‘‘(i) RULEMAKING.—Not later than 

17 November 1, 2015, the Secretary shall, 

18 through notice and comment rulemaking, 

19 following a request for information, estab20 lish criteria for physician-focused payment 

21 models, including models for specialist phy22 sicians, that could be used by the Com23 mittee for making comments and rec24 ommendations pursuant to paragraph 

25 (1)(D). 


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1 ‘‘(ii) MEDPAC SUBMISSION OF COM2 MENTS.—During the comment period for 

3 the proposed rule described in clause (i), 

4 the Medicare Payment Advisory Commis5 sion may submit comments to the Sec6 retary on the proposed criteria under such 

7 clause. 

8 ‘‘(iii) UPDATING.—The Secretary may 

9 update the criteria established under this 

10 subparagraph through rulemaking. 

11 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY12 SICIAN FOCUSED PAYMENT MODELS.—On an 

13 ongoing basis, individuals and stakeholder enti14 ties may submit to the Committee proposals for 

15 physician-focused payment models that such in16 dividuals and entities believe meet the criteria 

17 described in subparagraph (A). 

18 ‘‘(C) TAC REVIEW OF MODELS SUB19 MITTED.—The Committee shall, on a periodic 

20 basis, review models submitted under subpara21 graph (B), prepare comments and recommenda22 tions regarding whether such models meet the 

23 criteria described in subparagraph (A), and 

24 submit such comments and recommendations to 

25 the Secretary. 


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1 ‘‘(D) SECRETARY REVIEW AND RE2 SPONSE.—The Secretary shall review the com3 ments and recommendations submitted by the 

4 Committee under subparagraph (C) and post a 

5 detailed response to such comments and rec6 ommendations on the Internet Website of the 

7 Centers for Medicare & Medicaid Services. 

8 ‘‘(3) RULE OF CONSTRUCTION.—Nothing in 

9 this subsection shall be construed to impact the de10 velopment or testing of models under this title or ti11 tles XI, XIX, or XXI.’’. 

12 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

13 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

14 Section 1833 of the Social Security Act (42 U.S.C. 

15 1395l) is amended by adding at the end the fol16 lowing new subsection: 

17 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

18 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

19 ‘‘(1) PAYMENT INCENTIVE.— 

20 ‘‘(A) IN GENERAL.—In the case of covered 

21 professional services furnished by an eligible 

22 professional during a year that is in the period 

23 beginning with 2018 and ending with 2023 and 

24 for which the professional is a qualifying APM 

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1 ment that would otherwise be made for such 

2 covered professional services under this part for 

3 such year, there also shall be paid to such pro4 fessional an amount equal to 5 percent of the 

5 payment amount for the covered professional 

6 services under this part for the preceding year. 

7 For purposes of the previous sentence, the pay8 ment amount for the preceding year may be an 

9 estimation for the full preceding year based on 

10 a period of such preceding year that is less than 

11 the full year. The Secretary shall establish poli12 cies to implement this subparagraph in cases 

13 where payment for covered professional services 

14 furnished by a qualifying APM participant in 

15 an alternative payment model is made to an en16 tity participating in the alternative payment 

17 model rather than directly to the qualifying 

18 APM participant. 

19 ‘‘(B) FORM OF PAYMENT.—Payments 

20 under this subsection shall be made in a lump 

21 sum, on an annual basis, as soon as practicable. 

22 ‘‘(C) TREATMENT OF PAYMENT INCEN23 TIVE.—Payments under this subsection shall 

24 not be taken into account for purposes of deter25 mining actual expenditures under an alternative 


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1 payment model and for purposes of determining 

2 or rebasing any benchmarks used under the al3 ternative payment model. 

4 ‘‘(D) COORDINATION.—The amount of the 

5 additional payment for an item or service under 

6 this subsection or subsection (m) shall be deter7 mined without regard to any additional pay8 ment for the item or service under subsection 

9 (m) and this subsection, respectively. The 

10 amount of the additional payment for an item 

11 or service under this subsection or subsection 

12 (x) shall be determined without regard to any 

13 additional payment for the item or service 

14 under subsection (x) and this subsection, re15 spectively. The amount of the additional pay16 ment for an item or service under this sub17 section or subsection (y) shall be determined 

18 without regard to any additional payment for 

19 the item or service under subsection (y) and 

20 this subsection, respectively. 

21 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur22 poses of this subsection, the term ‘qualifying APM 

23 participant’ means the following: 

24 ‘‘(A) 2018 AND 2019.—With respect to 

25 2018 and 2019, an eligible professional for 


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1 whom the Secretary determines that at least 25 

2 percent of payments under this part for covered 

3 professional services furnished by such profes4 sional during the most recent period for which 

5 data are available (which may be less than a 

6 year) were attributable to such services fur7 nished under this part through an entity that 

8 participates in an eligible alternative payment 

9 model with respect to such services. 

10 ‘‘(B) 2020 AND 2021.—With respect to 

11 2020 and 2021, an eligible professional de12 scribed in either of the following clauses: 

13 ‘‘(i) MEDICARE REVENUE THRESHOLD

14 OPTION.—An eligible professional for 

15 whom the Secretary determines that at 

16 least 50 percent of payments under this 

17 part for covered professional services fur18 nished by such professional during the 

19 most recent period for which data are 

20 available (which may be less than a year) 

21 were attributable to such services furnished 

22 under this part through an entity that par23 ticipates in an eligible alternative payment 

24 model with respect to such services. 


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1 ‘‘(ii) COMBINATION ALL-PAYER AND

2 MEDICARE REVENUE THRESHOLD OP3 TION.—An eligible professional— 

4 ‘‘(I) for whom the Secretary de5 termines, with respect to items and 

6 services furnished by such professional 

7 during the most recent period for 

8 which data are available (which may 

9 be less than a year), that at least 50 

10 percent of the sum of— 

11 ‘‘(aa) payments described in 

12 clause (i); and 

13 ‘‘(bb) all other payments, re14 gardless of payer (other than 

15 payments made by the Secretary 

16 of Defense or the Secretary of 

17 Veterans Affairs under chapter 

18 55 of title 10, United States 

19 Code, or title 38, United States 

20 Code, or any other provision of 

21 law, and other than payments 

22 made under title XIX in a State 

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1 able under the State program 

2 under that title), 

3 meet the requirement described in 

4 clause (iii)(I) with respect to pay5 ments described in item (aa) and meet 

6 the requirement described in clause 

7 (iii)(II) with respect to payments de8 scribed in item (bb); 

9 ‘‘(II) for whom the Secretary de10 termines at least 25 percent of pay11 ments under this part for covered pro12 fessional services furnished by such 

13 professional during the most recent 

14 period for which data are available 

15 (which may be less than a year) were 

16 attributable to such services furnished 

17 under this part through an entity that 

18 participates in an eligible alternative 

19 payment model with respect to such 

20 services; and 

21 ‘‘(III) who provides to the Sec22 retary such information as is nec23 essary for the Secretary to make a de24 termination under subclause (I), with 

25 respect to such professional. 


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1 ‘‘(iii) REQUIREMENT.—For purposes 

2 of clause (ii)(I)— 

3 ‘‘(I) the requirement described in 

4 this subclause, with respect to pay5 ments described in item (aa) of such 

6 clause, is that such payments are 

7 made under an eligible alternative 

8 payment model; and 

9 ‘‘(II) the requirement described 

10 in this subclause, with respect to pay11 ments described in item (bb) of such 

12 clause, is that such payments are 

13 made under an arrangement in 

14 which— 

15 ‘‘(aa) quality measures com16 parable to measures under the 

17 performance category described 

18 in section 1848(q)(2)(B)(i) apply; 

19 ‘‘(bb) certified EHR tech20 nology is used; and 

21 ‘‘(cc) the eligible profes22 sional (AA) bears more than 

23 nominal financial risk if actual 

24 aggregate expenditures exceeds 

25 expected aggregate expenditures; 


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1 or (BB) is a medical home (with 

2 respect to beneficiaries under 

3 title XIX) that meets criteria 

4 comparable to medical homes ex5 panded under section 1115A(c). 

6 ‘‘(C) BEGINNING IN 2022.—With respect to 

7 2022 and each subsequent year, an eligible pro8 fessional described in either of the following 

9 clauses: 

10 ‘‘(i) MEDICARE REVENUE THRESHOLD

11 OPTION.—An eligible professional for 

12 whom the Secretary determines that at 

13 least 75 percent of payments under this 

14 part for covered professional services fur15 nished by such professional during the 

16 most recent period for which data are 

17 available (which may be less than a year) 

18 were attributable to such services furnished 

19 under this part through an entity that par20 ticipates in an eligible alternative payment 

21 model with respect to such services. 

22 ‘‘(ii) COMBINATION ALL-PAYER AND

23 MEDICARE REVENUE THRESHOLD OP24 TION.—An eligible professional— 


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1 ‘‘(I) for whom the Secretary de2 termines, with respect to items and 

3 services furnished by such professional 

4 during the most recent period for 

5 which data are available (which may 

6 be less than a year), that at least 75 

7 percent of the sum of— 

8 ‘‘(aa) payments described in 

9 clause (i); and 

10 ‘‘(bb) all other payments, re11 gardless of payer (other than 

12 payments made by the Secretary 

13 of Defense or the Secretary of 

14 Veterans Affairs under chapter 

15 55 of title 10, United States 

16 Code, or title 38, United States 

17 Code, or any other provision of 

18 law, and other than payments 

19 made under title XIX in a State 

20 in which no medical home or al21 ternative payment model is avail22 able under the State program 

23 under that title), 

24 meet the requirement described in 

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1 ments described in item (aa) and meet 

2 the requirement described in clause 

3 (iii)(II) with respect to payments de4 scribed in item (bb); 

5 ‘‘(II) for whom the Secretary de6 termines at least 25 percent of pay7 ments under this part for covered pro8 fessional services furnished by such 

9 professional during the most recent 

10 period for which data are available 

11 (which may be less than a year) were 

12 attributable to such services furnished 

13 under this part through an entity that 

14 participates in an eligible alternative 

15 payment model with respect to such 

16 services; and 

17 ‘‘(III) who provides to the Sec18 retary such information as is nec19 essary for the Secretary to make a de20 termination under subclause (I), with 

21 respect to such professional. 

22 ‘‘(iii) REQUIREMENT.—For purposes 

23 of clause (ii)(I)— 

24 ‘‘(I) the requirement described in 

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1 ments described in item (aa) of such 

2 clause, is that such payments are 

3 made under an eligible alternative 

4 payment model; and 

5 ‘‘(II) the requirement described 

6 in this subclause, with respect to pay7 ments described in item (bb) of such 

8 clause, is that such payments are 

9 made under an arrangement in 

10 which— 

11 ‘‘(aa) quality measures com12 parable to measures under the 

13 performance category described 

14 in section 1848(q)(2)(B)(i) apply; 

15 ‘‘(bb) certified EHR tech16 nology is used; and 

17 ‘‘(cc) the eligible profes18 sional (AA) bears more than 

19 nominal financial risk if actual 

20 aggregate expenditures exceeds 

21 expected aggregate expenditures; 

22 or (BB) is a medical home (with 

23 respect to beneficiaries under 

24 title XIX) that meets criteria 


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1 comparable to medical homes ex2 panded under section 1115A(c). 

3 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub4 section: 

5 ‘‘(A) COVERED PROFESSIONAL SERV6 ICES.—The term ‘covered professional services’ 

7 has the meaning given that term in section 

8 1848(k)(3)(A). 

9 ‘‘(B) ELIGIBLE PROFESSIONAL.—The term 

10 ‘eligible professional’ has the meaning given 

11 that term in section 1848(k)(3)(B). 

12 ‘‘(C) ALTERNATIVE PAYMENT MODEL

13 (APM).—The term ‘alternative payment model’ 

14 means any of the following: 

15 ‘‘(i) A model under section 1115A 

16 (other than a health care innovation 

17 award). 

18 ‘‘(ii) The shared savings program 

19 under section 1899. 

20 ‘‘(iii) A demonstration under section 

21 1866C. 

22 ‘‘(iv) A demonstration required by 

23 Federal law. 

24 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

25 MODEL (APM).— 


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1 ‘‘(i) IN GENERAL.—The term ‘eligible 

2 alternative payment model’ means, with re3 spect to a year, an alternative payment 

4 model— 

5 ‘‘(I) that requires use of certified 

6 EHR technology (as defined in sub7 section (o)(4)); 

8 ‘‘(II) that provides for payment 

9 for covered professional services based 

10 on quality measures comparable to 

11 measures under the performance cat12 egory described in section 

13 1848(q)(2)(B)(i); and 

14 ‘‘(III) that satisfies the require15 ment described in clause (ii). 

16 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

17 For purposes of clause (i)(III), the require18 ment described in this clause, with respect 

19 to a year and an alternative payment 

20 model, is that the alternative payment 

21 model— 

22 ‘‘(I) is one in which one or more 

23 entities bear financial risk for mone24 tary losses under such model that are 

25 in excess of a nominal amount; or 


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1 ‘‘(II) is a medical home expanded 

2 under section 1115A(c). 

3 ‘‘(4) LIMITATION.—There shall be no adminis4 trative or judicial review under section 1869, 1878, 

5 or otherwise, of the following: 

6 ‘‘(A) The determination that an eligible 

7 professional is a qualifying APM participant 

8 under paragraph (2) and the determination 

9 that an alternative payment model is an eligible 

10 alternative payment model under paragraph 

11 (3)(D). 

12 ‘‘(B) The determination of the amount of 

13 the 5 percent payment incentive under para14 graph (1)(A), including any estimation as part 

15 of such determination.’’. 

16 (3) COORDINATION CONFORMING AMEND17 MENTS.—Section 1833 of the Social Security Act 

18 (42 U.S.C. 1395l) is further amended— 

19 (A) in subsection (x)(3), by adding at the 

20 end the following new sentence: ‘‘The amount 

21 of the additional payment for a service under 

22 this subsection and subsection (z) shall be de23 termined without regard to any additional pay24 ment for the service under subsection (z) and 

25 this subsection, respectively.’’; and 


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1 (B) in subsection (y)(3), by adding at the 

2 end the following new sentence: ‘‘The amount 

3 of the additional payment for a service under 

4 this subsection and subsection (z) shall be de5 termined without regard to any additional pay6 ment for the service under subsection (z) and 

7 this subsection, respectively.’’. 

8 (4) ENCOURAGING DEVELOPMENT AND TEST9 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

10 the Social Security Act (42 U.S.C. 1315a(b)(2)) is 

11 amended— 

12 (A) in subparagraph (B), by adding at the 

13 end the following new clauses: 

14 ‘‘(xxi) Focusing primarily on physi15 cians’ services (as defined in section 

16 1848(j)(3)) furnished by physicians who 

17 are not primary care practitioners. 

18 ‘‘(xxii) Focusing on practices of 15 or 

19 fewer professionals. 

20 ‘‘(xxiii) Focusing on risk-based models 

21 for small physician practices which may in22 volve two-sided risk and prospective patient 

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1 pital readmissions rates, and other relevant 

2 and appropriate clinical measures. 

3 ‘‘(xxiv) Focusing primarily on title 

4 XIX, working in conjunction with the Cen5 ter for Medicaid and CHIP Services.’’; and 

6 (B) in subparagraph (C)(viii), by striking 

7 ‘‘other public sector or private sector payers’’ 

8 and inserting ‘‘other public sector payers, pri9 vate sector payers, or Statewide payment mod10 els’’. 

11 (5) CONSTRUCTION REGARDING TELEHEALTH

12 SERVICES.—Nothing in the provisions of, or amend13 ments made by, this Act shall be construed as pre14 cluding an alternative payment model or a qualifying 

15 APM participant (as those terms are defined in sec16 tion 1833(z) of the Social Security Act, as added by 

17 paragraph (1)) from furnishing a telehealth service 

18 for which payment is not made under section 

19 1834(m) of the Social Security Act (42 U.S.C. 

20 1395m(m)). 

21 (6) INTEGRATING MEDICARE ADVANTAGE AL22 TERNATIVE PAYMENT MODELS.—Not later than July 

23 1, 2015, the Secretary of Health and Human Serv24 ices shall submit to Congress a study that examines 

25 the feasibility of integrating alternative payment 


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1 models in the Medicare Advantage payment system. 

2 The study shall include the feasibility of including a 

3 value-based modifier and whether such modifier 

4 should be budget neutral. 

5 (7) STUDY AND REPORT ON FRAUD RELATED

6 TO ALTERNATIVE PAYMENT MODELS UNDER THE

7 MEDICARE PROGRAM.— 

8 (A) STUDY.—The Secretary of Health and 

9 Human Services, in consultation with the In10 spector General of the Department of Health 

11 and Human Services, shall conduct a study 

12 that— 

13 (i) examines the applicability of the 

14 Federal fraud prevention laws to items and 

15 services furnished under title XVIII of the 

16 Social Security Act for which payment is 

17 made under an alternative payment model 

18 (as defined in section 1833(z)(3)(C) of 

19 such Act (42 U.S.C. 1395l(z)(3)(C))); 

20 (ii) identifies aspects of such alter21 native payment models that are vulnerable 

22 to fraudulent activity; and 

23 (iii) examines the implications of waiv24 ers to such laws granted in support of such 

25 alternative payment models, including 


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1 under any potential expansion of such 

2 models. 

3 (B) REPORT.—Not later than 2 years after 

4 the date of the enactment of this Act, the Sec5 retary shall submit to Congress a report con6 taining the results of the study conducted under 

7 subparagraph (A). Such report shall include 

8 recommendations for actions to be taken to re9 duce the vulnerability of such alternative pay10 ment models to fraudulent activity. Such report 

11 also shall include, as appropriate, recommenda12 tions of the Inspector General for changes in 

13 Federal fraud prevention laws to reduce such 

14 vulnerability. 

15 (f) IMPROVING PAYMENT ACCURACY.— 

16 (1) STUDIES AND REPORTS OF EFFECT OF CER17 TAIN INFORMATION ON QUALITY AND RESOURCE

18 USE.— 

19 (A) STUDY USING EXISTING MEDICARE

20 DATA.— 

21 (i) STUDY.—The Secretary of Health 

22 and Human Services (in this subsection re23 ferred to as the ‘‘Secretary’’) shall conduct 

24 a study that examines the effect of individ25 uals’ socioeconomic status on quality and 


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1 resource use outcome measures for individ2 uals under the Medicare program (such as 

3 to recognize that less healthy individuals 

4 may require more intensive interventions). 

5 The study shall use information collected 

6 on such individuals in carrying out such 

7 program, such as urban and rural location, 

8 eligibility for Medicaid (recognizing and ac9 counting for varying Medicaid eligibility 

10 across States), and eligibility for benefits 

11 under the supplemental security income 

12 (SSI) program. The Secretary shall carry 

13 out this paragraph acting through the As14 sistant Secretary for Planning and Evalua15 tion. 

16 (ii) REPORT.—Not later than 2 years 

17 after the date of the enactment of this Act, 

18 the Secretary shall submit to Congress a 

19 report on the study conducted under clause 

20 (i). 

21 (B) STUDY USING OTHER DATA.— 

22 (i) STUDY.—The Secretary shall con23 duct a study that examines the impact of 

24 risk factors, such as those described in sec25 tion 1848(p)(3) of the Social Security Act 


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1 (42 U.S.C. 1395w–4(p)(3)), race, health 

2 literacy, limited English proficiency (LEP), 

3 and patient activation, on quality and re4 source use outcome measures under the 

5 Medicare program (such as to recognize 

6 that less healthy individuals may require 

7 more intensive interventions). In con8 ducting such study the Secretary may use 

9 existing Federal data and collect such ad10 ditional data as may be necessary to com11 plete the study. 

12 (ii) REPORT.—Not later than 5 years 

13 after the date of the enactment of this Act, 

14 the Secretary shall submit to Congress a 

15 report on the study conducted under clause 

16 (i). 

17 (C) EXAMINATION OF DATA IN CON18 DUCTING STUDIES.—In conducting the studies 

19 under subparagraphs (A) and (B), the Sec20 retary shall examine what non-Medicare data 

21 sets, such as data from the American Commu22 nity Survey (ACS), can be useful in conducting 

23 the types of studies under such paragraphs and 

24 how such data sets that are identified as useful 

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1 tive data in order to improve the overall data 

2 set available to do such studies and for the ad3 ministration of the Medicare program. 

4 (D) RECOMMENDATIONS TO ACCOUNT FOR

5 INFORMATION IN PAYMENT ADJUSTMENT

6 MECHANISMS.—If the studies conducted under 

7 subparagraphs (A) and (B) find a relationship 

8 between the factors examined in the studies and 

9 quality and resource use outcome measures, 

10 then the Secretary shall also provide rec11 ommendations for how the Centers for Medicare 

12 & Medicaid Services should— 

13 (i) obtain access to the necessary data 

14 (if such data is not already being collected) 

15 on such factors, including recommenda16 tions on how to address barriers to the 

17 Centers in accessing such data; and 

18 (ii) account for such factors in deter19 mining payment adjustments based on 

20 quality and resource use outcome measures 

21 under the eligible professional Merit-based 

22 Incentive Payment System under section 

23 1848(q) of the Social Security Act (42 

24 U.S.C. 1395w–4(q)) and, as the Secretary 


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1 determines appropriate, other similar pro2 visions of title XVIII of such Act. 

3 (E) FUNDING.—There are hereby appro4 priated from the Federal Supplementary Med5 ical Insurance Trust Fund under section 1841 

6 of the Social Security Act to the Secretary to 

7 carry out this paragraph $6,000,000, to remain 

8 available until expended. 

9 (2) CMS ACTIVITIES.— 

10 (A) HIERARCHAL CONDITION CATEGORY

11 (HCC) IMPROVEMENT.—Taking into account the 

12 relevant studies conducted and recommenda13 tions made in reports under paragraph (1), the 

14 Secretary, on an ongoing basis, shall, as the 

15 Secretary determines appropriate, estimate how 

16 an individual’s health status and other risk fac17 tors affect quality and resource use outcome 

18 measures and, as feasible, shall incorporate in19 formation from quality and resource use out20 come measurement (including care episode and 

21 patient condition groups) into provisions of title 

22 XVIII of the Social Security Act that are simi23 lar to the eligible professional Merit-based In24 centive Payment System under section 1848(q) 

25 of such Act. 


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1 (B) ACCOUNTING FOR OTHER FACTORS IN

2 PAYMENT ADJUSTMENT MECHANISMS.— 

3 (i) IN GENERAL.—Taking into ac4 count the studies conducted and rec5 ommendations made in reports under para6 graph (1) and other information as appro7 priate, the Secretary shall, as the Sec8 retary determines appropriate, account for 

9 identified factors with an effect on quality 

10 and resource use outcome measures when 

11 determining payment adjustment mecha12 nisms under provisions of title XVIII of 

13 the Social Security Act that are similar to 

14 the eligible professional Merit-based Incen15 tive Payment System under section 

16 1848(q) of such Act. 

17 (ii) ACCESSING DATA.—The Secretary 

18 shall collect or otherwise obtain access to 

19 the data necessary to carry out this para20 graph through existing and new data 

21 sources. 

22 (iii) PERIODIC ANALYSES.—The Sec23 retary shall carry out periodic analyses, at 

24 least every 3 years, based on the factors 


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1 referred to in clause (i) so as to monitor 

2 changes in possible relationships. 

3 (C) FUNDING.—There are hereby appro4 priated from the Federal Supplementary Med5 ical Insurance Trust Fund under section 1841 

6 of the Social Security Act to the Secretary to 

7 carry out this paragraph and the application of 

8 this paragraph to the Merit-based Incentive 

9 Payment System under section 1848(q) of such 

10 Act $10,000,000, to remain available until ex11 pended. 

12 (3) STRATEGIC PLAN FOR ACCESSING RACE

13 AND ETHNICITY DATA.—Not later than 18 months 

14 after the date of the enactment of this Act, the Sec15 retary shall develop and report to Congress on a 

16 strategic plan for collecting or otherwise accessing 

17 data on race and ethnicity for purposes of carrying 

18 out the eligible professional Merit-based Incentive 

19 Payment System under section 1848(q) of the Social 

20 Security Act and, as the Secretary determines ap21 propriate, other similar provisions of title XVIII of 

22 such Act. 

23 (g) COLLABORATING WITH THE PHYSICIAN, PRACTI24 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

25 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 


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1 of the Social Security Act (42 U.S.C. 1395w–4), as 

2 amended by subsection (c), is further amended by adding 

3 at the end the following new subsection: 

4 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC5 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

6 IMPROVE RESOURCE USE MEASUREMENT.— 

7 ‘‘(1) IN GENERAL.—In order to involve the phy8 sician, practitioner, and other stakeholder commu9 nities in enhancing the infrastructure for resource 

10 use measurement, including for purposes of the 

11 value-based performance incentive program under 

12 subsection (q) and alternative payment models under 

13 section 1833(z), the Secretary shall undertake the 

14 steps described in the succeeding provisions of this 

15 subsection. 

16 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA17 TIENT CONDITION GROUPS AND CLASSIFICATION

18 CODES.— 

19 ‘‘(A) IN GENERAL.—In order to classify 

20 similar patients into care episode groups and 

21 patient condition groups, the Secretary shall 

22 undertake the steps described in the succeeding 

23 provisions of this paragraph. 

24 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

25 EFFORTS TO DESIGN AN EPISODE GROUPER.— 


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1 Not later than 120 days after the date of the 

2 enactment of this subsection, the Secretary 

3 shall post on the Internet website of the Cen4 ters for Medicare & Medicaid Services a list of 

5 the episode groups developed pursuant to sub6 section (n)(9)(A) and related descriptive infor7 mation. 

8 ‘‘(C) STAKEHOLDER INPUT.—The Sec9 retary shall accept, through the date that is 60 

10 days after the day the Secretary posts the list 

11 pursuant to subparagraph (B), suggestions 

12 from physician specialty societies, applicable 

13 practitioner organizations, and other stake14 holders for episode groups in addition to those 

15 posted pursuant to such subparagraph, and 

16 specific clinical criteria and patient characteris17 tics to classify patients into— 

18 ‘‘(i) care episode groups; and 

19 ‘‘(ii) patient condition groups. 

20 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS21 SIFICATION CODES.— 

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1 ceived under subparagraph (C), the Sec2 retary shall— 

3 ‘‘(I) establish care episode groups 

4 and patient condition groups, which 

5 account for a target of an estimated 

2 6 ⁄3 of expenditures under parts A and 

7 B; and 

8 ‘‘(II) assign codes to such 

9 groups. 

10 ‘‘(ii) CARE EPISODE GROUPS.—In es11 tablishing the care episode groups under 

12 clause (i), the Secretary shall take into ac13 count— 

14 ‘‘(I) the patient’s clinical prob15 lems at the time items and services 

16 are furnished during an episode of 

17 care, such as the clinical conditions or 

18 diagnoses, whether or not inpatient 

19 hospitalization is anticipated or oc20 curs, and the principal procedures or 

21 services planned or furnished; and 

22 ‘‘(II) other factors determined 

23 appropriate by the Secretary. 

24 ‘‘(iii) PATIENT CONDITION GROUPS.— 

25 In establishing the patient condition 


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1 groups under clause (i), the Secretary shall 

2 take into account— 

3 ‘‘(I) the patient’s clinical history 

4 at the time of each medical visit, such 

5 as the patient’s combination of chron6 ic conditions, current health status, 

7 and recent significant history (such as 

8 hospitalization and major surgery dur9 ing a previous period, such as 3 

10 months); and 

11 ‘‘(II) other factors determined 

12 appropriate by the Secretary, such as 

13 eligibility status under this title (in14 cluding eligibility under section 

15 226(a), 226(b), or 226A, and dual eli16 gibility under this title and title XIX). 

17 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

18 CONDITION GROUPS AND CLASSIFICATION

19 CODES.—Not later than 180 days after the end 

20 of the comment period described in subpara21 graph (C), the Secretary shall post on the 

22 Internet website of the Centers for Medicare & 

23 Medicaid Services a draft list of the care epi24 sode and patient condition codes established 


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1 under subparagraph (D) (and the criteria and 

2 characteristics assigned to such code). 

3 ‘‘(F) SOLICITATION OF INPUT.—The Sec4 retary shall seek, through the date that is 60 

5 days after the Secretary posts the list pursuant 

6 to subparagraph (E), comments from physician 

7 specialty societies, applicable practitioner orga8 nizations, and other stakeholders, including rep9 resentatives of individuals entitled to benefits 

10 under part A or enrolled under this part, re11 garding the care episode and patient condition 

12 groups (and codes) posted under subparagraph 

13 (E). In seeking such comments, the Secretary 

14 shall use one or more mechanisms (other than 

15 notice and comment rulemaking) that may in16 clude use of open door forums, town hall meet17 ings, or other appropriate mechanisms. 

18 ‘‘(G) OPERATIONAL LIST OF CARE EPI19 SODE AND PATIENT CONDITION GROUPS AND

20 CODES.—Not later than 180 days after the end 

21 of the comment period described in subpara22 graph (F), taking into account the comments 

23 received under such subparagraph, the Sec24 retary shall post on the Internet website of the 

25 Centers for Medicare & Medicaid Services an 


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1 operational list of care episode and patient con2 dition codes (and the criteria and characteris3 tics assigned to such code). 

4 ‘‘(H) SUBSEQUENT REVISIONS.—Not later 

5 than November 1 of each year (beginning with 

6 2017), the Secretary shall, through rulemaking, 

7 make revisions to the operational lists of care 

8 episode and patient condition codes as the Sec9 retary determines may be appropriate. Such re10 visions may be based on experience, new infor11 mation developed pursuant to subsection 

12 (n)(9)(A), and input from the physician spe13 cialty societies, applicable practitioner organiza14 tions, and other stakeholders, including rep15 resentatives of individuals entitled to benefits 

16 under part A or enrolled under this part. 

17 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI18 CIANS OR PRACTITIONERS.— 

19 ‘‘(A) IN GENERAL.—In order to facilitate 

20 the attribution of patients and episodes (in 

21 whole or in part) to one or more physicians or 

22 applicable practitioners furnishing items and 

23 services, the Secretary shall undertake the steps 

24 described in the succeeding provisions of this 

25 paragraph. 


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1 ‘‘(B) DEVELOPMENT OF PATIENT RELA2 TIONSHIP CATEGORIES AND CODES.—The Sec3 retary shall develop patient relationship cat4 egories and codes that define and distinguish 

5 the relationship and responsibility of a physi6 cian or applicable practitioner with a patient at 

7 the time of furnishing an item or service. Such 

8 patient relationship categories shall include dif9 ferent relationships of the physician or applica10 ble practitioner to the patient (and the codes 

11 may reflect combinations of such categories), 

12 such as a physician or applicable practitioner 

13 who— 

14 ‘‘(i) considers themself to have the 

15 primary responsibility for the general and 

16 ongoing care for the patient over extended 

17 periods of time; 

18 ‘‘(ii) considers themself to be the lead 

19 physician or practitioner and who furnishes 

20 items and services and coordinates care 

21 furnished by other physicians or practi22 tioners for the patient during an acute epi23 sode; 

24 ‘‘(iii) furnishes items and services to 

25 the patient on a continuing basis during an 


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1 acute episode of care, but in a supportive 

2 rather than a lead role; 

3 ‘‘(iv) furnishes items and services to 

4 the patient on an occasional basis, usually 

5 at the request of another physician or 

6 practitioner; or 

7 ‘‘(v) furnishes items and services only 

8 as ordered by another physician or practi9 tioner. 

10 ‘‘(C) DRAFT LIST OF PATIENT RELATION11 SHIP CATEGORIES AND CODES.—Not later than 

12 270 days after the date of the enactment of this 

13 subsection, the Secretary shall post on the 

14 Internet website of the Centers for Medicare & 

15 Medicaid Services a draft list of the patient re16 lationship categories and codes developed under 

17 subparagraph (B). 

18 ‘‘(D) STAKEHOLDER INPUT.—The Sec19 retary shall seek, through the date that is 60 

20 days after the Secretary posts the list pursuant 

21 to subparagraph (C), comments from physician 

22 specialty societies, applicable practitioner orga23 nizations, and other stakeholders, including rep24 resentatives of individuals entitled to benefits 

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1 garding the patient relationship categories and 

2 codes posted under subparagraph (C). In seek3 ing such comments, the Secretary shall use one 

4 or more mechanisms (other than notice and 

5 comment rulemaking) that may include open 

6 door forums, town hall meetings, or other ap7 propriate mechanisms. 

8 ‘‘(E) OPERATIONAL LIST OF PATIENT RE9 LATIONSHIP CATEGORIES AND CODES.—Not 

10 later than 180 days after the end of the com11 ment period described in subparagraph (D), 

12 taking into account the comments received 

13 under such subparagraph, the Secretary shall 

14 post on the Internet website of the Centers for 

15 Medicare & Medicaid Services an operational 

16 list of patient relationship categories and codes. 

17 ‘‘(F) SUBSEQUENT REVISIONS.—Not later 

18 than November 1 of each year (beginning with 

19 2017), the Secretary shall, through rulemaking, 

20 make revisions to the operational list of patient 

21 relationship categories and codes as the Sec22 retary determines appropriate. Such revisions 

23 may be based on experience, new information 

24 developed pursuant to subsection (n)(9)(A), and 

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1 plicable practitioner organizations, and other 

2 stakeholders, including representatives of indi3 viduals entitled to benefits under part A or en4 rolled under this part. 

5 ‘‘(4) REPORTING OF INFORMATION FOR RE6 SOURCE USE MEASUREMENT.—Claims submitted for 

7 items and services furnished by a physician or appli8 cable practitioner on or after January 1, 2017, shall, 

9 as determined appropriate by the Secretary, in10 clude— 

11 ‘‘(A) applicable codes established under 

12 paragraphs (2) and (3); and 

13 ‘‘(B) the national provider identifier of the 

14 ordering physician or applicable practitioner (if 

15 different from the billing physician or applicable 

16 practitioner). 

17 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL18 YSIS.— 

19 ‘‘(A) IN GENERAL.—In order to evaluate 

20 the resources used to treat patients (with re21 spect to care episode and patient condition 

22 groups), the Secretary shall— 

23 ‘‘(i) use the patient relationship codes 

24 reported on claims pursuant to paragraph 

25 (4) to attribute patients (in whole or in 


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1 part) to one or more physicians and appli2 cable practitioners; 

3 ‘‘(ii) use the care episode and patient 

4 condition codes reported on claims pursu5 ant to paragraph (4) as a basis to compare 

6 similar patients and care episodes and pa7 tient condition groups; and 

8 ‘‘(iii) conduct an analysis of resource 

9 use (with respect to care episodes and pa10 tient condition groups of such patients), as 

11 the Secretary determines appropriate. 

12 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI13 CIANS AND PRACTITIONERS.—In conducting the 

14 analysis described in subparagraph (A)(iii) with 

15 respect to patients attributed to physicians and 

16 applicable practitioners, the Secretary shall, as 

17 feasible— 

18 ‘‘(i) use the claims data experience of 

19 such patients by patient condition codes 

20 during a common period, such as 12 

21 months; and 

22 ‘‘(ii) use the claims data experience of 

23 such patients by care episode codes— 

24 ‘‘(I) in the case of episodes with25 out a hospitalization, during periods 


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1 of time (such as the number of days) 

2 determined appropriate by the Sec3 retary; and 

4 ‘‘(II) in the case of episodes with 

5 a hospitalization, during periods of 

6 time (such as the number of days) be7 fore, during, and after the hospitaliza8 tion. 

9 ‘‘(C) MEASUREMENT OF RESOURCE USE.— 

10 In measuring such resource use, the Sec11 retary— 

12 ‘‘(i) shall use per patient total allowed 

13 charges for all services under part A and 

14 this part (and, if the Secretary determines 

15 appropriate, part D) for the analysis of pa16 tient resource use, by care episode codes 

17 and by patient condition codes; and 

18 ‘‘(ii) may, as determined appropriate, 

19 use other measures of allowed charges 

20 (such as subtotals for categories of items 

21 and services) and measures of utilization of 

22 items and services (such as frequency of 

23 specific items and services and the ratio of 

24 specific items and services among attrib25 uted patients or episodes). 


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1 ‘‘(D) STAKEHOLDER INPUT.—The Sec2 retary shall seek comments from the physician 

3 specialty societies, applicable practitioner orga4 nizations, and other stakeholders, including rep5 resentatives of individuals entitled to benefits 

6 under part A or enrolled under this part, re7 garding the resource use methodology estab8 lished pursuant to this paragraph. In seeking 

9 comments the Secretary shall use one or more 

10 mechanisms (other than notice and comment 

11 rulemaking) that may include open door fo12 rums, town hall meetings, or other appropriate 

13 mechanisms. 

14 ‘‘(6) IMPLEMENTATION.—To the extent that 

15 the Secretary contracts with an entity to carry out 

16 any part of the provisions of this subsection, the 

17 Secretary may not contract with an entity or an en18 tity with a subcontract if the entity or subcon19 tracting entity currently makes recommendations to 

20 the Secretary on relative values for services under 

21 the fee schedule for physicians’ services under this 

22 section. 

23 ‘‘(7) LIMITATION.—There shall be no adminis24 trative or judicial review under section 1869, section 

25 1878, or otherwise of— 


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1 ‘‘(A) care episode and patient condition 

2 groups and codes established under paragraph 

3 (2); 

4 ‘‘(B) patient relationship categories and 

5 codes established under paragraph (3); and 

6 ‘‘(C) measurement of, and analyses of re7 source use with respect to, care episode and pa8 tient condition codes and patient relationship 

9 codes pursuant to paragraph (5). 

10 ‘‘(8) ADMINISTRATION.—Chapter 35 of title 44, 

11 United States Code, shall not apply to this section. 

12 ‘‘(9) DEFINITIONS.—In this section: 

13 ‘‘(A) PHYSICIAN.—The term ‘physician’ 

14 has the meaning given such term in section 

15 1861(r)(1). 

16 ‘‘(B) APPLICABLE PRACTITIONER.—The 

17 term ‘applicable practitioner’ means— 

18 ‘‘(i) a physician assistant, nurse prac19 titioner, and clinical nurse specialist (as 

20 such terms are defined in section 

21 1861(aa)(5)), and a certified registered 

22 nurse anesthetist (as defined in section 

23 1861(bb)(2)); and 

24 ‘‘(ii) beginning January 1, 2018, such 

25 other eligible professionals (as defined in 


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1 subsection (k)(3)(B)) as specified by the 

2 Secretary. 

3 ‘‘(10) CLARIFICATION.—The provisions of sec4 tions 1890(b)(7) and 1890A shall not apply to this 

5 subsection.’’. 

6 SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVEL7 OPMENT. 

8 Section 1848 of the Social Security Act (42 U.S.C. 

9 1395w–4), as amended by subsections (c) and (g) of sec10 tion 2, is further amended by inserting at the end the fol11 lowing new subsection: 

12 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE13 VELOPMENT.— 

14 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP15 MENT PRIORITIES AND TIMELINES.— 

16 ‘‘(A) DRAFT MEASURE DEVELOPMENT

17 PLAN.—Not later than January 1, 2015, the 

18 Secretary shall develop, and post on the Inter19 net website of the Centers for Medicare & Med20 icaid Services, a draft plan for the development 

21 of quality measures for application under the 

22 applicable provisions (as defined in paragraph 

23 (5)). Under such plan the Secretary shall— 

24 ‘‘(i) address how measures used by 

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1 tems could be incorporated under title 

2 XVIII; 

3 ‘‘(ii) describe how coordination, to the 

4 extent possible, will occur across organiza5 tions developing such measures; and 

6 ‘‘(iii) take into account how clinical 

7 best practices and clinical practice guide8 lines should be used in the development of 

9 quality measures. 

10 ‘‘(B) QUALITY DOMAINS.—For purposes of 

11 this subsection, the term ‘quality domains’ 

12 means at least the following domains: 

13 ‘‘(i) Clinical care. 

14 ‘‘(ii) Safety. 

15 ‘‘(iii) Care coordination. 

16 ‘‘(iv) Patient and caregiver experience. 

17 ‘‘(v) Population health and preven18 tion. 

19 ‘‘(C) CONSIDERATION.—In developing the 

20 draft plan under this paragraph, the Secretary 

21 shall consider— 

22 ‘‘(i) gap analyses conducted by the en23 tity with a contract under section 1890(a) 

24 or other contractors or entities; 


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1 ‘‘(ii) whether measures are applicable 

2 across health care settings; 

3 ‘‘(iii) clinical practice improvement ac4 tivities submitted under subsection 

5 (q)(2)(C)(iv) for identifying possible areas 

6 for future measure development and identi7 fying existing gaps with respect to such 

8 measures; and 

9 ‘‘(iv) the quality domains applied 

10 under this subsection. 

11 ‘‘(D) PRIORITIES.—In developing the draft 

12 plan under this paragraph, the Secretary shall 

13 give priority to the following types of measures: 

14 ‘‘(i) Outcome measures, including pa15 tient reported outcome and functional sta16 tus measures. 

17 ‘‘(ii) Patient experience measures. 

18 ‘‘(iii) Care coordination measures. 

19 ‘‘(iv) Measures of appropriate use of 

20 services, including measures of over use. 

21 ‘‘(E) STAKEHOLDER INPUT.—The Sec22 retary shall accept through March 1, 2015, 

23 comments on the draft plan posted under para24 graph (1)(A) from the public, including health 


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1 care providers, payers, consumers, and other 

2 stakeholders. 

3 ‘‘(F) FINAL MEASURE DEVELOPMENT

4 PLAN.—Not later than May 1, 2015, taking 

5 into account the comments received under this 

6 subparagraph, the Secretary shall finalize the 

7 plan and post on the Internet website of the 

8 Centers for Medicare & Medicaid Services an 

9 operational plan for the development of quality 

10 measures for use under the applicable provi11 sions. Such plan shall be updated as appro12 priate. 

13 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

14 FOR QUALITY MEASURE DEVELOPMENT.— 

15 ‘‘(A) IN GENERAL.—The Secretary shall 

16 enter into contracts or other arrangements with 

17 entities for the purpose of developing, improv18 ing, updating, or expanding in accordance with 

19 the plan under paragraph (1) quality measures 

20 for application under the applicable provisions. 

21 Such entities shall include organizations with 

22 quality measure development expertise. 

23 ‘‘(B) PRIORITIZATION.— 

24 ‘‘(i) IN GENERAL.—In entering into 

25 contracts or other arrangements under 


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1 subparagraph (A), the Secretary shall give 

2 priority to the development of the types of 

3 measures described in paragraph (1)(D). 

4 ‘‘(ii) CONSIDERATION.—In selecting 

5 measures for development under this sub6 section, the Secretary shall consider— 

7 ‘‘(I) whether such measures 

8 would be electronically specified; and 

9 ‘‘(II) clinical practice guidelines 

10 to the extent that such guidelines 

11 exist. 

12 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

13 ‘‘(A) IN GENERAL.—Not later than May 1, 

14 2016, and annually thereafter, the Secretary 

15 shall post on the Internet website of the Cen16 ters for Medicare & Medicaid Services a report 

17 on the progress made in developing quality 

18 measures for application under the applicable 

19 provisions. 

20 ‘‘(B) REQUIREMENTS.—Each report sub21 mitted pursuant to subparagraph (A) shall in22 clude the following: 

23 ‘‘(i) A description of the Secretary’s 

24 efforts to implement this paragraph. 


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1 ‘‘(ii) With respect to the measures de2 veloped during the previous year— 

3 ‘‘(I) a description of the total 

4 number of quality measures developed 

5 and the types of such measures, such 

6 as an outcome or patient experience 

7 measure; 

8 ‘‘(II) the name of each measure 

9 developed; 

10 ‘‘(III) the name of the developer 

11 and steward of each measure; 

12 ‘‘(IV) with respect to each type 

13 of measure, an estimate of the total 

14 amount expended under this title to 

15 develop all measures of such type; and 

16 ‘‘(V) whether the measure would 

17 be electronically specified. 

18 ‘‘(iii) With respect to measures in de19 velopment at the time of the report— 

20 ‘‘(I) the information described in 

21 clause (ii), if available; and 

22 ‘‘(II) a timeline for completion of 

23 the development of such measures. 

24 ‘‘(iv) A description of any updates to 

25 the plan under paragraph (1) (including 


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1 newly identified gaps and the status of pre2 viously identified gaps) and the inventory 

3 of measures applicable under the applicable 

4 provisions. 

5 ‘‘(v) Other information the Secretary 

6 determines to be appropriate. 

7 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

8 paragraph (1), the Secretary shall seek stakeholder 

9 input with respect to— 

10 ‘‘(A) the identification of gaps where no 

11 quality measures exist, particularly with respect 

12 to the types of measures described in paragraph 

13 (1)(D); 

14 ‘‘(B) prioritizing quality measure develop15 ment to address such gaps; and 

16 ‘‘(C) other areas related to quality measure 

17 development determined appropriate by the Sec18 retary. 

19 ‘‘(5) DEFINITION OF APPLICABLE PROVI20 SIONS.—In this subsection, the term ‘applicable pro21 visions’ means the following provisions: 

22 ‘‘(A) Subsection (q)(2)(B)(i). 

23 ‘‘(B) Section 1833(z)(2)(C). 

24 ‘‘(6) FUNDING.—For purposes of carrying out 

25 this subsection, the Secretary shall provide for the 


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1 transfer, from the Federal Supplementary Medical 

2 Insurance Trust Fund under section 1841, of 

3 $15,000,000 to the Centers for Medicare & Medicaid 

4 Services Program Management Account for each of 

5 fiscal years 2014 through 2018. Amounts trans6 ferred under this paragraph shall remain available 

7 through the end of fiscal year 2021.’’. 

8 SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVID9 UALS WITH CHRONIC CARE NEEDS. 

10 (a) IN GENERAL.—Section 1848(b) of the Social Se11 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

12 at the end the following new paragraph: 

13 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

14 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

15 ‘‘(A) IN GENERAL.—In order to encourage 

16 the management of care by an applicable pro17 vider (as defined in subparagraph (B)) for indi18 viduals with chronic care needs the Secretary 

19 shall— 

20 ‘‘(i) establish one or more HCPCS 

21 codes for chronic care management serv22 ices for such individuals; and 

23 ‘‘(ii) subject to subparagraph (D), 

24 make payment (as the Secretary deter25 mines to be appropriate) under this section 


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1 for such management services furnished on 

2 or after January 1, 2015, by an applicable 

3 provider. 

4 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

5 For purposes of this paragraph, the term ‘ap6 plicable provider’ means a physician (as defined 

7 in section 1861(r)(1)), physician assistant or 

8 nurse practitioner (as defined in section 

9 1861(aa)(5)(A)), or clinical nurse specialist (as 

10 defined in section 1861(aa)(5)(B)) who fur11 nishes services as part of a patient-centered 

12 medical home or a comparable specialty practice 

13 that— 

14 ‘‘(i) is recognized as such a medical 

15 home or comparable specialty practice by 

16 an organization that is recognized by the 

17 Secretary for purposes of such recognition 

18 as such a medical home or practice; or 

19 ‘‘(ii) meets such other comparable 

20 qualifications as the Secretary determines 

21 to be appropriate. 

22 ‘‘(C) BUDGET NEUTRALITY.—The budget 

23 neutrality provision under subsection 

24 (c)(2)(B)(ii)(II) shall apply in establishing the 

25 payment under subparagraph (A)(ii). 


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1 ‘‘(D) POLICIES RELATING TO PAYMENT.— 

2 In carrying out this paragraph, with respect to 

3 chronic care management services, the Sec4 retary shall— 

5 ‘‘(i) make payment to only one appli6 cable provider for such services furnished 

7 to an individual during a period; 

8 ‘‘(ii) not make payment under sub9 paragraph (A) if such payment would be 

10 duplicative of payment that is otherwise 

11 made under this title for such services 

12 (such as in the case of hospice care or 

13 home health services); and 

14 ‘‘(iii) not require that an annual 

15 wellness visit (as defined in section 

16 1861(hhh)) or an initial preventive phys17 ical examination (as defined in section 

18 1861(ww)) be furnished as a condition of 

19 payment for such management services.’’. 

20 (b) EDUCATION AND OUTREACH.— 

21 (1) CAMPAIGN.— 

22 (A) IN GENERAL.—The Secretary of 

23 Health and Human Services (in this subsection 

24 referred to as the ‘‘Secretary’’) shall conduct an 

25 education and outreach campaign to inform 


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1 professionals who furnish items and services 

2 under part B of title XVIII of the Social Secu3 rity Act and individuals enrolled under such 

4 part of the benefits of chronic care management 

5 services described in section 1848(b)(8) of the 

6 Social Security Act, as added by subsection (a), 

7 and encourage such individuals with chronic 

8 care needs to receive such services. 

9 (B) REQUIREMENTS.—Such campaign 

10 shall— 

11 (i) be directed by the Office of Rural 

12 Health Policy of the Department of Health 

13 and Human Services and the Office of Mi14 nority Health of the Centers for Medicare 

15 & Medicaid Services; and 

16 (ii) focus on encouraging participation 

17 by underserved rural populations and ra18 cial and ethnic minority populations. 

19 (2) REPORT.— 

20 (A) IN GENERAL.—Not later than Decem21 ber 31, 2017, the Secretary shall submit to 

22 Congress a report on the use of chronic care 

23 management services described in such section 

24 1848(b)(8) by individuals living in rural areas 


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1 and by racial and ethnic minority populations. 

2 Such report shall— 

3 (i) identify barriers to receiving chron4 ic care management services; and 

5 (ii) make recommendations for in6 creasing the appropriate use of chronic 

7 care management services. 

8 SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES 

9 UNDER THE PHYSICIAN FEE SCHEDULE. 

10 (a) AUTHORITY TO COLLECT AND USE INFORMA11 TION ON PHYSICIANS’ SERVICES IN THE DETERMINATION

12 OF RELATIVE VALUES.— 

13 (1) IN GENERAL.—Section 1848(c)(2) of the 

14 Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 

15 amended by adding at the end the following new 

16 subparagraph: 

17 ‘‘(M) AUTHORITY TO COLLECT AND USE

18 INFORMATION ON PHYSICIANS’ SERVICES IN

19 THE DETERMINATION OF RELATIVE VALUES.— 

20 ‘‘(i) COLLECTION OF INFORMATION.— 

21 Notwithstanding any other provision of 

22 law, the Secretary may collect or obtain in23 formation on the resources directly or indi24 rectly related to furnishing services for 

25 which payment is made under the fee 


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1 schedule established under subsection (b). 

2 Such information may be collected or ob3 tained from any eligible professional or any 

4 other source. 

5 ‘‘(ii) USE OF INFORMATION.—Not6 withstanding any other provision of law, 

7 subject to clause (v), the Secretary may 

8 (as the Secretary determines appropriate) 

9 use information collected or obtained pur10 suant to clause (i) in the determination of 

11 relative values for services under this sec12 tion. 

13 ‘‘(iii) TYPES OF INFORMATION.—The 

14 types of information described in clauses 

15 (i) and (ii) may, at the Secretary’s discre16 tion, include any or all of the following: 

17 ‘‘(I) Time involved in furnishing 

18 services. 

19 ‘‘(II) Amounts and types of prac20 tice expense inputs involved with fur21 nishing services. 

22 ‘‘(III) Prices (net of any dis23 counts) for practice expense inputs, 

24 which may include paid invoice prices 

25 or other documentation or records. 


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1 ‘‘(IV) Overhead and accounting 

2 information for practices of physicians 

3 and other suppliers. 

4 ‘‘(V) Any other element that 

5 would improve the valuation of serv6 ices under this section. 

7 ‘‘(iv) INFORMATION COLLECTION

8 MECHANISMS.—Information may be col9 lected or obtained pursuant to this sub10 paragraph from any or all of the following: 

11 ‘‘(I) Surveys of physicians, other 

12 suppliers, providers of services, manu13 facturers, and vendors. 

14 ‘‘(II) Surgical logs, billing sys15 tems, or other practice or facility 

16 records. 

17 ‘‘(III) Electronic health records. 

18 ‘‘(IV) Any other mechanism de19 termined appropriate by the Sec20 retary. 

21 ‘‘(v) TRANSPARENCY OF USE OF IN22 FORMATION.— 

23 ‘‘(I) IN GENERAL.—Subject to 

24 subclauses (II) and (III), if the Sec25 retary uses information collected or 


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1 obtained under this subparagraph in 

2 the determination of relative values 

3 under this subsection, the Secretary 

4 shall disclose the information source 

5 and discuss the use of such informa6 tion in such determination of relative 

7 values through notice and comment 

8 rulemaking. 

9 ‘‘(II) THRESHOLDS FOR USE.— 

10 The Secretary may establish thresh11 olds in order to use such information, 

12 including the exclusion of information 

13 collected or obtained from eligible pro14 fessionals who use very high resources 

15 (as determined by the Secretary) in 

16 furnishing a service. 

17 ‘‘(III) DISCLOSURE OF INFORMA18 TION.—The Secretary shall make ag19 gregate information available under 

20 this subparagraph but shall not dis21 close information in a form or manner 

22 that identifies an eligible professional 

23 or a group practice, or information 

24 collected or obtained pursuant to a 

25 nondisclosure agreement. 


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1 ‘‘(vi) INCENTIVE TO PARTICIPATE.— 

2 The Secretary may provide for such pay3 ments under this part to an eligible profes4 sional that submits such solicited informa5 tion under this subparagraph as the Sec6 retary determines appropriate in order to 

7 compensate such eligible professional for 

8 such submission. Such payments shall be 

9 provided in a form and manner specified 

10 by the Secretary. 

11 ‘‘(vii) ADMINISTRATION.—Chapter 35 

12 of title 44, United States Code, shall not 

13 apply to information collected or obtained 

14 under this subparagraph. 

15 ‘‘(viii) DEFINITION OF ELIGIBLE PRO16 FESSIONAL.—In this subparagraph, the 

17 term ‘eligible professional’ has the meaning 

18 given such term in subsection (k)(3)(B). 

19 ‘‘(ix) FUNDING.—For purposes of car20 rying out this subparagraph, in addition to 

21 funds otherwise appropriated, the Sec22 retary shall provide for the transfer, from 

23 the Federal Supplementary Medical Insur24 ance Trust Fund under section 1841, of 

25 $2,000,000 to the Centers for Medicare & 


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1 Medicaid Services Program Management 

2 Account for each fiscal year beginning with 

3 fiscal year 2014. Amounts transferred 

4 under the preceding sentence for a fiscal 

5 year shall be available until expended.’’. 

6 (2) LIMITATION ON REVIEW.—Section 

7 1848(i)(1) of the Social Security Act (42 U.S.C. 

8 1395w–4(i)(1)) is amended— 

9 (A) in subparagraph (D), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (E), by striking the 

12 period at the end and inserting ‘‘, and’’; and 

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(F) the collection and use of information 

16 in the determination of relative values under 

17 subsection (c)(2)(M).’’. 

18 (b) AUTHORITY FOR ALTERNATIVE APPROACHES TO

19 ESTABLISHING PRACTICE EXPENSE RELATIVE VAL20 UES.—Section 1848(c)(2) of the Social Security Act (42 

21 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

22 amended by adding at the end the following new subpara23 graph: 

24 ‘‘(N) AUTHORITY FOR ALTERNATIVE AP25 PROACHES TO ESTABLISHING PRACTICE EXVerDate Mar 15 2010 02:53 Feb 08, 2014 Jkt 039200 PO 00000 Frm 00138 Fmt 6652 Sfmt 6201 E:\BILLS\S2000.IS S2000

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1 PENSE RELATIVE VALUES.—The Secretary may 

2 establish or adjust practice expense relative val3 ues under this subsection using cost, charge, or 

4 other data from suppliers or providers of serv5 ices, including information collected or obtained 

6 under subparagraph (M).’’. 

7 (c) REVISED AND EXPANDED IDENTIFICATION OF

8 POTENTIALLY MISVALUED CODES.—Section 

9 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 

10 1395w–4(c)(2)(K)(ii)) is amended to read as follows: 

11 ‘‘(ii) IDENTIFICATION OF POTEN12 TIALLY MISVALUED CODES.—For purposes 

13 of identifying potentially misvalued codes 

14 pursuant to clause (i)(I), the Secretary 

15 shall examine codes (and families of codes 

16 as appropriate) based on any or all of the 

17 following criteria: 

18 ‘‘(I) Codes that have experienced 

19 the fastest growth. 

20 ‘‘(II) Codes that have experi21 enced substantial changes in practice 

22 expenses. 

23 ‘‘(III) Codes that describe new 

24 technologies or services within an ap25 propriate time period (such as 3 


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1 years) after the relative values are ini2 tially established for such codes. 

3 ‘‘(IV) Codes which are multiple 

4 codes that are frequently billed in con5 junction with furnishing a single serv6 ice. 

7 ‘‘(V) Codes with low relative val8 ues, particularly those that are often 

9 billed multiple times for a single treat10 ment. 

11 ‘‘(VI) Codes that have not been 

12 subject to review since implementation 

13 of the fee schedule. 

14 ‘‘(VII) Codes that account for 

15 the majority of spending under the 

16 physician fee schedule. 

17 ‘‘(VIII) Codes for services that 

18 have experienced a substantial change 

19 in the hospital length of stay or proce20 dure time. 

21 ‘‘(IX) Codes for which there may 

22 be a change in the typical site of serv23 ice since the code was last valued. 

24 ‘‘(X) Codes for which there is a 

25 significant difference in payment for 


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1 the same service between different 

2 sites of service. 

3 ‘‘(XI) Codes for which there may 

4 be anomalies in relative values within 

5 a family of codes. 

6 ‘‘(XII) Codes for services where 

7 there may be efficiencies when a serv8 ice is furnished at the same time as 

9 other services. 

10 ‘‘(XIII) Codes with high intra11 service work per unit of time. 

12 ‘‘(XIV) Codes with high practice 

13 expense relative value units. 

14 ‘‘(XV) Codes with high cost sup15 plies. 

16 ‘‘(XVI) Codes as determined ap17 propriate by the Secretary.’’. 

18 (d) TARGET FOR RELATIVE VALUE ADJUSTMENTS

19 FOR MISVALUED SERVICES.— 

20 (1) IN GENERAL.—Section 1848(c)(2) of the 

21 Social Security Act (42 U.S.C. 1395w–4(c)(2)), as 

22 amended by subsections (a) and (b), is amended by 

23 adding at the end the following new subparagraph: 

24 ‘‘(O) TARGET FOR RELATIVE VALUE AD25 JUSTMENTS FOR MISVALUED SERVICES.—With 


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1 respect to fee schedules established for each of 

2 2015 through 2018, the following shall apply: 

3 ‘‘(i) DETERMINATION OF NET REDUC4 TION IN EXPENDITURES.—For each year, 

5 the Secretary shall determine the esti6 mated net reduction in expenditures under 

7 the fee schedule under this section with re8 spect to the year as a result of adjust9 ments to the relative values established 

10 under this paragraph for misvalued codes. 

11 ‘‘(ii) BUDGET NEUTRAL REDISTRIBU12 TION OF FUNDS IF TARGET MET AND

13 COUNTING OVERAGES TOWARDS THE TAR14 GET FOR THE SUCCEEDING YEAR.—If the 

15 estimated net reduction in expenditures de16 termined under clause (i) for the year is 

17 equal to or greater than the target for the 

18 year— 

19 ‘‘(I) reduced expenditures attrib20 utable to such adjustments shall be 

21 redistributed for the year in a budget 

22 neutral manner in accordance with 

23 subparagraph (B)(ii)(II); and 

24 ‘‘(II) the amount by which such 

25 reduced expenditures exceeds the tarVerDate Mar 15 2010 02:53 Feb 08, 2014 Jkt 039200 PO 00000 Frm 00142 Fmt 6652 Sfmt 6201 E:\BILLS\S2000.IS S2000

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1 get for the year shall be treated as a 

2 reduction in expenditures described in 

3 clause (i) for the succeeding year, for 

4 purposes of determining whether the 

5 target has or has not been met under 

6 this subparagraph with respect to that 

7 year. 

8 ‘‘(iii) EXEMPTION FROM BUDGET

9 NEUTRALITY IF TARGET NOT MET.—If the 

10 estimated net reduction in expenditures de11 termined under clause (i) for the year is 

12 less than the target for the year, reduced 

13 expenditures in an amount equal to the 

14 target recapture amount shall not be taken 

15 into account in applying subparagraph 

16 (B)(ii)(II) with respect to fee schedules be17 ginning with 2015. 

18 ‘‘(iv) TARGET RECAPTURE AMOUNT.— 

19 For purposes of clause (iii), the target re20 capture amount is, with respect to a year, 

21 an amount equal to the difference be22 tween— 

23 ‘‘(I) the target for the year; and 


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1 ‘‘(II) the estimated net reduction 

2 in expenditures determined under 

3 clause (i) for the year. 

4 ‘‘(v) TARGET.—For purposes of this 

5 subparagraph, with respect to a year, the 

6 target is calculated as 0.5 percent of the 

7 estimated amount of expenditures under 

8 the fee schedule under this section for the 

9 year.’’. 

10 (2) CONFORMING AMENDMENT.—Section 

11 1848(c)(2)(B)(v) of the Social Security Act (42 

12 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by adding 

13 at the end the following new subclause: 

14 ‘‘(VIII) REDUCTIONS FOR

15 MISVALUED SERVICES IF TARGET NOT

16 MET.—Effective for fee schedules be17 ginning with 2015, reduced expendi18 tures attributable to the application of 

19 the target recapture amount described 

20 in subparagraph (O)(iii).’’. 

21 (e) PHASE-IN OF SIGNIFICANT RELATIVE VALUE

22 UNIT (RVU) REDUCTIONS.— 

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1 ed by adding at the end the following new para2 graph: 

3 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

4 VALUE UNIT (RVU) REDUCTIONS.—Effective for fee 

5 schedules established beginning with 2015, if the 

6 total relative value units for a service for a year 

7 would otherwise be decreased by an estimated 

8 amount equal to or greater than 20 percent as com9 pared to the total relative value units for the pre10 vious year, the applicable adjustments in work, prac11 tice expense, and malpractice relative value units 

12 shall be phased-in over a 2-year period.’’. 

13 (2) CONFORMING AMENDMENTS.—Section 

14 1848(c)(2) of the Social Security Act (42 U.S.C. 

15 1395w–4(c)(2)) is amended— 

16 (A) in subparagraph (B)(ii)(I), by striking 

17 ‘‘subclause (II)’’ and inserting ‘‘subclause (II) 

18 and paragraph (7)’’; and 

19 (B) in subparagraph (K)(iii)(VI)— 

20 (i) by striking ‘‘provisions of subpara21 graph (B)(ii)(II)’’ and inserting ‘‘provi22 sions of subparagraph (B)(ii)(II) and para23 graph (7)’’; and 


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1 (ii) by striking ‘‘under subparagraph 

2 (B)(ii)(II)’’ and inserting ‘‘under subpara3 graph (B)(ii)(I)’’. 

4 (f) AUTHORITY TO SMOOTH RELATIVE VALUES

5 WITHIN GROUPS OF SERVICES.—Section 1848(c)(2)(C) of 

6 the Social Security Act (42 U.S.C. 1395w–4(c)(2)(C)) is 

7 amended— 

8 (1) in each of clauses (i) and (iii), by striking 

9 ‘‘the service’’ and inserting ‘‘the service or group of 

10 services’’ each place it appears; and 

11 (2) in the first sentence of clause (ii), by insert12 ing ‘‘or group of services’’ before the period. 

13 (g) GAO STUDY AND REPORT ON RELATIVE VALUE

14 SCALE UPDATE COMMITTEE.— 

15 (1) STUDY.—The Comptroller General of the 

16 United States (in this subsection referred to as the 

17 ‘‘Comptroller General’’) shall conduct a study of the 

18 processes used by the Relative Value Scale Update 

19 Committee (RUC) to provide recommendations to 

20 the Secretary of Health and Human Services regard21 ing relative values for specific services under the 

22 Medicare physician fee schedule under section 1848 

23 of the Social Security Act (42 U.S.C. 1395w–4). 

24 (2) REPORT.—Not later than 1 year after the 

25 date of the enactment of this Act, the Comptroller 


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1 General shall submit to Congress a report containing 

2 the results of the study conducted under paragraph 

3 (1). 

4 (h) ADJUSTMENT TO MEDICARE PAYMENT LOCAL5 ITIES.— 

6 (1) IN GENERAL.—Section 1848(e) of the So7 cial Security Act (42 U.S.C. 1395w–4(e)) is amend8 ed by adding at the end the following new para9 graph: 

10 ‘‘(6) USE OF MSAS AS FEE SCHEDULE AREAS IN

11 CALIFORNIA.— 

12 ‘‘(A) IN GENERAL.—Subject to the suc13 ceeding provisions of this paragraph and not14 withstanding the previous provisions of this 

15 subsection, for services furnished on or after 

16 January 1, 2017, the fee schedule areas used 

17 for payment under this section applicable to 

18 California shall be the following: 

19 ‘‘(i) Each Metropolitan Statistical 

20 Area (each in this paragraph referred to as 

21 an ‘MSA’), as defined by the Director of 

22 the Office of Management and Budget as 

23 of December 31 of the previous year, shall 

24 be a fee schedule area. 


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1 ‘‘(ii) All areas not included in an MSA 

2 shall be treated as a single rest-of-State 

3 fee schedule area. 

4 ‘‘(B) TRANSITION FOR MSAS PREVIOUSLY

5 IN REST-OF-STATE PAYMENT LOCALITY OR IN

6 LOCALITY 3.— 

7 ‘‘(i) IN GENERAL.—For services fur8 nished in California during a year begin9 ning with 2017 and ending with 2021 in 

10 an MSA in a transition area (as defined in 

11 subparagraph (D)), subject to subpara12 graph (C), the geographic index values to 

13 be applied under this subsection for such 

14 year shall be equal to the sum of the fol15 lowing: 

16 ‘‘(I) CURRENT LAW COMPO17 NENT.—The old weighting factor (de18 scribed in clause (ii)) for such year 

19 multiplied by the geographic index 

20 values under this subsection for the 

21 fee schedule area that included such 

22 MSA that would have applied in such 

23 area (as estimated by the Secretary) 

24 if this paragraph did not apply. 


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1 ‘‘(II) MSA-BASED COMPO2 NENT.—The MSA-based weighting 

3 factor (described in clause (iii)) for 

4 such year multiplied by the geographic 

5 index values computed for the fee 

6 schedule area under subparagraph (A) 

7 for the year (determined without re8 gard to this subparagraph). 

9 ‘‘(ii) OLD WEIGHTING FACTOR.—The 

10 old weighting factor described in this 

11 clause— 

‘‘(I) for 2017, is 5 12 ⁄6; and 

13 ‘‘(II) for each succeeding year, is 

14 the old weighting factor described in 

15 this clause for the previous year 

minus 1 16 ⁄6. 

17 ‘‘(iii) MSA-BASED WEIGHTING FAC18 TOR.—The MSA-based weighting factor 

19 described in this clause for a year is 1 

20 minus the old weighting factor under 

21 clause (ii) for that year. 

22 ‘‘(C) HOLD HARMLESS.—For services fur23 nished in a transition area in California during 

24 a year beginning with 2017, the geographic 

25 index values to be applied under this subsection 


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1 for such year shall not be less than the cor2 responding geographic index values that would 

3 have applied in such transition area (as esti4 mated by the Secretary) if this paragraph did 

5 not apply. 

6 ‘‘(D) TRANSITION AREA DEFINED.—In 

7 this paragraph, the term ‘transition area’ 

8 means each of the following fee schedule areas 

9 for 2013: 

10 ‘‘(i) The rest-of-State payment local11 ity. 

12 ‘‘(ii) Payment locality 3. 

13 ‘‘(E) REFERENCES TO FEE SCHEDULE

14 AREAS.—Effective for services furnished on or 

15 after January 1, 2017, for California, any ref16 erence in this section to a fee schedule area 

17 shall be deemed a reference to a fee schedule 

18 area established in accordance with this para19 graph.’’. 

20 (2) CONFORMING AMENDMENT TO DEFINITION

21 OF FEE SCHEDULE AREA.—Section 1848(j)(2) of the 

22 Social Security Act (42 U.S.C. 1395w–4(j)(2)) is 

23 amended by striking ‘‘The term’’ and inserting ‘‘Ex24 cept as provided in subsection (e)(6)(D), the term’’. 


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1 (i) DISCLOSURE OF DATA USED TO ESTABLISH

2 MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY.— 

3 The Secretary of Health and Human Services shall make 

4 publicly available the information used to establish the 

5 multiple procedure payment reduction policy to the profes6 sional component of imaging services in the final rule pub7 lished in the Federal Register, v. 77, n. 222, November 

8 16, 2012, pages 68891–69380 under the physician fee 

9 schedule under section 1848 of the Social Security Act (42 

10 U.S.C. 1395w–4). 

11 SEC. 6. PROMOTING EVIDENCE-BASED CARE. 

12 (a) IN GENERAL.—Section 1834 of the Social Secu13 rity Act (42 U.S.C. 1395m) is amended by adding at the 

14 end the following new subsection: 

15 ‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR

16 CERTAIN IMAGING SERVICES.— 

17 ‘‘(1) PROGRAM ESTABLISHED.— 

18 ‘‘(A) IN GENERAL.—The Secretary shall 

19 establish a program to promote the use of ap20 propriate use criteria (as defined in subpara21 graph (B)) for applicable imaging services (as 

22 defined in subparagraph (C)) furnished in an 

23 applicable setting (as defined in subparagraph 

24 (D)) by ordering professionals and furnishing 


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1 professionals (as defined in subparagraphs (E) 

2 and (F), respectively). 

3 ‘‘(B) APPROPRIATE USE CRITERIA DE4 FINED.—In this subsection, the term ‘appro5 priate use criteria’ means criteria, only devel6 oped or endorsed by national professional med7 ical specialty societies or other provider-led enti8 ties, to assist ordering professionals and fur9 nishing professionals in making the most appro10 priate treatment decision for a specific clinical 

11 condition. To the extent feasible, such criteria 

12 shall be evidence-based. 

13 ‘‘(C) APPLICABLE IMAGING SERVICE DE14 FINED.—In this subsection, the term ‘applicable 

15 imaging service’ means an advanced diagnostic 

16 imaging service (as defined in subsection 

17 (e)(1)(B)) for which the Secretary determines— 

18 ‘‘(i) one or more applicable appro19 priate use criteria specified under para20 graph (2) apply; 

21 ‘‘(ii) there are one or more qualified 

22 clinical decision support mechanisms listed 

23 under paragraph (3)(C); and 

24 ‘‘(iii) one or more of such mechanisms 

25 is available free of charge. 


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1 ‘‘(D) APPLICABLE SETTING DEFINED.—In 

2 this subsection, the term ‘applicable setting’ 

3 means a physician’s office, a hospital outpatient 

4 department (including an emergency depart5 ment), an ambulatory surgical center, and any 

6 other provider-led outpatient setting determined 

7 appropriate by the Secretary. 

8 ‘‘(E) ORDERING PROFESSIONAL DE9 FINED.—In this subsection, the term ‘ordering 

10 professional’ means a physician (as defined in 

11 section 1861(r)) or a practitioner described in 

12 section 1842(b)(18)(C) who orders an applica13 ble imaging service for an individual. 

14 ‘‘(F) FURNISHING PROFESSIONAL DE15 FINED.—In this subsection, the term ‘fur16 nishing professional’ means a physician (as de17 fined in section 1861(r)) or a practitioner de18 scribed in section 1842(b)(18)(C) who furnishes 

19 an applicable imaging service for an individual. 

20 ‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO21 PRIATE USE CRITERIA.— 

22 ‘‘(A) IN GENERAL.—Not later than No23 vember 15, 2015, the Secretary shall through 

24 rulemaking, and in consultation with physi25 cians, practitioners, and other stakeholders, 


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1 specify applicable appropriate use criteria for 

2 applicable imaging services only from among 

3 appropriate use criteria developed or endorsed 

4 by national professional medical specialty soci5 eties or other provider-led entities. 

6 ‘‘(B) CONSIDERATIONS.—In specifying ap7 plicable appropriate use criteria under subpara8 graph (A), the Secretary shall take into account 

9 whether the criteria— 

10 ‘‘(i) have stakeholder consensus; 

11 ‘‘(ii) are scientifically valid and evi12 dence based; and 

13 ‘‘(iii) are based on studies that are 

14 published and reviewable by stakeholders. 

15 ‘‘(C) REVISIONS.—The Secretary shall re16 view, on an annual basis, the specified applica17 ble appropriate use criteria to determine if 

18 there is a need to update or revise (as appro19 priate) such specification of applicable appro20 priate use criteria and make such updates or 

21 revisions through rulemaking. 

22 ‘‘(D) TREATMENT OF MULTIPLE APPLICA23 BLE APPROPRIATE USE CRITERIA.—In the case 

24 where the Secretary determines that more than 

25 one appropriate use criteria applies with respect 


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1 to an applicable imaging service, the Secretary 

2 shall permit one or more applicable appropriate 

3 use criteria under this paragraph for the serv4 ice. 

5 ‘‘(3) MECHANISMS FOR CONSULTATION WITH

6 APPLICABLE APPROPRIATE USE CRITERIA.— 

7 ‘‘(A) IDENTIFICATION OF MECHANISMS TO

8 CONSULT WITH APPLICABLE APPROPRIATE USE

9 CRITERIA.— 

10 ‘‘(i) IN GENERAL.—The Secretary 

11 shall specify qualified clinical decision sup12 port mechanisms that could be used by or13 dering professionals to consult with appli14 cable appropriate use criteria for applicable 

15 imaging services. 

16 ‘‘(ii) CONSULTATION.—The Secretary 

17 shall consult with physicians, practitioners, 

18 health care technology experts, and other 

19 stakeholders in specifying mechanisms 

20 under this paragraph. 

21 ‘‘(iii) INCLUSION OF CERTAIN MECHA22 NISMS.—Mechanisms specified under this 

23 paragraph may include any or all of the 

24 following that meet the requirements de25 scribed in subparagraph (B)(ii): 


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1 ‘‘(I) Use of clinical decision sup2 port modules in certified EHR tech3 nology (as defined in section 

4 1848(o)(4)). 

5 ‘‘(II) Use of private sector clin6 ical decision support mechanisms that 

7 are independent from certified EHR 

8 technology, which may include use of 

9 clinical decision support mechanisms 

10 available from medical specialty orga11 nizations. 

12 ‘‘(III) Use of a clinical decision 

13 support mechanism established by the 

14 Secretary. 

15 ‘‘(B) QUALIFIED CLINICAL DECISION SUP16 PORT MECHANISMS.— 

17 ‘‘(i) IN GENERAL.—For purposes of 

18 this subsection, a qualified clinical decision 

19 support mechanism is a mechanism that 

20 the Secretary determines meets the re21 quirements described in clause (ii). 

22 ‘‘(ii) REQUIREMENTS.—The require23 ments described in this clause are the fol24 lowing: 


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1 ‘‘(I) The mechanism makes avail2 able to the ordering professional appli3 cable appropriate use criteria specified 

4 under paragraph (2) and the sup5 porting documentation for the applica6 ble imaging service ordered. 

7 ‘‘(II) In the case where there are 

8 more than one applicable appropriate 

9 use criteria specified under such para10 graph for an applicable imaging serv11 ice, the mechanism indicates the cri12 teria that it uses for the service. 

13 ‘‘(III) The mechanism determines 

14 the extent to which an applicable im15 aging service ordered is consistent 

16 with the applicable appropriate use 

17 criteria so specified. 

18 ‘‘(IV) The mechanism generates 

19 and provides to the ordering profes20 sional a certification or documentation 

21 that documents that the qualified clin22 ical decision support mechanism was 

23 consulted by the ordering professional. 

24 ‘‘(V) The mechanism is updated 

25 on a timely basis to reflect revisions 


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1 to the specification of applicable ap2 propriate use criteria under such 

3 paragraph. 

4 ‘‘(VI) The mechanism meets pri5 vacy and security standards under ap6 plicable provisions of law. 

7 ‘‘(VII) The mechanism performs 

8 such other functions as specified by 

9 the Secretary, which may include a re10 quirement to provide aggregate feed11 back to the ordering professional. 

12 ‘‘(C) LIST OF MECHANISMS FOR CON13 SULTATION WITH APPLICABLE APPROPRIATE

14 USE CRITERIA.— 

15 ‘‘(i) INITIAL LIST.—Not later than 

16 April 1, 2016, the Secretary shall publish 

17 a list of mechanisms specified under this 

18 paragraph. 

19 ‘‘(ii) PERIODIC UPDATING OF LIST.— 

20 The Secretary shall identify on an annual 

21 basis the list of qualified clinical decision 

22 support mechanisms specified under this 

23 paragraph. 

24 ‘‘(4) CONSULTATION WITH APPLICABLE APPRO25 PRIATE USE CRITERIA.— 


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1 ‘‘(A) CONSULTATION BY ORDERING PRO2 FESSIONAL.—Beginning with January 1, 2017, 

3 subject to subparagraph (C), with respect to an 

4 applicable imaging service ordered by an order5 ing professional that would be furnished in an 

6 applicable setting and paid for under an appli7 cable payment system (as defined in subpara8 graph (D)), an ordering professional shall— 

9 ‘‘(i) consult with a qualified decision 

10 support mechanism listed under paragraph 

11 (3)(C); and 

12 ‘‘(ii) provide to the furnishing profes13 sional the information described in clauses 

14 (i) through (iii) of subparagraph (B). 

15 ‘‘(B) REPORTING BY FURNISHING PROFES16 SIONAL.—Beginning with January 1, 2017, 

17 subject to subparagraph (C), with respect to an 

18 applicable imaging service furnished in an ap19 plicable setting and paid for under an applica20 ble payment system (as defined in subpara21 graph (D)), payment for such service may only 

22 be made if the claim for the service includes the 

23 following: 

24 ‘‘(i) Information about which qualified 

25 clinical decision support mechanism was 


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1 consulted by the ordering professional for 

2 the service. 

3 ‘‘(ii) Information regarding— 

4 ‘‘(I) whether the service ordered 

5 would adhere to the applicable appro6 priate use criteria specified under 

7 paragraph (2); 

8 ‘‘(II) whether the service ordered 

9 would not adhere to such criteria; or 

10 ‘‘(III) whether such criteria was 

11 not applicable to the service ordered. 

12 ‘‘(iii) The national provider identifier 

13 of the ordering professional (if different 

14 from the furnishing professional). 

15 ‘‘(C) EXCEPTIONS.—The provisions of sub16 paragraphs (A) and (B) and paragraph (6)(A) 

17 shall not apply to the following: 

18 ‘‘(i) EMERGENCY SERVICES.—An ap19 plicable imaging service ordered for an in20 dividual with an emergency medical condi21 tion (as defined in section 1867(e)(1)). 

22 ‘‘(ii) INPATIENT SERVICES.—An appli23 cable imaging service ordered for an inpa24 tient and for which payment is made under 

25 part A. 


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1 ‘‘(iii) ALTERNATIVE PAYMENT MOD2 ELS.—An applicable imaging service or3 dered by an ordering professional with re4 spect to an individual attributed to an al5 ternative payment model (as defined in 

6 section 1833(z)(3)(C)). 

7 ‘‘(iv) SIGNIFICANT HARDSHIP.—An 

8 applicable imaging service ordered by an 

9 ordering professional who the Secretary 

10 may, on a case-by-case basis, exempt from 

11 the application of such provisions if the 

12 Secretary determines, subject to annual re13 newal, that consultation with applicable ap14 propriate use criteria would result in a sig15 nificant hardship, such as in the case of a 

16 professional who practices in a rural area 

17 without sufficient Internet access. 

18 ‘‘(D) APPLICABLE PAYMENT SYSTEM DE19 FINED.—In this subsection, the term ‘applicable 

20 payment system’ means the following: 

21 ‘‘(i) The physician fee schedule estab22 lished under section 1848(b). 

23 ‘‘(ii) The prospective payment system 

24 for hospital outpatient department services 

25 under section 1833(t). 


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1 ‘‘(iii) The ambulatory surgical center 

2 payment systems under section 1833(i). 

3 ‘‘(5) IDENTIFICATION OF OUTLIER ORDERING

4 PROFESSIONALS.— 

5 ‘‘(A) IN GENERAL.—With respect to appli6 cable imaging services furnished beginning with 

7 2017, the Secretary shall determine, on an an8 nual basis, no more than five percent of the 

9 total number of ordering professionals who are 

10 outlier ordering professionals. 

11 ‘‘(B) OUTLIER ORDERING PROFES12 SIONALS.—The determination of an outlier or13 dering professional shall— 

14 ‘‘(i) be based on low adherence to ap15 plicable appropriate use criteria specified 

16 under paragraph (2), which may be based 

17 on comparison to other ordering profes18 sionals; and 

19 ‘‘(ii) include data for ordering profes20 sionals for whom prior authorization under 

21 paragraph (6)(A) applies. 

22 ‘‘(C) USE OF TWO YEARS OF DATA.—The 

23 Secretary shall use two years of data to identify 

24 outlier ordering professionals under this para25 graph. 


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1 ‘‘(D) PROCESS.—The Secretary shall es2 tablish a process for determining when an 

3 outlier ordering professional is no longer an 

4 outlier ordering professional. 

5 ‘‘(E) CONSULTATION WITH STAKE6 HOLDERS.—The Secretary shall consult with 

7 physicians, practitioners and other stakeholders 

8 in developing methods to identify outlier order9 ing professionals under this paragraph. 

10 ‘‘(6) PRIOR AUTHORIZATION FOR ORDERING

11 PROFESSIONALS WHO ARE OUTLIERS.— 

12 ‘‘(A) IN GENERAL.—Beginning January 1, 

13 2020, subject to paragraph (4)(C), with respect 

14 to services furnished during a year, the Sec15 retary shall, for a period determined appro16 priate by the Secretary, apply prior authoriza17 tion for applicable imaging services that are or18 dered by an outlier ordering professional identi19 fied under paragraph (5). 

20 ‘‘(B) APPROPRIATE USE CRITERIA IN

21 PRIOR AUTHORIZATION.—In applying prior au22 thorization under subparagraph (A), the Sec23 retary shall utilize only the applicable appro24 priate use criteria specified under this sub25 section. 


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1 ‘‘(C) FUNDING.—For purposes of carrying 

2 out this paragraph, the Secretary shall provide 

3 for the transfer, from the Federal Supple4 mentary Medical Insurance Trust Fund under 

5 section 1841, of $5,000,000 to the Centers for 

6 Medicare & Medicaid Services Program Man7 agement Account for each of fiscal years 2019 

8 through 2021. Amounts transferred under the 

9 preceding sentence shall remain available until 

10 expended. 

11 ‘‘(7) CONSTRUCTION.—Nothing in this sub12 section shall be construed as granting the Secretary 

13 the authority to develop or initiate the development 

14 of clinical practice guidelines or appropriate use cri15 teria.’’. 

16 (b) CONFORMING AMENDMENT.—Section 

17 1833(t)(16) of the Social Security Act (42 U.S.C. 

18 1395l(t)(16)) is amended by adding at the end the fol19 lowing new subparagraph: 

20 ‘‘(E) APPLICATION OF APPROPRIATE USE

21 CRITERIA FOR CERTAIN IMAGING SERVICES.— 

22 For provisions relating to the application of ap23 propriate use criteria for certain imaging serv24 ices, see section 1834(p).’’. 


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1 (c) REPORT ON EXPERIENCE OF IMAGING APPRO2 PRIATE USE CRITERIA PROGRAM.—Not later than 18 

3 months after the date of the enactment of this Act, the 

4 Comptroller General of the United States shall submit to 

5 Congress a report that includes a description of the extent 

6 to which appropriate use criteria could be used for other 

7 services under part B of title XVIII of the Social Security 

8 Act (42 U.S.C. 1395j et seq.), such as radiation therapy 

9 and clinical diagnostic laboratory services. 

10 SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH 

11 ACCESS TO INFORMATION ON PHYSICIANS’ 

12 SERVICES. 

13 (a) IN GENERAL.—The Secretary shall make publicly 

14 available on Physician Compare the information described 

15 in subsection (b) with respect to eligible professionals. 

16 (b) INFORMATION DESCRIBED.—The following infor17 mation, with respect to an eligible professional, is de18 scribed in this subsection: 

19 (1) Information on the number of services fur20 nished by the eligible professional under part B of 

21 title XVIII of the Social Security Act (42 U.S.C. 

22 1395j et seq.), which may include information on the 

23 most frequent services furnished or groupings of 

24 services. 


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1 (2) Information on submitted charges and pay2 ments for services under such part. 

3 (3) A unique identifier for the eligible profes4 sional that is available to the public, such as a na5 tional provider identifier. 

6 (c) SEARCHABILITY.—The information made avail7 able under this section shall be searchable by at least the 

8 following: 

9 (1) The specialty or type of the eligible profes10 sional. 

11 (2) Characteristics of the services furnished, 

12 such as volume or groupings of services. 

13 (3) The location of the eligible professional. 

14 (d) DISCLOSURE.—The information made available 

15 under this section shall indicate, where appropriate, that 

16 publicized information may not be representative of the 

17 eligible professional’s entire patient population, the variety 

18 of services furnished by the eligible professional, or the 

19 health conditions of individuals treated. 

20 (e) IMPLEMENTATION.— 

21 (1) INITIAL IMPLEMENTATION.—Physician 

22 Compare shall include the information described in 

23 subsection (b)— 

24 (A) with respect to physicians, by not later 

25 than July 1, 2015; and 


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1 (B) with respect to other eligible profes2 sionals, by not later than July 1, 2016. 

3 (2) ANNUAL UPDATING.—The information 

4 made available under this section shall be updated 

5 on Physician Compare not less frequently than on 

6 an annual basis. 

7 (f) OPPORTUNITY TO REVIEW AND SUBMIT CORREC8 TIONS.—The Secretary shall provide for an opportunity 

9 for an eligible professional to review, and submit correc10 tions for, the information to be made public with respect 

11 to the eligible professional under this section prior to such 

12 information being made public. 

13 (g) DEFINITIONS.—In this section: 

14 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC15 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi16 cian’’, and ‘‘Secretary’’ have the meaning given such 

17 terms in section 10331(i) of Public Law 111–148. 

18 (2) PHYSICIAN COMPARE.—The term ‘‘Physi19 cian Compare’’ means the Physician Compare Inter20 net website of the Centers for Medicare & Medicaid 

21 Services (or a successor website). 

22 SEC. 8. EXPANDING AVAILABILITY OF MEDICARE DATA. 

23 (a) EXPANDING USES OF MEDICARE DATA BY

24 QUALIFIED ENTITIES.— 

25 (1) ADDITIONAL ANALYSES.— 


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1 (A) IN GENERAL.—Subject to subpara2 graph (B), to the extent consistent with appli3 cable information, privacy, security, and disclo4 sure laws (including paragraph (3)), notwith5 standing paragraph (4)(B) of section 1874(e) of 

6 the Social Security Act (42 U.S.C. 1395kk(e)) 

7 and the second sentence of paragraph (4)(D) of 

8 such section, beginning July 1, 2015, a quali9 fied entity may use the combined data described 

10 in paragraph (4)(B)(iii) of such section received 

11 by such entity under such section, and informa12 tion derived from the evaluation described in 

13 such paragraph (4)(D), to conduct additional 

14 non-public analyses (as determined appropriate 

15 by the Secretary) and provide or sell such anal16 yses to authorized users for non-public use (in17 cluding for the purposes of assisting providers 

18 of services and suppliers to develop and partici19 pate in quality and patient care improvement 

20 activities, including developing new models of 

21 care). 

22 (B) LIMITATIONS WITH RESPECT TO ANAL23 YSES.— 

24 (i) EMPLOYERS.—Any analyses pro25 vided or sold under subparagraph (A) to 


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1 an employer described in paragraph 

2 (9)(A)(iii) may only be used by such em3 ployer for purposes of providing health in4 surance to employees and retirees of the 

5 employer. 

6 (ii) HEALTH INSURANCE ISSUERS.—A 

7 qualified entity may not provide or sell an 

8 analysis to a health insurance issuer de9 scribed in paragraph (9)(A)(iv) unless the 

10 issuer is providing the qualified entity with 

11 data under section 1874(e)(4)(B)(iii) of 

12 the Social Security Act (42 U.S.C. 

13 1395kk(e)(4)(B)(iii)). 

14 (2) ACCESS TO CERTAIN DATA.— 

15 (A) ACCESS.—To the extent consistent 

16 with applicable information, privacy, security, 

17 and disclosure laws (including paragraph (3)), 

18 notwithstanding paragraph (4)(B) of section 

19 1874(e) of the Social Security Act (42 U.S.C. 

20 1395kk(e)) and the second sentence of para21 graph (4)(D) of such section, beginning July 1, 

22 2015, a qualified entity may— 

23 (i) provide or sell the combined data 

24 described in paragraph (4)(B)(iii) of such 

25 section to authorized users described in 


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1 clauses (i), (ii), and (v) of paragraph 

2 (9)(A) for non-public use, including for the 

3 purposes described in subparagraph (B); 

4 or 

5 (ii) subject to subparagraph (C), pro6 vide Medicare claims data to authorized 

7 users described in clauses (i), (ii), and (v), 

8 of paragraph (9)(A) for non-public use, in9 cluding for the purposes described in sub10 paragraph (B). 

11 (B) PURPOSES DESCRIBED.—The purposes 

12 described in this subparagraph are assisting 

13 providers of services and suppliers in developing 

14 and participating in quality and patient care 

15 improvement activities, including developing 

16 new models of care. 

17 (C) MEDICARE CLAIMS DATA MUST BE

18 PROVIDED AT NO COST.—A qualified entity may 

19 not charge a fee for providing the data under 

20 subparagraph (A)(ii). 

21 (3) PROTECTION OF INFORMATION.— 

22 (A) IN GENERAL.—Except as provided in 

23 subparagraph (B), an analysis or data that is 

24 provided or sold under paragraph (1) or (2) 


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1 shall not contain information that individually 

2 identifies a patient. 

3 (B) INFORMATION ON PATIENTS OF THE

4 PROVIDER OF SERVICES OR SUPPLIER.—To the 

5 extent consistent with applicable information, 

6 privacy, security, and disclosure laws, an anal7 ysis or data that is provided or sold to a pro8 vider of services or supplier under paragraph 

9 (1) or (2) may contain information that individ10 ually identifies a patient of such provider or 

11 supplier, including with respect to items and 

12 services furnished to the patient by other pro13 viders of services or suppliers. 

14 (C) PROHIBITION ON USING ANALYSES OR

15 DATA FOR MARKETING PURPOSES.—An author16 ized user shall not use an analysis or data pro17 vided or sold under paragraph (1) or (2) for 

18 marketing purposes. 

19 (4) DATA USE AGREEMENT.—A qualified entity 

20 and an authorized user described in clauses (i), (ii), 

21 and (v) of paragraph (9)(A) shall enter into an 

22 agreement regarding the use of any data that the 

23 qualified entity is providing or selling to the author24 ized user under paragraph (2). Such agreement shall 

25 describe the requirements for privacy and security of 


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1 the data and, as determined appropriate by the Sec2 retary, any prohibitions on using such data to link 

3 to other individually identifiable sources of informa4 tion. If the authorized user is not a covered entity 

5 under the rules promulgated pursuant to the Health 

6 Insurance Portability and Accountability Act of 

7 1996, the agreement shall identify the relevant regu8 lations, as determined by the Secretary, that the 

9 user shall comply with as if it were acting in the ca10 pacity of such a covered entity. 

11 (5) NO REDISCLOSURE OF ANALYSES OR

12 DATA.— 

13 (A) IN GENERAL.—Except as provided in 

14 subparagraph (B), an authorized user that is 

15 provided or sold an analysis or data under 

16 paragraph (1) or (2) shall not redisclose or 

17 make public such analysis or data or any anal18 ysis using such data. 

19 (B) PERMITTED REDISCLOSURE.—A pro20 vider of services or supplier that is provided or 

21 sold an analysis or data under paragraph (1) or 

22 (2) may, as determined by the Secretary, redis23 close such analysis or data for the purposes of 

24 performance improvement and care coordination 


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1 activities but shall not make public such anal2 ysis or data or any analysis using such data. 

3 (6) OPPORTUNITY FOR PROVIDERS OF SERV4 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali5 fied entity providing or selling an analysis to an au6 thorized user under paragraph (1), to the extent 

7 that such analysis would individually identify a pro8 vider of services or supplier who is not being pro9 vided or sold such analysis, such qualified entity 

10 shall provide such provider or supplier with the op11 portunity to appeal and correct errors in the manner 

12 described in section 1874(e)(4)(C)(ii) of the Social 

13 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

14 (7) ASSESSMENT FOR A BREACH.— 

15 (A) IN GENERAL.—In the case of a breach 

16 of a data use agreement under this section or 

17 section 1874(e) of the Social Security Act (42 

18 U.S.C. 1395kk(e)), the Secretary shall impose 

19 an assessment on the qualified entity both in 

20 the case of— 

21 (i) an agreement between the Sec22 retary and a qualified entity; and 

23 (ii) an agreement between a qualified 

24 entity and an authorized user. 


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1 (B) ASSESSMENT.—The assessment under 

2 subparagraph (A) shall be an amount up to 

3 $100 for each individual entitled to, or enrolled 

4 for, benefits under part A of title XVIII of the 

5 Social Security Act or enrolled for benefits 

6 under part B of such title— 

7 (i) in the case of an agreement de8 scribed in subparagraph (A)(i), for whom 

9 the Secretary provided data on to the 

10 qualified entity under paragraph (2); and 

11 (ii) in the case of an agreement de12 scribed in subparagraph (A)(ii), for whom 

13 the qualified entity provided data on to the 

14 authorized user under paragraph (2). 

15 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

16 Any amounts collected pursuant to this para17 graph shall be deposited in Federal Supple18 mentary Medical Insurance Trust Fund under 

19 section 1841 of the Social Security Act (42 

20 U.S.C. 1395t). 

21 (8) ANNUAL REPORTS.—Any qualified entity 

22 that provides or sells an analysis or data under 

23 paragraph (1) or (2) shall annually submit to the 

24 Secretary a report that includes— 


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1 (A) a summary of the analyses provided or 

2 sold, including the number of such analyses, the 

3 number of purchasers of such analyses, and the 

4 total amount of fees received for such analyses; 

5 (B) a description of the topics and pur6 poses of such analyses; 

7 (C) information on the entities who re8 ceived the data under paragraph (2), the uses 

9 of the data, and the total amount of fees re10 ceived for providing, selling, or sharing the 

11 data; and 

12 (D) other information determined appro13 priate by the Secretary. 

14 (9) DEFINITIONS.—In this subsection and sub15 section (b): 

16 (A) AUTHORIZED USER.—The term ‘‘au17 thorized user’’ means the following: 

18 (i) A provider of services. 

19 (ii) A supplier. 

20 (iii) An employer (as defined in sec21 tion 3(5) of the Employee Retirement In22 surance Security Act of 1974). 

23 (iv) A health insurance issuer (as de24 fined in section 2791 of the Public Health 

25 Service Act). 


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1 (v) A medical society or hospital asso2 ciation. 

3 (vi) Any entity not described in 

4 clauses (i) through (v) that is approved by 

5 the Secretary (other than an employer or 

6 health insurance issuer not described in 

7 clauses (iii) and (iv), respectively, as deter8 mined by the Secretary). 

9 (B) PROVIDER OF SERVICES.—The term 

10 ‘‘provider of services’’ has the meaning given 

11 such term in section 1861(u) of the Social Se12 curity Act (42 U.S.C. 1395x(u)). 

13 (C) QUALIFIED ENTITY.—The term ‘‘quali14 fied entity’’ has the meaning given such term in 

15 section 1874(e)(2) of the Social Security Act 

16 (42 U.S.C. 1395kk(e)). 

17 (D) SECRETARY.—The term ‘‘Secretary’’ 

18 means the Secretary of Health and Human 

19 Services. 

20 (E) SUPPLIER.—The term ‘‘supplier’’ has 

21 the meaning given such term in section 1861(d) 

22 of the Social Security Act (42 U.S.C. 

23 1395x(d)). 


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1 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

2 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

3 IMPROVEMENT.— 

4 (1) ACCESS.— 

5 (A) IN GENERAL.—To the extent con6 sistent with applicable information, privacy, se7 curity, and disclosure laws, beginning July 1, 

8 2015, the Secretary shall, at the request of a 

9 qualified clinical data registry under section 

10 1848(m)(3)(E) of the Social Security Act (42 

11 U.S.C. 1395w–4(m)(3)(E)), provide the data 

12 described in subparagraph (B) (in a form and 

13 manner determined to be appropriate) to such 

14 qualified clinical data registry for purposes of 

15 linking such data with clinical outcomes data 

16 and performing risk-adjusted, scientifically valid 

17 analyses and research to support quality im18 provement or patient safety, provided that any 

19 public reporting of such analyses or research 

20 that identifies a provider of services or supplier 

21 shall only be conducted with the opportunity of 

22 such provider or supplier to appeal and correct 

23 errors in the manner described in subsection 

24 (a)(6). 


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1 (B) DATA DESCRIBED.—The data de2 scribed in this subparagraph is— 

3 (i) claims data under the Medicare 

4 program under title XVIII of the Social 

5 Security Act; and 

6 (ii) if the Secretary determines appro7 priate, claims data under the Medicaid 

8 program under title XIX of such Act and 

9 the State Children’s Health Insurance Pro10 gram under title XXI of such Act. 

11 (2) FEE.—Data described in paragraph (1)(B) 

12 shall be provided to a qualified clinical data registry 

13 under paragraph (1) at a fee equal to the cost of 

14 providing such data. Any fee collected pursuant to 

15 the preceding sentence shall be deposited in the Cen16 ters for Medicare & Medicaid Services Program 

17 Management Account. 

18 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

19 ENTITIES.—Section 1874(e) of the Social Security Act 

20 (42 U.S.C. 1395kk(e)) is amended— 

21 (1) in the subsection heading, by striking 

22 ‘‘MEDICARE’’; and 

23 (2) in paragraph (3)— 

24 (A) by inserting after the first sentence the 

25 following new sentence: ‘‘Beginning July 1, 


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1 2015, if the Secretary determines appropriate, 

2 the data described in this paragraph may also 

3 include standardized extracts (as determined by 

4 the Secretary) of claims data under titles XIX 

5 and XXI for assistance provided under such ti6 tles for one or more specified geographic areas 

7 and time periods requested by a qualified enti8 ty.’’; and 

9 (B) in the last sentence, by inserting ‘‘or 

10 under titles XIX or XXI’’ before the period at 

11 the end. 

12 (d) REVISION OF PLACEMENT OF FEES.—Section 

13 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

14 1395kk(e)(4)(A)) is amended, in the second sentence— 

15 (1) by inserting ‘‘, for periods prior to July 1, 

16 2015,’’ after ‘‘deposited’’; and 

17 (2) by inserting the following before the period 

18 at the end: ‘‘, and, beginning July 1, 2015, into the 

19 Centers for Medicare & Medicaid Services Program 

20 Management Account’’. 

21 SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER 

22 PROVISIONS. 

23 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT24 OUT TO PRIVATE CONTRACT.— 


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1 (1) INDEFINITE, CONTINUING AUTOMATIC EX2 TENSION OF OPT OUT ELECTION.— 

3 (A) IN GENERAL.—Section 1802(b)(3) of 

4 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

5 is amended— 

6 (i) in subparagraph (B)(ii), by strik7 ing ‘‘during the 2-year period beginning on 

8 the date the affidavit is signed’’ and insert9 ing ‘‘during the applicable 2-year period 

10 (as defined in subparagraph (D))’’; 

11 (ii) in subparagraph (C), by striking 

12 ‘‘during the 2-year period described in sub13 paragraph (B)(ii)’’ and inserting ‘‘during 

14 the applicable 2-year period’’; and 

15 (iii) by adding at the end the fol16 lowing new subparagraph: 

17 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

18 EFFECTIVENESS OF AFFIDAVITS.—In this sub19 section, the term ‘applicable 2-year period’ 

20 means, with respect to an affidavit of a physi21 cian or practitioner under subparagraph (B), 

22 the 2-year period beginning on the date the af23 fidavit is signed and includes each subsequent 

24 2-year period unless the physician or practi25 tioner involved provides notice to the Secretary 


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1 (in a form and manner specified by the Sec2 retary), not later than 30 days before the end 

3 of the previous 2-year period, that the physician 

4 or practitioner does not want to extend the ap5 plication of the affidavit for such subsequent 2- 

6 year period.’’. 

7 (B) EFFECTIVE DATE.—The amendments 

8 made by subparagraph (A) shall apply to affi9 davits entered into on or after the date that is 

10 60 days after the date of the enactment of this 

11 Act. 

12 (2) PUBLIC AVAILABILITY OF INFORMATION ON

13 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 

14 1802(b) of the Social Security Act (42 U.S.C. 

15 1395a(b)) is amended— 

16 (A) in paragraph (5), by adding at the end 

17 the following new subparagraph: 

18 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

19 The term ‘opt-out physician or practitioner’ means 

20 a physician or practitioner who has in effect an affi21 davit under paragraph (3)(B).’’; 

22 (B) by redesignating paragraph (5) as 

23 paragraph (6); and 

24 (C) by inserting after paragraph (4) the 

25 following new paragraph: 


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1 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

2 PHYSICIANS AND PRACTITIONERS.— 

3 ‘‘(A) IN GENERAL.—Beginning not later 

4 than February 1, 2015, the Secretary shall 

5 make publicly available through an appropriate 

6 publicly accessible website of the Department of 

7 Health and Human Services information on the 

8 number and characteristics of opt-out physi9 cians and practitioners and shall update such 

10 information on such website not less often than 

11 annually. 

12 ‘‘(B) INFORMATION TO BE INCLUDED.— 

13 The information to be made available under 

14 subparagraph (A) shall include at least the fol15 lowing with respect to opt-out physicians and 

16 practitioners: 

17 ‘‘(i) Their number. 

18 ‘‘(ii) Their physician or professional 

19 specialty or other designation. 

20 ‘‘(iii) Their geographic distribution. 

21 ‘‘(iv) The timing of their becoming 

22 opt-out physicians and practitioners, rel23 ative to when they first entered practice 

24 and with respect to applicable 2-year peri25 ods. 


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1 ‘‘(v) The proportion of such physi2 cians and practitioners who billed for 

3 emergency or urgent care services.’’. 

4 (b) GAINSHARING STUDY AND REPORT.—Not later 

5 than 6 months after the date of the enactment of this Act, 

6 the Secretary of Health and Human Services, in consulta7 tion with the Inspector General of the Department of 

8 Health and Human Services, shall submit to Congress a 

9 report with legislative recommendations to amend existing 

10 fraud and abuse laws, through exceptions, safe harbors, 

11 or other narrowly targeted provisions, to permit 

12 gainsharing or similar arrangements between physicians 

13 and hospitals that improve care while reducing waste and 

14 increasing efficiency. The report shall— 

15 (1) consider whether such provisions should 

16 apply to ownership interests, compensation arrange17 ments, or other relationships; 

18 (2) describe how the recommendations address 

19 accountability, transparency, and quality, including 

20 how best to limit inducements to stint on care, dis21 charge patients prematurely, or otherwise reduce or 

22 limit medically necessary care; and 

23 (3) consider whether a portion of any savings 

24 generated by such arrangements should accrue to 


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1 the Medicare program under title XVIII of the So2 cial Security Act. 

3 (c) PROMOTING INTEROPERABILITY OF ELECTRONIC

4 HEALTH RECORD SYSTEMS.— 

5 (1) RECOMMENDATIONS FOR ACHIEVING WIDE6 SPREAD EHR INTEROPERABILITY.— 

7 (A) OBJECTIVE.—As a consequence of a 

8 significant Federal investment in the implemen9 tation of health information technology through 

10 the Medicare and Medicaid EHR incentive pro11 grams, Congress declares it a national objective 

12 to achieve widespread exchange of health infor13 mation through interoperable certified EHR 

14 technology nationwide by December 31, 2017. 

15 (B) DEFINITIONS.—In this paragraph: 

16 (i) WIDESPREAD INTEROPER17 ABILITY.—The term ‘‘widespread inter18 operability’’ means interoperability between 

19 certified EHR technology systems em20 ployed by meaningful EHR users under 

21 the Medicare and Medicaid EHR incentive 

22 programs and other clinicians and health 

23 care providers on a nationwide basis. 

24 (ii) INTEROPERABILITY.—The term 

25 ‘‘interoperability’’ means the ability of two 


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1 or more health information systems or 

2 components to exchange clinical and other 

3 information and to use the information 

4 that has been exchanged using common 

5 standards as to provide access to longitu6 dinal information for health care providers 

7 in order to facilitate coordinated care and 

8 improved patient outcomes. 

9 (C) ESTABLISHMENT OF METRICS.—Not 

10 later than July 1, 2015, and in consultation 

11 with stakeholders, the Secretary shall establish 

12 metrics to be used to determine if and to the 

13 extent that the objective described in subpara14 graph (A) has been achieved. 

15 (D) RECOMMENDATIONS IF OBJECTIVE

16 NOT ACHIEVED.—If the Secretary of Health 

17 and Human Services determines that the objec18 tive described in subparagraph (A) has not been 

19 achieved by December 31, 2017, then the Sec20 retary shall submit to Congress a report, by not 

21 later than December 31, 2018, that identifies 

22 barriers to such objective and recommends ac23 tions that the Federal Government can take to 

24 achieve such objective. Such recommended ac25 tions may include recommendations— 


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1 (i) to adjust payments for not being 

2 meaningful EHR users under the Medicare 

3 EHR incentive programs; and 

4 (ii) for criteria for decertifying cer5 tified EHR technology products. 

6 (2) PREVENTING BLOCKING THE SHARING OF

7 INFORMATION.— 

8 (A) FOR MEANINGFUL EHR PROFES9 SIONALS.—Section 1848(o)(2)(A)(ii) of the So10 cial Security Act (42 U.S.C. 1395w– 

11 4(o)(2)(A)(ii)) is amended by inserting before 

12 the period at the end the following: ‘‘, and the 

13 professional demonstrates (through a process 

14 specified by the Secretary, such as the use of an 

15 attestation) that the professional has not know16 ingly and willfully taken any action to limit or 

17 restrict the compatibility or interoperability of 

18 the certified EHR technology’’. 

19 (B) FOR MEANINGFUL EHR HOSPITALS.— 

20 Section 1886(n)(3)(A)(ii) of the Social Security 

21 Act (42 U.S.C. 1395ww(n)(3)(A)(ii)) is amend22 ed by inserting before the period at the end the 

23 following: ‘‘, and the hospital demonstrates 

24 (through a process specified by the Secretary, 

25 such as the use of an attestation) that the hosVerDate Mar 15 2010 02:53 Feb 08, 2014 Jkt 039200 PO 00000 Frm 00186 Fmt 6652 Sfmt 6201 E:\BILLS\S2000.IS S2000

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1 pital has not knowingly and willfully taken any 

2 action to limit or restrict the compatibility or 

3 interoperability of the certified EHR tech4 nology’’. 

5 (C) EFFECTIVE DATE.—The amendments 

6 made by this subsection shall apply to meaning7 ful EHR users as of the date that is one year 

8 after the date of the enactment of this Act. 

9 (3) STUDY AND REPORT ON THE FEASIBILITY

10 OF ESTABLISHING A WEBSITE TO COMPARE CER11 TIFIED EHR TECHNOLOGY PRODUCTS.— 

12 (A) STUDY.—The Secretary shall conduct 

13 a study to examine the feasibility of estab14 lishing mechanisms that includes aggregated re15 sults of surveys of meaningful EHR users on 

16 the functionality of certified EHR technology 

17 products to enable such users to directly com18 pare the functionality and other features of 

19 such products. Such information may be made 

20 available through contracts with physician, hos21 pital, or other organizations that maintain such 

22 comparative information. 

23 (B) REPORT.—Not later than 1 year after 

24 the date of the enactment of this Act, the Sec25 retary shall submit to Congress a report on the 


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1 website. The report shall include information on 

2 the benefits of, and resources needed to develop 

3 and maintain, such a website. 

4 (4) DEFINITIONS.—In this subsection: 

5 (A) The term ‘‘certified EHR technology’’ 

6 has the meaning given such term in section 

7 1848(o)(4) of the Social Security Act (42 

8 U.S.C. 1395w–4(o)(4)). 

9 (B) The term ‘‘meaningful EHR user’’ has 

10 the meaning given such term under the Medi11 care EHR incentive programs. 

12 (C) The term ‘‘Medicare and Medicaid 

13 EHR incentive programs’’ means— 

14 (i) in the case of the Medicare pro15 gram under title XVIII of the Social Secu16 rity Act, the incentive programs under sec17 tion 1814(l)(3), section 1848(o), sub18 sections (l) and (m) of section 1853, and 

19 section 1886(n) of the Social Security Act 

20 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

21 1395w–23, 1395ww(n)); and 

22 (ii) in the case of the Medicaid pro23 gram under title XIX of such Act, the in24 centive program under subsections 


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1 (a)(3)(F) and (t) of section 1903 of such 

2 Act (42 U.S.C. 1396b). 

3 (D) The term ‘‘Secretary’’ means the Sec4 retary of Health and Human Services. 

5 (d) GAO STUDIES AND REPORTS ON THE USE OF

6 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE7 MOTE PATIENT MONITORING SERVICES.— 

8 (1) STUDY ON TELEHEALTH SERVICES.—The 

9 Comptroller General of the United States shall con10 duct a study on the following: 

11 (A) How the definition of telehealth across 

12 various Federal programs and Federal efforts 

13 can inform the use of telehealth in the Medicare 

14 program under title XVIII of the Social Secu15 rity Act (42 U.S.C. 1395 et seq.). 

16 (B) Issues that can facilitate or inhibit the 

17 use of telehealth under the Medicare program 

18 under such title, including oversight and profes19 sional licensure, changing technology, privacy 

20 and security, infrastructure requirements, and 

21 varying needs across urban and rural areas. 

22 (C) Potential implications of greater use of 

23 telehealth with respect to payment and delivery 

24 system transformations under the Medicare 

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1 icaid program under title XIX of such Act (42 

2 U.S.C. 1396 et seq.). 

3 (D) How the Centers for Medicare & Med4 icaid Services conducts oversight of payments 

5 made under the Medicare program under such 

6 title XVIII to providers for telehealth services. 

7 (2) STUDY ON REMOTE PATIENT MONITORING

8 SERVICES.— 

9 (A) IN GENERAL.—The Comptroller Gen10 eral of the United States shall conduct a 

11 study— 

12 (i) of the dissemination of remote pa13 tient monitoring technology in the private 

14 health insurance market; 

15 (ii) of the financial incentives in the 

16 private health insurance market relating to 

17 adoption of such technology; 

18 (iii) of the barriers to adoption of 

19 such services under the Medicare program 

20 under title XVIII of the Social Security 

21 Act; 

22 (iv) that evaluates the patients, condi23 tions, and clinical circumstances that could 

24 most benefit from remote patient moni25 toring services; and 


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1 (v) that evaluates the challenges re2 lated to establishing appropriate valuation 

3 for remote patient monitoring services 

4 under the Medicare physician fee schedule 

5 under section 1848 of the Social Security 

6 Act (42 U.S.C. 1395w–4) in order to accu7 rately reflect the resources involved in fur8 nishing such services. 

9 (B) DEFINITIONS.—For purposes of this 

10 paragraph: 

11 (i) REMOTE PATIENT MONITORING

12 SERVICES.—The term ‘‘remote patient 

13 monitoring services’’ means services fur14 nished through remote patient monitoring 

15 technology. 

16 (ii) REMOTE PATIENT MONITORING

17 TECHNOLOGY.—The term ‘‘remote patient 

18 monitoring technology’’ means a coordi19 nated system that uses one or more home20 based or mobile monitoring devices that 

21 automatically transmit vital sign data or 

22 information on activities of daily living and 

23 may include responses to assessment ques24 tions collected on the devices wirelessly or 

25 through a telecommunications connection 


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1 to a server that complies with the Federal 

2 regulations (concerning the privacy of indi3 vidually identifiable health information) 

4 promulgated under section 264(c) of the 

5 Health Insurance Portability and Account6 ability Act of 1996, as part of an estab7 lished plan of care for that patient that in8 cludes the review and interpretation of that 

9 data by a health care professional. 

10 (3) REPORTS.—Not later than 24 months after 

11 the date of the enactment of this Act, the Comp12 troller General shall submit to Congress— 

13 (A) a report containing the results of the 

14 study conducted under paragraph (1); and 

15 (B) a report containing the results of the 

16 study conducted under paragraph (2). 

17 A report required under this paragraph shall be sub18 mitted together with recommendations for such leg19 islation and administrative action as the Comptroller 

20 General determines appropriate. The Comptroller 

21 General may submit one report containing the re22 sults described in subparagraphs (A) and (B) and 

23 the recommendations described in the previous sen24 tence. 


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1 (e) RULE OF CONSTRUCTION REGARDING

2 HEALTHCARE PROVIDER STANDARDS OF CARE.— 

3 (1) MAINTENANCE OF STATE STANDARDS.— 

4 The development, recognition, or implementation of 

5 any guideline or other standard under any Federal 

6 health care provision shall not be construed— 

7 (A) to establish the standard of care or 

8 duty of care owed by a health care provider to 

9 a patient in any medical malpractice or medical 

10 product liability action or claim; or 

11 (B) to preempt any standard of care or 

12 duty of care, owed by a health care provider to 

13 a patient, duly established under State or com14 mon law. 

15 (2) DEFINITIONS.—For purposes of this sub16 section: 

17 (A) FEDERAL HEALTH CARE PROVISION.— 

18 The term ‘‘Federal health care provision’’ 

19 means any provision of the Patient Protection 

20 and Affordable Care Act (Public Law 111– 

21 148), title I or subtitle B of title II of the 

22 Health Care and Education Reconciliation Act 

23 of 2010 (Public Law 111–152), or title XVIII 

24 or XIX of the Social Security Act. 


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1 (B) HEALTH CARE PROVIDER.—The term 

2 ‘‘health care provider’’ means any individual or 

3 entity— 

4 (i) licensed, registered, or certified 

5 under Federal or State laws or regulations 

6 to provide health care services; or 

7 (ii) required to be so licensed, reg8 istered, or certified but that is exempted 

9 by other statute or regulation. 

10 (C) MEDICAL MALPRACTICE OR MEDICAL

11 PRODUCT LIABILITY ACTION OR CLAIM.—The 

12 term ‘‘medical malpractice or medical product 

13 liability action or claim’’ means a medical mal14 practice action or claim (as defined in section 

15 431(7) of the Health Care Quality Improve16 ment Act of 1986 (42 U.S.C. 11151(7))) and 

17 includes a liability action or claim relating to a 

18 health care provider’s prescription or provision 

19 of a drug, device, or biological product (as such 

20 terms are defined in section 201 of the Federal 

21 Food, Drug, and Cosmetic Act or section 351 

22 of the Public Health Service Act). 

23 (D) STATE.—The term ‘‘State’’ includes 

24 the District of Columbia, Puerto Rico, and any 


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1 other commonwealth, possession, or territory of 

2 the United States. 

3 (3) PRESERVATION OF STATE LAW.—No provi4 sion of the Patient Protection and Affordable Care 

5 Act (Public Law 111–148), title I or subtitle B of 

6 title II of the Health Care and Education Reconcili7 ation Act of 2010 (Public Law 111–152), or title 

8 XVIII or XIX of the Social Security Act shall be 

9 construed to preempt any State or common law gov10 erning medical professional or medical product liabil11 ity actions or claims. 

Æ 


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