IB 

Union Calendar No. 283 

113TH CONGRESS 

2D SESSION H. R. 2810 

[Report No. 113–257, Parts I and II] 

To amend title XVIII of the Social Security Act to reform the sustainable 

growth rate and Medicare payment for physicians’ services, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 24, 2013 

Mr. BURGESS (for himself, Mr. PALLONE, Mr. UPTON, Mr. WAXMAN, Mr. 

PITTS, and Mr. DINGELL) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committees on Ways and Means and the Judiciary, for a period to 

be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee 

concerned 

NOVEMBER 12, 2013 

Reported from the Committee on Energy and Commerce with an amendment 

[Strike out all after the enacting clause and insert the part printed in italic] 

NOVEMBER 12, 2013 

The Committee on the Judiciary discharged 

NOVEMBER 12, 2013 

Referral to the Committee on Ways and Means extended for a period ending 

not later than December 2, 2013 

DECEMBER 2, 2013 

Referral to the Committee on Ways and Means extended for a period ending 

not later than January 10, 2014 

JANUARY 10, 2014 

Referral to the Committee on Ways and Means extended for a period ending 

not later than March 14, 2014 


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MARCH 14, 2014 

Additional sponsors: Mr. CASSIDY, Mr. BUCSHON, Mrs. CHRISTENSEN, Mr. 

GINGREY of Georgia, Mr. STOCKMAN, Mr. THORNBERRY, Mr. BENISHEK, 

Mr. MURPHY of Pennsylvania, Mr. GOSAR, Ms. MATSUI, Ms. CASTOR of 

Florida, Mr. ENGEL, Mr. CUELLAR, Mr. SESSIONS, Mr. YOUNG of Alaska, Mr. GENE GREEN of Texas, Mr. OLSON, Mrs. ELLMERS, Mr. ROE

of Tennessee, Mrs. BLACKBURN, Mr. LATTA, Mrs. MCMORRIS RODGERS, 

Mr. TERRY, Mr. ROGERS of Michigan, Mr. WALDEN, Mr. BILIRAKIS, Ms. 

SCHAKOWSKY, Mr. BRALEY of Iowa, Mrs. CAPPS, Mr. CARTER, Mr. BARTON, Mr. WHITFIELD, Mr. LANCE, Mr. HOLDING, Mr. WESTMORELAND, 

Mr. LATHAM, Mrs. BROOKS of Indiana, Mr. WALBERG, Mr. RICE of 

South Carolina, Mr. LOEBSACK, Mr. COFFMAN, Mr. BERA of California, 

Mr. RUIZ, Mr. STIVERS, Mr. MCKINLEY, Mr. KENNEDY, Mr. BEN RAY

LUJA ́N of New Mexico, Mr. RUSH, Mr. YODER, Mr. MARINO, Mr. 

MCNERNEY, and Mr. LANGEVIN

MARCH 14, 2014 

Reported from the Committee on Ways and Means with an amendment, committed to the Committee of the Whole House on the State of the Union, 

and ordered to be printed 

[Strike out all after the enacting clause and insert the part printed in boldface roman] 

[For text of introduced bill, see copy of bill as introduced on July 24, 2013] 

A BILL 

To amend title XVIII of the Social Security Act to reform 

the sustainable growth rate and Medicare payment for 

physicians’ services, and for other purposes. 


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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 ‘‘Medicare Patient Access and Quality Improvement Act of 

6 2013’’. 

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

8 Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Reform of sustainable growth rate (SGR) and Medicare payment for physicians’ services. 

Sec. 3. Expanding availability of Medicare data. 

Sec. 4. Encouraging care coordination and medical homes. 

Sec. 5. Miscellaneous. 

9 SEC. 2. REFORM OF SUSTAINABLE GROWTH RATE (SGR) 

10 AND MEDICARE PAYMENT FOR PHYSICIANS’ 

11 SERVICES. 

12 (a) STABILIZING FEE UPDATES (PHASE I).— 

13 (1) REPEAL OF SGR PAYMENT METHODOLOGY.— 

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

15 1395w–4) is amended— 

16 (A) in subsection (d)— 

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

18 ‘‘or a subsequent paragraph or section 

19 1848A’’ after ‘‘paragraph (4)’’; and 

20 (ii) in paragraph (4)— 


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1 (I) in the heading, by striking 

2 ‘‘YEARS BEGINNING WITH 2001’’ and in3 serting ‘‘2001, 2002, AND 2003’’; and 

4 (II) in subparagraph (A), by 

5 striking ‘‘a year beginning with 2001’’ 

6 and inserting ‘‘2001, 2002, and 2003’’; 

7 and 

8 (B) in subsection (f)— 

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

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

11 year’’; and 

12 (ii) in paragraph (2), by inserting 

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

14 with 2000’’. 

15 (2) UPDATE OF RATES FOR 2014 THROUGH

16 2018.—Subsection (d) of section 1848 of the Social Se17 curity Act (42 U.S.C. 1395w–4) is amended by add18 ing at the end the following new paragraph: 

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

20 update to the single conversion factor established in 

21 paragraph (1)(C) for each of 2014 through 2018 shall 

22 be 0.5 percent.’’. 

23 (b) QUALITY UPDATE INCENTIVE PROGRAM (PHASE

24 II).— 


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1 (1) IN GENERAL.—Section 1848 of the Social Se2 curity Act (42 U.S.C. 1395w–4), as amended by sub3 section (a), is further amended— 

4 (A) in subsection (d), by adding at the end 

5 the following new paragraph: 

6 ‘‘(16) UPDATE BEGINNING WITH 2019.— 

7 ‘‘(A) IN GENERAL.—Subject to subpara8 graph (B), the update to the single conversion 

9 factor established in paragraph (1)(C) for each 

10 year beginning with 2019 shall be 0.5 percent. 

11 ‘‘(B) ADJUSTMENT.—In the case of an eligi12 ble professional (as defined in subsection (k)(3)) 

13 who does not have a payment arrangement de14 scribed in section 1848A(a) in effect, the update 

15 under subparagraph (A) for a year beginning 

16 with 2019 shall be adjusted by the applicable 

17 quality adjustment determined under subsection 

18 (q)(3) for the year involved.’’; and 

19 (B) in subsection (i)(1)— 

20 (i) by striking ‘‘and’’ at the end of sub21 paragraph (D); 

22 (ii) by striking the period at the end of 

23 subparagraph (E) and inserting ‘‘, and’’; 

24 and 


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1 (iii) by adding at the end the following 

2 new subparagraph: 

3 ‘‘(F) the implementation of subsection (q).’’. 

4 (2) ENHANCING PHYSICIAN QUALITY REPORTING

5 SYSTEM TO SUPPORT QUALITY UPDATE INCENTIVE

6 PROGRAM.—Section 1848 of the Social Security Act 

7 (42 U.S.C. 1395w–4) is amended— 

8 (A) in subsection (k)(1), in the first sen9 tence, by inserting ‘‘and, if applicable, clinical 

10 practice improvement activities,’’ after ‘‘quality 

11 measures’’; 

12 (B) in subsection (k)(2)— 

13 (i) in subparagraph (C)— 

14 (I) in the subparagraph heading, 

15 by striking ‘‘AND SUBSEQUENT YEARS’’ 

16 and inserting ‘‘THROUGH 2018’’; and 

17 (II) in clause (i), by inserting 

18 ‘‘(before 2019)’’ after ‘‘subsequent 

19 year’’; 

20 (ii) by redesignating subparagraph (D) 

21 as subparagraph (E); 

22 (iii) by inserting after subparagraph 

23 (C) the following new subparagraph: 

24 ‘‘(D) FOR 2019 AND SUBSEQUENT YEARS.— 

25 For purposes of reporting data on quality measVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6203 E:\BILLS\H2810.RH H2810

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1 ures and, as applicable clinical practice im2 provement activities, for covered professional 

3 services furnished during the performance period 

4 (as defined in subsection (q)(2)(B)) with respect 

5 to 2019 and the performance period with respect 

6 to each subsequent year, subject to subsection 

7 (q)(1)(D), the quality measures and clinical 

8 practice improvement activities specified under 

9 this paragraph shall be, with respect to an eligi10 ble professional, the quality measures and, as ap11 plicable, clinical practice improvement activities 

12 within the final core measure set under para13 graph (9)(F) applicable to the peer cohort of such 

14 provider and year involved.’’; and 

15 (iv) in subparagraph (E), as redesig16 nated by subparagraph (B)(ii) of this para17 graph, by striking ‘‘AND SUBSEQUENT

18 YEARS’’; 

19 (C) in subsection (k)(3)— 

20 (i) in the paragraph heading, by strik21 ing ‘‘COVERED PROFESSIONAL SERVICES

22 AND ELIGIBLE PROFESSIONALS DEFINED’’ 

23 and inserting ‘‘DEFINITIONS’’; and 

24 (ii) by adding at the end the following 

25 new subparagraphs: 


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1 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT AC2 TIVITIES.—The term ‘clinical practice improve3 ment activity’ means an activity that relevant 

4 eligible professional organizations and other rel5 evant stakeholders identify as improving clinical 

6 practice or care delivery and that the Secretary 

7 determines, when effectively executed, is likely to 

8 result in improved outcomes. 

9 ‘‘(D) ELIGIBLE PROFESSIONAL ORGANIZA10 TION.—The term ‘eligible professional organiza11 tion’ means a professional organization as de12 fined by nationally recognized multispecialty 

13 boards of certification or equivalent certification 

14 boards. 

15 ‘‘(E) PEER COHORT.—The term ‘peer co16 hort’ means a peer cohort identified on the list 

17 under paragraph (9)(B), as updated under 

18 clause (ii) of such paragraph.’’; 

19 (D) in subsection (k)(7), by striking ‘‘ and 

20 the application of paragraphs (4) and (5)’’ and 

21 inserting ‘‘, the application of paragraphs (4) 

22 and (5), and the implementation of paragraph 

23 (9)’’; 

24 (E) by adding at the end of subsection (k) 

25 the following new paragraph: 


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1 ‘‘(9) ESTABLISHMENT OF FINAL CORE MEASURE

2 SETS.— 

3 ‘‘(A) IN GENERAL.—Under the system under 

4 this subsection— 

5 ‘‘(i) for each peer cohort identified 

6 under subparagraph (B) and in accordance 

7 with this paragraph, there shall be pub8 lished a final core measure set under sub9 paragraph (F), which shall consist of qual10 ity measures and may also consist of clin11 ical practice improvement activities, with 

12 respect to which eligible professionals shall, 

13 subject to subsection (m)(3)(C), be assessed 

14 for purposes of determining, for years begin15 ning with 2019, the quality adjustment 

16 under subsection (q)(3) applicable to such 

17 professionals; and 

18 ‘‘(ii) each eligible professional shall 

19 self-identify, in accordance with subpara20 graph (B), within such a peer cohort for 

21 purposes of such assessments. 

22 ‘‘(B) PEER COHORTS.—The Secretary shall 

23 identify (and publish a list of) peer cohorts by 

24 which eligible professionals shall self-identify for 

25 purposes of this subsection and subsection (q) 


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1 with respect to a performance period (as defined 

2 in subsection (q)(2)(B)) for a year beginning 

3 with 2019. For purposes of this subsection and 

4 subsection (q), the Secretary shall develop one or 

5 more peer cohorts for multispecialty groups, each 

6 of which shall be included as a peer cohort under 

7 this subparagraph. Such self-identification will 

8 be made through such a process and at such time 

9 as specified under the system under this sub10 section. Such list— 

11 ‘‘(i) shall include, as peer cohorts, pro12 vider specialties defined by nationally rec13 ognized multispecialty boards of certifi14 cation or equivalent certification boards 

15 and such other cohorts as established under 

16 this section in order to capture classifica17 tions of providers across eligible professional 

18 organizations and other practice areas, 

19 groupings, or categories; and 

20 ‘‘(ii) shall be updated from time to 

21 time. 

22 ‘‘(C) QUALITY MEASURES FOR CORE MEAS23 URE SETS.— 

24 ‘‘(i) DEVELOPMENT.—Under the sys25 tem under this subsection there shall be esVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6203 E:\BILLS\H2810.RH H2810

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1 tablished a process for the development of 

2 quality measures under this subparagraph 

3 for purposes of potential inclusion of such 

4 measures in core measure sets under this 

5 paragraph. Under such process— 

6 ‘‘(I) there shall be coordination, to 

7 the extent possible, across organizations 

8 developing such measures; 

9 ‘‘(II) eligible professional organi10 zations and other relevant stakeholders 

11 may submit best practices and clinical 

12 practice guidelines for the development 

13 of quality measures that address qual14 ity domains (as defined under clause 

15 (ii)) for potential inclusion in such 

16 core measure sets; 

17 ‘‘(III) there is encouraged to be 

18 developed, as appropriate, meaningful 

19 outcome measures (or quality of life 

20 measures in cases for which outcomes 

21 may not be a valid measurement), 

22 functional status measures, and pa23 tient experience measures; and 

24 ‘‘(IV) measures developed under 

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1 tent possible, in accordance with best 

2 practices and clinical practice guide3 lines. 

4 ‘‘(ii) QUALITY DOMAINS.—For pur5 poses of this paragraph, the term ‘quality 

6 domains’ means at least the following do7 mains: 

8 ‘‘(I) Clinical care. 

9 ‘‘(II) Safety. 

10 ‘‘(III) Care coordination. 

11 ‘‘(IV) Patient and caregiver expe12 rience. 

13 ‘‘(V) Population health and pre14 vention. 

15 ‘‘(D) PROCESS FOR ESTABLISHING CORE

16 MEASURE SETS.— 

17 ‘‘(i) IN GENERAL.—Under the system 

18 under this subsection, for purposes of sub19 paragraph (A), there shall be established a 

20 process to approve final core measure sets 

21 under this paragraph for peer cohorts. Each 

22 such final core measure set shall be com23 posed of quality measures (and, as applica24 ble, clinical practice improvement activi25 ties) with respect to which eligible profesVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6203 E:\BILLS\H2810.RH H2810

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1 sionals within such peer cohort shall report 

2 under this subsection and be assessed under 

3 subsection (q). Such process shall provide— 

4 ‘‘(I) for the establishment of cri5 teria, which shall be made publicly 

6 available before the request is made 

7 under clause (ii), for selecting such 

8 measures and activities for potential 

9 inclusion in such a final core measure 

10 set; and 

11 ‘‘(II) that all peer cohorts, and to 

12 the extent practicable all quality do13 mains, are addressed by measures and, 

14 as applicable, clinical practice im15 provement activities selected to be in16 cluded in a core measure set under this 

17 paragraph, which may include through 

18 the use of such a measure or clinical 

19 practice improvement activity that ad20 dresses more than one such domain or 

21 cohort. 

22 ‘‘(ii) SOLICITATION OF PUBLIC INPUT

23 ON QUALITY MEASURES AND CLINICAL PRAC24 TICE IMPROVEMENT ACTIVITIES.—Under the 

25 process established under clause (i), relevant 


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1 eligible professional organizations and other 

2 relevant stakeholders shall be requested to 

3 identify and submit quality measures and 

4 clinical practice improvement activities (as 

5 defined in paragraph (3)(C)) for selection 

6 under this paragraph. For purposes of the 

7 previous sentence, measures and activities 

8 may be submitted regardless of whether such 

9 measures were previously published in a 

10 proposed rule or endorsed by an entity with 

11 a contract under section 1890(a). 

12 ‘‘(E) CORE MEASURE SETS.— 

13 ‘‘(i) IN GENERAL.—Under the process 

14 established under subparagraph (D)(i), the 

15 Secretary— 

16 ‘‘(I) shall select, from quality 

17 measures described in clause (ii) appli18 cable to a peer cohort, quality measures 

19 to be included in a core measure set for 

20 such cohort; 

21 ‘‘(II) shall, to the extent there are 

22 insufficient quality measures applica23 ble to a peer cohort to address one or 

24 more applicable quality domains, select 

25 to be included in a core measure set for 


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1 such cohort such clinical practice im2 provement activities described in clause 

3 (ii)(IV) as are needed and available to 

4 sufficiently address such an applicable 

5 domain with respect to such peer co6 hort; and 

7 ‘‘(III) may select, to the extent de8 termined appropriate, any additional 

9 clinical practice improvement activi10 ties described in clause (ii)(IV) appli11 cable to a peer cohort to be included in 

12 a core measure set for such cohort. 

13 Activities selected under this paragraph 

14 shall be selected with consideration of best 

15 practices and clinical practice guidelines 

16 identified under subparagraph (C)(i)(II). 

17 ‘‘(ii) SOURCES OF QUALITY MEASURES

18 AND CLINICAL PRACTICE IMPROVEMENT AC19 TIVITIES.—A quality measure or clinical 

20 practice improvement activity selected for 

21 inclusion in a core measure set under the 

22 process under subparagraph (D)(i) shall 

23 be— 

24 ‘‘(I) a measure endorsed by a con25 sensus-based entity; 


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1 ‘‘(II) a measure developed under 

2 paragraph (2)(C) or a measure other3 wise applied or developed for a similar 

4 purpose under this section; 

5 ‘‘(III) a measure developed under 

6 subparagraph (C); or 

7 ‘‘(IV) a measure or activity sub8 mitted under subparagraph (D)(ii). 

9 A measure or activity may be selected under 

10 this subparagraph, regardless of whether 

11 such measure or activity was previously 

12 published in a proposed rule. A measure so 

13 selected shall be evidence-based but (other 

14 than a measure described in subclause (I)) 

15 shall not be required to be consensus-based. 

16 ‘‘(iii) TRANSPARENCY.—Before pub17 lishing in a final regulation a core measure 

18 set under clause (i) as a final core measure 

19 set under subparagraph (F), the Secretary 

20 shall— 

21 ‘‘(I) submit for publication in ap22 plicable specialty-appropriate peer-re23 viewed journals such core measure set 

24 under clause (i) and the method for de25 veloping and selecting measures within 


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1 such set, including clinical and other 

2 data supporting such measures, and, 

3 as applicable, the method for selecting 

4 clinical practice improvement activi5 ties included within such set; and 

6 ‘‘(II) regardless of whether or not 

7 the core measure set or method is pub8 lished in such a journal under sub9 clause (I), provide for notice of the pro10 posed regulation in the Federal Reg11 ister, including with respect to the ap12 plicable methods and data described in 

13 subclause (I), and a period for public 

14 comment thereon. 

15 ‘‘(F) FINAL CORE MEASURE SETS.—Not 

16 later than November 15 of the year prior to the 

17 first day of a performance period, the Secretary 

18 shall publish a final regulation in the Federal 

19 Register that includes a final core measure set 

20 (and the applicable methods and data described 

21 in subparagraph (E)(iii)(I)) for each peer cohort 

22 to be applied for such performance period. 

23 ‘‘(G) PERIODIC REVIEW AND UPDATES.— 

24 ‘‘(i) IN GENERAL.—In carrying out 

25 this paragraph, under the system under this 


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1 subsection, there shall periodically be re2 viewed— 

3 ‘‘(I) the quality measures and 

4 clinical practice improvement activi5 ties selected for inclusion in final core 

6 measure sets under this paragraph for 

7 each year such measures and activities 

8 are to be applied under this subsection 

9 or subsection (q) to ensure that such 

10 measures and activities continue to 

11 meet the conditions applicable to such 

12 measures and activities for such selec13 tion; and 

14 ‘‘(II) the final core measure sets 

15 published under subparagraph (F) for 

16 each year such sets are to be applied to 

17 peer cohorts of eligible professionals to 

18 ensure that each applicable set con19 tinues to meet the conditions applica20 ble to such sets before being so pub21 lished. 

22 ‘‘(ii) COLLABORATION WITH STAKE23 HOLDERS.—In carrying out clause (i), rel24 evant eligible professional organizations and 

25 other relevant stakeholders may identify 


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1 and submit updates to quality measures 

2 and clinical practice improvement activities 

3 selected under this paragraph for inclusion 

4 in final core measure sets as well as any 

5 additional quality measures and clinical 

6 practice improvement activities. Not later 

7 than November 15 of the year prior to the 

8 first day of a performance period, submis9 sions under this clause shall be reviewed. 

10 ‘‘(iii) ADDITIONAL, AND UPDATES TO, 

11 MEASURES AND ACTIVITIES.—Based on the 

12 review conducted under this subparagraph 

13 for a period, as needed, there shall be— 

14 ‘‘(I) selected additional, and up15 dates to, quality measures and clinical 

16 practice improvement activities selected 

17 under this paragraph for potential in18 clusion in final core measure sets in 

19 the same manner such quality meas20 ures and clinical practice improvement 

21 activities are selected under this para22 graph for such potential inclusion; 

23 ‘‘(II) removed, from final core 

24 measure sets, quality measures and 


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1 clinical practice improvement activi2 ties that are no longer meaningful; and 

3 ‘‘(III) updated final core measure 

4 sets published under subparagraph (F) 

5 in the same manner as such sets are 

6 approved under such subparagraph. 

7 For purposes of this subsection and sub8 section (q), a final core measure set, as up9 dated under this subparagraph, shall be 

10 treated in the same manner as a final core 

11 measure set published under subparagraph 

12 (F). 

13 ‘‘(iv) TRANSPARENCY.— 

14 ‘‘(I) NOTIFICATION REQUIRED

15 FOR CERTAIN UPDATES.—In the case of 

16 an update under subclause (II) or (III) 

17 of clause (iii) that adds, materially 

18 changes, or removes a measure or ac19 tivity from a measure set, such update 

20 shall not apply under this subsection 

21 or subsection (q) unless notification of 

22 such update is made available to ap23 plicable eligible professionals. 

24 ‘‘(II) PUBLIC AVAILABILITY OF

25 UPDATED FINAL CORE MEASURE


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1 SETS.—Subparagraph (E)(iii) shall 

2 apply with respect to measure sets up3 dated under subclause (II) or (III) of 

4 clause (iii) in the same manner as 

5 such subparagraph applies to applica6 ble core measure sets under subpara7 graph (E). 

8 ‘‘(H) COORDINATION WITH EXISTING PRO9 GRAMS.—The development and selection of qual10 ity measures and clinical practice improvement 

11 activities under this paragraph shall, as appro12 priate, be coordinated with the development and 

13 selection of existing measures and requirements, 

14 such as the development of the Physician Com15 pare Website under subsection (m)(5)(G) and the 

16 application of resource use management under 

17 subsection (n). To the extent feasible, such meas18 ures and activities shall align with measures 

19 used by other payers and with measures and ac20 tivities in use under other programs in order to 

21 streamline the process of such development and 

22 selection under this paragraph. The Secretary 

23 shall develop a plan to integrate reporting on 

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1 ing to the meaningful use of certified EHR tech2 nology. 

3 ‘‘(I) CONSULTATION WITH RELEVANT ELIGI4 BLE PROFESSIONAL ORGANIZATIONS AND OTHER

5 RELEVANT STAKEHOLDERS.—Relevant eligible 

6 professional organizations (as defined in para7 graph (3)(D)) and other relevant stakeholders, 

8 including State and national medical societies, 

9 shall be consulted in carrying out this para10 graph. 

11 ‘‘(J) OPTIONAL APPLICATION.—The process 

12 under section 1890A is not required to apply to 

13 the development or selection of measures under 

14 this paragraph.’’; and 

15 (F) in subsection (m)(3)(C)(i), by adding at 

16 the end the following new sentence: ‘‘Such process 

17 shall, beginning for 2019, treat eligible profes18 sionals in such a group practice as reporting on 

19 measures for purposes of application of sub20 sections (q) and (a)(8)(A)(iii) if, in lieu of re21 porting measures under subsection (k)(2)(D), the 

22 group practice reports measures determined ap23 propriate by the Secretary.’’. 

24 (3) ESTABLISHMENT OF QUALITY UPDATE INCEN25 TIVE PROGRAM.— 


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1 (A) IN GENERAL.—Section 1848 of the So2 cial Security Act (42 U.S.C. 1395w–4) is 

3 amended by adding at the end the following new 

4 subsection: 

5 ‘‘(q) QUALITY UPDATE INCENTIVE PROGRAM.— 

6 ‘‘(1) ESTABLISHMENT.— 

7 ‘‘(A) IN GENERAL.—The Secretary shall es8 tablish an eligible professional quality update 

9 incentive program (in this section referred to as 

10 the ‘quality update incentive program’) under 

11 which— 

12 ‘‘(i) there is developed and applied, in 

13 accordance with paragraph (2), appropriate 

14 methodologies for assessing the performance 

15 of eligible professionals with respect to qual16 ity measures and clinical practice improve17 ment activities included within the final 

18 core measure sets published under subsection 

19 (k)(9)(F) applicable to the peer cohorts of 

20 such providers; 

21 ‘‘(ii) there is applied, consistent with 

22 the system under subsection (k), methods for 

23 collecting information needed for such as24 sessments (which shall involve the minimum 


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1 amount of administrative burden required 

2 to ensure reliable results); and 

3 ‘‘(iii) the applicable update adjust4 ments under paragraph (3) are determined 

5 by such assessments. 

6 ‘‘(B) DEFINITIONS.— 

7 ‘‘(i) ELIGIBLE PROFESSIONAL.—In this 

8 subsection, the term ‘eligible professional’ 

9 has the meaning given such term in sub10 section (k)(3), except that such term shall 

11 not include a professional who has a pay12 ment arrangement described in section 

13 1848A(a)(1) in effect. 

14 ‘‘(ii) PEER COHORTS; CLINICAL PRAC15 TICE IMPROVEMENT ACTIVITIES; ELIGIBLE

16 PROFESSIONAL ORGANIZATIONS.—In this 

17 subsection, the terms ‘peer cohort’, ‘clinical 

18 practice improvement activity’, and ‘eligible 

19 professional organization’ have the mean20 ings given such terms in subsection (k)(3). 

21 ‘‘(C) CONSULTATION WITH ELIGIBLE PRO22 FESSIONAL ORGANIZATIONS AND OTHER REL23 EVANT STAKEHOLDERS.—Eligible professional 

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1 cluding State and national medical societies, 

2 shall be consulted in carrying out this subsection. 

3 ‘‘(D) APPLICATION AT GROUP PRACTICE

4 LEVEL.—The Secretary shall establish a process, 

5 consistent with subsection (m)(3)(C), under 

6 which the provisions of this subsection are ap7 plied to eligible professionals in a group practice 

8 if the group practice reports measures deter9 mined appropriate by the Secretary under such 

10 subsection. 

11 ‘‘(E) COORDINATION WITH EXISTING PRO12 GRAMS.—The application of measures and clin13 ical practice improvement activities and assess14 ment of performance under this subsection shall, 

15 as appropriate, be coordinated with the applica16 tion of measures and assessment of performance 

17 under other provisions of this section. 

18 ‘‘(2) ASSESSING PERFORMANCE WITH RESPECT

19 TO FINAL CORE MEASURE SETS FOR APPLICABLE

20 PEER COHORTS.— 

21 ‘‘(A) ESTABLISHMENT OF METHODS FOR

22 ASSESSMENT.— 

23 ‘‘(i) IN GENERAL.—Under the quality 

24 update incentive program, the Secretary 

25 shall— 


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1 ‘‘(I) establish one or more meth2 ods, applicable with respect to a per3 formance period, to assess (using a 

4 scoring scale of 0 to 100) the perform5 ance of an eligible professional with re6 spect to, subject to paragraph (1)(D), 

7 quality measures and clinical practice 

8 improvement activities included within 

9 the final core measure set published 

10 under subsection (k)(9)(F) applicable 

11 for the period to the peer cohort in 

12 which the provider self-identified under 

13 subsection (k)(9)(B) for such period; 

14 and 

15 ‘‘(II) subject to paragraph (1)(D), 

16 compute a composite score for such 

17 provider for such performance period 

18 with respect to the measures and ac19 tivities included within such final core 

20 measure set. 

21 ‘‘(ii) METHODS.—Such methods shall, 

22 with respect to an eligible professional, pro23 vide that the performance of such profes24 sional shall, subject to paragraph (1)(D), be 

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1 spect to the quality measures and clinical 

2 practice improvement activities within the 

3 final core measure set for such period for 

4 the peer cohort of such professional and on 

5 which information is collected from such 

6 professional. 

7 ‘‘(iii) WEIGHTING OF MEASURES.— 

8 Such a method may provide for the assign9 ment of different scoring weights or, as ap10 propriate, other factors— 

11 ‘‘(I) for quality measures and 

12 clinical practice improvement activi13 ties; 

14 ‘‘(II) based on the type or cat15 egory of measure or activity; and 

16 ‘‘(III) based on the extent to 

17 which a quality measure or clinical 

18 practice improvement activity mean19 ingfully assesses quality. 

20 ‘‘(iv) RISK ADJUSTMENT.—Such a 

21 method shall provide for appropriate risk 

22 adjustments. 

23 ‘‘(v) INCORPORATION OF OTHER METH24 ODS OF MEASURING PHYSICIAN QUALITY.— 

25 In establishing such methods, there shall be, 


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1 as appropriate, incorporated comparable 

2 methods of measurement from physician 

3 quality incentive programs under this sub4 section. 

5 ‘‘(B) PERFORMANCE PERIOD.—There shall 

6 be established a period (in this subsection re7 ferred to as a ‘performance period’), with respect 

8 to a year (beginning with 2019) for which the 

9 quality adjustment is applied under paragraph 

10 (3), to assess performance on quality measures 

11 and clinical practice improvement activities. 

12 Each such performance period shall be a period 

13 of 12 consecutive months and shall end as close 

14 as possible to the beginning of the year for which 

15 such adjustment is applied. 

16 ‘‘(3) QUALITY ADJUSTMENT TAKING INTO AC17 COUNT QUALITY ASSESSMENTS.— 

18 ‘‘(A) QUALITY ADJUSTMENT.—For purposes 

19 of subsection (d)(16), if the composite score com20 puted under paragraph (2)(A) for an eligible 

21 professional for a year (beginning with 2019) 

22 is— 

23 ‘‘(i) a score of 67 or higher, the quality 

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1 igible professional and year is 1 percentage 

2 point; 

3 ‘‘(ii) a score of at least 34, but below 

4 67, the quality adjustment under this para5 graph for the eligible professional and year 

6 is zero; or 

7 ‘‘(iii) a score below 34, the quality ad8 justment under this paragraph for the eligi9 ble professional and year is -1 percentage 

10 point. 

11 ‘‘(B) NO EFFECT ON SUBSEQUENT YEARS’ 

12 QUALITY ADJUSTMENTS.—Each such quality ad13 justment shall be made each year without regard 

14 to the quality adjustment for a previous year 

15 under this paragraph. 

16 ‘‘(4) TRANSITION FOR NEW ELIGIBLE PROFES17 SIONALS.—In the case of a physician, practitioner, or 

18 other supplier that during a performance period, with 

19 respect to a year for which a quality adjustment is 

20 applied under paragraph (3), first becomes an eligible 

21 professional (and had not previously submitted claims 

22 under this title as a person, as an entity, or as part 

23 of a physician group or under a different billing 

24 number or tax identifier), the quality adjustment 


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1 under this subsection applicable to such physician, 

2 practitioner, or supplier— 

3 ‘‘(A) for such year, with respect to such first 

4 performance period, shall be zero; and 

5 ‘‘(B) for a year, with respect to a subse6 quent performance period, shall be the quality 

7 adjustment that would otherwise be applied 

8 under this subsection. 

9 ‘‘(5) FEEDBACK.— 

10 ‘‘(A) FEEDBACK.— 

11 ‘‘(i) ONGOING FEEDBACK.—Under the 

12 process under subsection (m)(5)(H), there 

13 shall be provided, as real time as possible, 

14 but at least quarterly, beginning not later 

15 than 6 months after the first day of the first 

16 performance period, to each eligible profes17 sional feedback— 

18 ‘‘(I) on the performance of such 

19 provider with respect to quality meas20 ures and clinical practice improvement 

21 activities within the final core measure 

22 set published under subsection 

23 (k)(9)(F) for the applicable perform24 ance period and the peer cohort of such 

25 professional; and 


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1 ‘‘(II) to assess the progress of such 

2 professional under the quality update 

3 incentive program with respect to a 

4 performance period for a year. 

5 ‘‘(ii) USE OF REGISTRIES AND OTHER

6 MECHANISMS.—Feedback under this sub7 paragraph shall, to the extent an eligible 

8 professional chooses to participate in a data 

9 registry for purposes of this subsection (in10 cluding registries under subsections (k) and 

11 (m)), be provided and based on performance 

12 received through the use of such registry, 

13 and to the extent that an eligible profes14 sional chooses not to participate in such a 

15 registry for such purposes, be provided 

16 through other similar mechanisms that 

17 allow for the provision of such feedback and 

18 receipt of such performance information. 

19 ‘‘(B) DATA MECHANISM.—Under the quality 

20 update incentive program, there shall be devel21 oped an electronic interactive eligible profes22 sional mechanism through which such a profes23 sional may receive performance data, including 

24 data with respect to performance on the meas25 ures and activities developed and selected under 


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1 this section. Such mechanism shall be developed 

2 in consultation with private payers and health 

3 insurance issuers (as defined in section 

4 2791(b)(2) of the Public Health Service Act) as 

5 appropriate. 

6 ‘‘(C) TRANSFER OF FUNDS.—The Secretary 

7 shall provide for the transfer of $100,000,000 

8 from the Federal Supplementary Medical Insur9 ance Trust Fund established in section 1841 to 

10 the Center for Medicare & Medicaid Services 

11 Program Management Account to support such 

12 efforts to develop the infrastructure as necessary 

13 to carry out subsection (k)(9) and this subsection 

14 and for purposes of section 1889(h). Such funds 

15 shall be so transferred on the date of the enact16 ment of this subsection and shall remain avail17 able until expended.’’. 

18 (B) INCENTIVE TO REPORT UNDER QUALITY

19 UPDATE INCENTIVE PROGRAM.—Section 

20 1848(a)(8)(A) of the Social Security Act (42 

21 U.S.C. 1395w–4(a)(8)(A)) is amended— 

22 (i) in clause (i), by striking ‘‘With re23 spect to’’ and inserting ‘‘Subject to clause 

24 (iii), with respect to’’; and 


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1 (ii) by adding at the end the following 

2 new clause: 

3 ‘‘(iii) APPLICATION TO ELIGIBLE PRO4 FESSIONALS NOT REPORTING.—With respect 

5 to covered professional services (as defined 

6 in subsection (k)(3)) furnished by an eligi7 ble professional during 2019 or any subse8 quent year, if the eligible professional does 

9 not submit data for the performance period 

10 (as defined in subsection (q)(2)(B)) with re11 spect to such year on, subject to subsection 

12 (q)(1)(D), the quality measures and, as ap13 plicable, clinical practice improvement ac14 tivities within the final core measure set 

15 under subsection (k)(9)(F) applicable to the 

16 peer cohort of such provider, the fee schedule 

17 amount for such services furnished by such 

18 professional during the year (including the 

19 fee schedule amount for purposes of deter20 mining a payment based on such amount) 

21 shall be equal to 95 percent (in lieu of the 

22 applicable percent) of the fee schedule 

23 amount that would otherwise apply to such 

24 services under this subsection (determined 

25 after application of paragraphs (3), (5), 


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1 and (7), but without regard to this para2 graph). The Secretary shall develop a min3 imum per year caseload threshold, with re4 spect to eligible professionals, and the pre5 vious sentence shall not apply to eligible 

6 professionals with a caseload for a year 

7 below such threshold for such year.’’. 

8 (C) EDUCATION ON QUALITY UPDATE IN9 CENTIVE PROGRAM.—Section 1889 of the Social 

10 Security Act (42 U.S.C. 1395zz) is amended by 

11 adding at the end the following new subsection: 

12 ‘‘(h) QUALITY UPDATE INCENTIVE PROGRAM.—Under 

13 this section, information shall be disseminated to educate 

14 and assist eligible professionals (as defined in section 

15 1848(k)(3)) about the quality update incentive program 

16 under section 1848(q) and quality measures under section 

17 1848(k)(9) through multiple approaches, including a na18 tional dissemination strategy and outreach by medicare 

19 contractors.’’. 

20 (4) CONFORMING AMENDMENTS.— 

21 (A) TREATMENT OF SATISFACTORILY RE22 PORTING PQRS MEASURES THROUGH PARTICIPA23 TION IN A QUALIFIED CLINICAL DATA REG24 ISTRY.—Section 1848(m)(3)(D) of the Social Se25 curity Act (42 U.S.C. 1395w–4(m)(3)(D)) is 


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1 amended by striking ‘‘For 2014 and subsequent 

2 years’’ and inserting ‘‘For each of 2014 through 

3 2018’’. 

4 (B) COORDINATING ENHANCED PQRS RE5 PORTING WITH EHR.—Section 1848(o)(2)(B)(iii) 

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

7 4(o)(2)(B)(iii)) is amended by striking ‘‘sub8 section (k)(2)(C)’’ and inserting ‘‘subparagraph 

9 (C) or (D) of subsection (k)(2)’’. 

10 (C) COORDINATING PQRS REPORTING PE11 RIOD WITH QUALITY UPDATE INCENTIVE PRO12 GRAM PERFORMANCE PERIOD.—Section 

13 1848(m)(6)(C) of the Social Security Act (42 

14 U.S.C. 1395w–4(m)(6)(C)) is amended— 

15 (i) in clause (i), by striking ‘‘and 

16 (iii)’’ and inserting ‘‘, (iii), and (iv)’’; and 

17 (ii) by adding at the end the following 

18 new clause: 

19 ‘‘(iv) COORDINATION WITH QUALITY

20 UPDATE INCENTIVE PROGRAM.—For 2019 

21 and each subsequent year the reporting pe22 riod shall be coordinated with the perform23 ance period under subsection (q)(2)(B).’’. 

24 (D) COORDINATING EHR REPORTING WITH

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1 FORMANCE PERIOD.—Section 1848(o)(5)(B) of 

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

3 4(o)(5)(B)) is amended by adding at the end the 

4 following: ‘‘Beginning for 2019, the EHR report5 ing period shall be coordinated with the perform6 ance period under subsection (q)(2)(B).’’. 

7 (c) ADVANCING ALTERNATIVE PAYMENT MODELS.— 

8 (1) IN GENERAL.—Part B of title XVIII of the 

9 Social Security Act (42 U.S.C. 1395w–4 et seq.) is 

10 amended by adding at the end the following new sec11 tion: 

12 ‘‘SEC. 1848A. ADVANCING ALTERNATIVE PAYMENT MODELS. 

13 ‘‘(a) PAYMENT MODEL CHOICE PROGRAM.—Payment 

14 for covered professional services (as defined in section 

15 1848(k)) that are furnished by an eligible professional (as 

16 defined in such section) under an Alternative Payment 

17 Model specified on the list under subsection (h) (in this sec18 tion referred to as an ‘eligible APM’) shall be made under 

19 this title in accordance with the payment arrangement 

20 under such model. In applying the previous sentence, such 

21 a professional with such a payment arrangement in effect, 

22 shall be deemed for purposes of section 1848(a)(8) to be sat23 isfactorily submitting data on quality measures for such 

24 covered professional services. 


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1 ‘‘(b) PROCESS FOR IMPLEMENTING ELIGIBLE

2 APMS.— 

3 ‘‘(1) IN GENERAL.—For purposes of subsection 

4 (a) and in accordance with this section, the Secretary 

5 shall establish a process under which— 

6 ‘‘(A) a contract is entered into, in accord7 ance with paragraph (2); 

8 ‘‘(B) proposals for potential Alternative 

9 Payment Models are submitted in accordance 

10 with subsection (c); 

11 ‘‘(C) Alternative Payment Models so pro12 posed are recommended, in accordance with sub13 section (d), for testing and evaluation, including 

14 through the demonstration program under sub15 section (e), and approval under subsection (f); 

16 ‘‘(D) applicable Alternative Payment Mod17 els are tested and evaluated under such dem18 onstration program; 

19 ‘‘(E) models are implemented as eligible 

20 APMs in accordance with subsection (f); and 

21 ‘‘(F) a comprehensive list of all eligible 

22 APMs is made publicly available, in accordance 

23 with subsection (h), for application under sub24 section (a). 


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1 ‘‘(2) CONTRACT WITH APM CONTRACTING ENTI2 TY.— 

3 ‘‘(A) IN GENERAL.—For purposes of para4 graph (1)(A), the Secretary shall identify and 

5 have in effect a contract with an independent en6 tity that has appropriate expertise to carry out 

7 the functions applicable to such entity under this 

8 section. Such entity shall be referred to in this 

9 section as the ‘APM contracting entity’. 

10 ‘‘(B) TIMING FOR FIRST CONTRACT.—The 

11 Secretary shall enter into the first contract under 

12 subparagraph (A) to be in effect January 1, 

13 2019. 

14 ‘‘(C) COMPETITIVE PROCEDURES.—Com15 petitive procedures (as defined in section 4(5) of 

16 the Office of Federal Procurement Policy Act (41 

17 U.S.C. 403(5)) shall be used to enter into a con18 tract under subparagraph (A). 

19 ‘‘(c) SUBMISSION OF PROPOSED ALTERNATIVE PAY20 MENT MODELS.—Beginning not later than 90 days after 

21 the date the Secretary enters into a contract under sub22 section (b)(2) with the APM contracting entity, physicians, 

23 eligible professional organizations, health care provider or24 ganizations, and other entities may submit to the APM con25 tracting entity proposals for Alternative Payment Models 


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1 for application under this section. Such a proposal of a 

2 model shall include suggestions for measures to be used 

3 under subsection (e)(1)(B) for purposes of evaluating such 

4 model. In reviewing submissions under this subsection for 

5 purposes of making recommendations under subsection 

6 (d)(1), the contracting entity shall focus on submissions for 

7 such models that are intended to improve care coordination 

8 and quality for patients through modifying the manner in 

9 which physicians and other providers are paid under this 

10 title. 

11 ‘‘(d) RECOMMENDATION BY APM CONTRACTING ENTI12 TY OF PROPOSED MODELS.— 

13 ‘‘(1) RECOMMENDATION.— 

14 ‘‘(A) RECOMMENDATIONS TO SECRETARY.— 

15 ‘‘(i) IN GENERAL.—Under the process 

16 under subsection (b), the APM contracting 

17 entity shall at least quarterly recommend, 

18 in accordance with clause (ii), to the Sec19 retary— 

20 ‘‘(I) Alternative Payment Models 

21 submitted under subsection (c) to be 

22 tested and evaluated through a dem23 onstration program under subsection 

24 (e); and 


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1 ‘‘(II) Alternative Payment Models 

2 submitted under subsection (c) to be 

3 implemented under subsection (f) with4 out testing and evaluation through 

5 such a demonstration program. 

6 Such a recommendation under subclause (I) 

7 may be made with respect to a model for 

8 which a waiver would be required under 

9 paragraph (2). Any reference in this sub10 section to an Alternative Payment Model 

11 under this clause is a reference to such 

12 model as may be modified under clause 

13 (iii). 

14 ‘‘(ii) REQUIREMENTS.—In recom15 mending an Alternative Payment Model 

16 under clause (i), each of the following shall 

17 apply: 

18 ‘‘(I) The APM contracting entity 

19 may recommend an Alternative Pay20 ment Model under clause (i)(I) only if 

21 the entity determines that the model 

22 satisfies the criteria described in sub23 paragraph (B), including the criteria 

24 described in subparagraph (B)(iv). 


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1 ‘‘(II) The APM contracting entity 

2 may recommend an Alternative Pay3 ment Model under clause (i)(II) only if 

4 the entity determines that the model 

5 satisfies the criteria described in sub6 paragraph (C), including the criteria 

7 described in subparagraph (C)(iii). 

8 ‘‘(III) The APM contracting enti9 ty shall include with the recommended 

10 Alternative Payment Model rec11 ommendations for rules of coordination 

12 described in clause (v). 

13 ‘‘(iii) MODIFICATIONS BY APM CON14 TRACTING ENTITY.—For purposes of this 

15 subparagraph, to the extent necessary to 

16 meet the applicable requirements of clause 

17 (ii), the APM contracting entity may mod18 ify an Alternative Payment Model sub19 mitted under subsection (c) to ensure that 

20 the model would— 

21 ‘‘(I) reduce spending under this 

22 title without reducing the quality of 

23 care; or 


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1 ‘‘(II) improve the quality of care 

2 without increasing spending under this 

3 title. 

4 ‘‘(iv) FORMS OF MODIFICATIONS.— 

5 Such a modification under clause (iii) may 

6 include one or more of the following: 

7 ‘‘(I) A change to the payment ar8 rangement under which eligible profes9 sionals participating in such model 

10 would be paid for covered professional 

11 services furnished under such model. 

12 ‘‘(II) A change to the criteria for 

13 eligible professionals to be eligible to 

14 participate under such model in order 

15 to ensure that the requirement de16 scribed in subclause (I) or (II) is satis17 fied. 

18 ‘‘(III) A change to the rules of co19 ordination described in clause (v). 

20 ‘‘(IV) The application of a with21 hold mechanism under the payment ar22 rangement under which the distribu23 tion of withheld amounts is based on 

24 the success of the model in meeting 

25 spending reduction requirements. 


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1 ‘‘(V) Such other change as the 

2 contracting entity may specify. 

3 ‘‘(v) RULES OF COORDINATION FOR AP4 PLICATION OF PAYMENT ARRANGEMENTS

5 UNDER MODELS.— 

6 ‘‘(I) IN GENERAL.—Rules of co7 ordination described in this clause for 

8 an Alternative Payment Model shall be 

9 designed to determine, for purposes of 

10 applying subsection (a) and section 

11 1848(d)(16), under what circumstances 

12 an eligible professional is treated as 

13 having a payment arrangement under 

14 a particular model. 

15 ‘‘(II) NONDUPLICATION OF PAY16 MENT.—Such rules of coordination 

17 shall ensure coordination and non18 duplication of payment of services that 

19 might be covered under more than one 

20 payment arrangement or under section 

21 1848(d)(16). 

22 ‘‘(III) APPLICATION TO NON-APM

23 PAYMENT.—In applying such rules of 

24 coordination for purposes of section 

25 1848(d)(16), an eligible professional 


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1 shall not be treated as having a pay2 ment arrangement in effect under such 

3 a model for any covered professional 

4 services not treated as furnished under 

5 the model. 

6 ‘‘(B) CRITERIA FOR RECOMMENDING MOD7 ELS FOR DEMONSTRATION.—For purposes of sub8 paragraph (A)(ii)(I), the criteria described in 

9 this subparagraph, with respect to an Alter10 native Payment Model, are each of the following: 

11 ‘‘(i) The model has been supported by 

12 meaningful clinical and non-clinical data, 

13 with respect to a sufficient population sam14 ple, that indicates the model would be suc15 cessful at addressing each of the abilities de16 scribed in clause (iv). 

17 ‘‘(ii)(I) In the case of a model that has 

18 already been evaluated and supported by 

19 data with respect to a population of indi20 viduals enrolled under this part, if the 

21 model were evaluated under the demonstra22 tion under subsection (e) such a population 

23 would represent a sufficient number of indi24 viduals enrolled under this part to ensure a 


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1 meaningful evaluation of the likely effect of 

2 expanding the demonstration. 

3 ‘‘(II) In the case of a model that has 

4 not been so evaluated and supported by 

5 data with respect to such a population, the 

6 population that would be furnished services 

7 under such model if the model were evalu8 ated under the demonstration under sub9 section (e) would represent a sufficient 

10 number of individuals enrolled under this 

11 part to ensure a meaningful evaluation of 

12 the likely effect of expanding the demonstra13 tion. 

14 ‘‘(iii) Such model, including if tested 

15 and evaluated under the demonstration 

16 under subsection (e), would not deny or 

17 limit the coverage or provision of benefits 

18 under this title for applicable individuals. 

19 ‘‘(iv) The proposal for such model dem20 onstrates— 

21 ‘‘(I) the significant likelihood to 

22 successfully manage the cost of fur23 nishing items and services under this 

24 title so as to not result in expenditures 

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1 penditures under this title if the APM 

2 were not implemented; and 

3 ‘‘(II) the ability to maintain or 

4 improve the overall quality of patient 

5 care provided to individuals enrolled 

6 under this part. 

7 ‘‘(v) The model provides for a payment 

8 arrangement— 

9 ‘‘(I) that specifies the items and 

10 services covered under the arrangement 

11 and specifies rules of coordination de12 scribed in subparagraph (A)(v) be13 tween the items and services covered 

14 under the arrangement and other items 

15 and services not covered under the ar16 rangement; 

17 ‘‘(II) in the case such payment 

18 arrangement does not provide for pay19 ment under the fee schedule under sec20 tion 1848 for such items and services 

21 furnished by such eligible professionals, 

22 that provides for a payment adjust23 ment based on meaningful EHR use 

24 comparable to such adjustment that 


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1 would otherwise apply under section 

2 1848; and 

3 ‘‘(III) that provides for a pay4 ment adjustment based on quality 

5 measures comparable to such adjust6 ment that would otherwise apply under 

7 section 1848. 

8 ‘‘(C) CRITERIA FOR RECOMMENDING MOD9 ELS FOR APPROVAL WITHOUT EVALUATION

10 UNDER DEMONSTRATION.—For purposes of sub11 paragraph (A)(ii)(II), the criteria described in 

12 this subparagraph, with respect to an Alter13 native Payment Model, is that the model has al14 ready been tested and evaluated for a sufficient 

15 enough period and through such testing and 

16 evaluation the model was shown— 

17 ‘‘(i) to have satisfied the criteria de18 scribed in each of clauses (i), (ii), (iii), and 

19 (v) of subparagraph (B); and 

20 ‘‘(ii)(I) to have reduced spending 

21 under this title without reducing the quality 

22 of care; or 

23 ‘‘(II) to have improved the quality of 

24 patient care without increasing such spend25 ing. 


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1 ‘‘(D) TRANSPARENCY AND DISCLOSURES.— 

2 ‘‘(i) DISCLOSURES.—Not later than 90 

3 days after receipt of a submission of a 

4 model under subsection (c) by the APM con5 tracting entity, the APM contracting entity 

6 shall submit to the Secretary and the model 

7 submitter and make publicly available a no8 tification on whether or not, and if so how, 

9 the model meets criteria for recommending 

10 such model under subparagraph (A), in11 cluding whether or not such model requires 

12 a waiver under paragraph (2). In the case 

13 that the APM contracting entity determines 

14 not to recommend such model under this 

15 paragraph, such notification shall include 

16 an explanation of the reasons for not mak17 ing such a recommendation. Any informa18 tion made publicly available pursuant to 

19 the previous sentence shall not include pro20 prietary data. 

21 ‘‘(ii) SUBMISSION OF RECOMMENDED

22 MODELS.—The APM contracting entity 

23 shall at least quarterly submit to the Sec24 retary, the Medicare Payment Advisory 

25 Commission, and the Chief Actuary of the 


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1 Centers for Medicare & Medicaid Services 

2 the following: 

3 ‘‘(I) The models recommended 

4 under subparagraph (A)(i)(I), includ5 ing any such models that require a 

6 waiver under paragraph (2), and the 

7 data and analyses on such rec8 ommended models that support the cri9 teria described in subparagraph (B). 

10 ‘‘(II) The models recommended 

11 under subparagraph (A)(i)(II) and the 

12 data and analyses on such rec13 ommended models that support the cri14 teria described in subparagraph (C). 

15 ‘‘(iii) EXPLANATION FOR NO REC16 OMMENDATIONS.—For any year beginning 

17 with 2015 that the APM contracting entity 

18 does not recommend any models under sub19 paragraph (A)(i), the entity shall instead 

20 satisfy this clause by submitting to the Sec21 retary and making publicly available an ex22 planation for not having any such rec23 ommendations. 

24 ‘‘(iv) JUSTIFICATIONS FOR REC25 OMMENDATIONS.—In submitting data and 


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1 analyses under subclause (I) or (II) of 

2 clause (ii) with respect to a model, the APM 

3 contracting entity shall include a specific 

4 explanation of how the model would (and 

5 recommendations for ensuring that the 

6 model will) meet the criteria described in 

7 subparagraph (B) or (C), respectively. 

8 ‘‘(v) CONFIRMATION OF SPENDING ES9 TIMATES BY CMS CHIEF ACTUARY.—For 

10 each Alternative Payment Model described 

11 in subclause (I) or (II) of clause (ii), the 

12 Chief Actuary of the Centers for Medicare & 

13 Medicaid Services shall submit to the Sec14 retary a determination of whether or not 

15 the Chief Actuary confirms that the model 

16 satisfies the criterion described in subpara17 graph (B)(iv)(I) or (C)(ii), respectively. 

18 ‘‘(2) MODELS REQUIRING WAIVER APPROVAL.— 

19 ‘‘(A) IN GENERAL.—In the case that an Al20 ternative Payment Model recommended under 

21 paragraph (1)(A)(i) would require a waiver 

22 from any requirement under this title, in deter23 mining approval of such model, the Secretary 

24 may make such a waiver solely in order for such 


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1 model to be tested and evaluated under the dem2 onstration program. 

3 ‘‘(B) APPROVAL.—Not later than 180 days 

4 after the date of the receipt of such submission 

5 for a model, the Secretary shall notify the APM 

6 contracting entity and the entity submitting 

7 such model under subsection (c) whether or not 

8 such a waiver for such model is approved and 

9 the reason for any denial of such a waiver. 

10 ‘‘(e) DEMONSTRATION.— 

11 ‘‘(1) IN GENERAL.—Subject to paragraphs (5), 

12 (6), and (7), the Secretary may conduct a demonstra13 tion program, with respect to an Alternative Payment 

14 Model approved under paragraph (2), under which 

15 participating APM providers shall be paid under this 

16 title in accordance with the payment arrangement 

17 under such model and such model shall be evaluated 

18 by the independent evaluation entity under para19 graph (4). The duration of a demonstration program 

20 under this subsection, with respect to such a model, 

21 shall be 3 years. 

22 ‘‘(2) APPROVAL BY SECRETARY OF MODELS FOR

23 DEMONSTRATION.— 

24 ‘‘(A) IN GENERAL.—Not later than 180 

25 days after the date of receipt of a submission 


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1 under subsection (d)(1)(D)(ii), with respect to an 

2 Alternative Payment Model recommended under 

3 subsection (d)(1)(A)(i)(I), the Secretary shall— 

4 ‘‘(i) review the basis for such rec5 ommendation in order to assess, taking into 

6 account the determination of the Chief Actu7 ary under subsection (d)(1)(D)(v) with re8 spect to such model, if the model is signifi9 cantly likely to— 

10 ‘‘(I) reduce spending under this 

11 title without reducing the quality of 

12 care; or 

13 ‘‘(II) improve the quality of care 

14 without increasing spending under this 

15 title; 

16 ‘‘(ii) assess whether the model is sig17 nificantly likely to result in participation 

18 under such model of a sufficient number of 

19 those eligible professionals for whom the 

20 model was designed consistent with clause 

21 (i) to be able to evaluate the likely effect of 

22 expanding the demonstration; and 

23 ‘‘(iii) approve such model for a dem24 onstration program under this subsection, 


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1 including as modified under subparagraph 

2 (B), only if the Secretary determines— 

3 ‘‘(I) the model is significantly 

4 likely to satisfy the criterion described 

5 in subclause (I) or (II) of clause (i); 

6 ‘‘(II) the model is significantly 

7 likely to result in the participation of 

8 a sufficient number of eligible profes9 sionals described in clause (ii); 

10 ‘‘(III) the model applies rules of 

11 coordination described in subpara12 graph (C) applicable to such model; 

13 and 

14 ‘‘(IV) the model satisfies the cri15 teria described in subsection (d)(1)(B). 

16 The Secretary shall periodically make available 

17 a list of such models approved under clause (iii). 

18 ‘‘(B) MODIFICATIONS BY SECRETARY.— 

19 ‘‘(i) BEFORE APPROVAL.—For pur20 poses of subparagraph (A), the Secretary 

21 may modify an Alternative Payment Model 

22 recommended under subsection 

23 (d)(1)(A)(i)(I) to ensure that the model 

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1 paragraph (A)(iii). Such a modification 

2 may include one or more of the following: 

3 ‘‘(I) A change to the payment ar4 rangement under which eligible profes5 sionals participating in such model 

6 would be paid for covered professional 

7 services furnished under such model. 

8 ‘‘(II) A change to the criteria for 

9 eligible professionals to be eligible to 

10 participate under such model in order 

11 to ensure that such requirements are 

12 satisfied. 

13 ‘‘(III) A change to the rules of co14 ordination described in subparagraph 

15 (C). 

16 ‘‘(IV) The application of a with17 hold mechanism under the payment ar18 rangement under which the distribu19 tion of withheld amounts is based on 

20 the success of the model in meeting 

21 spending reduction requirements. 

22 ‘‘(V) Such other change as the 

23 Secretary may specify. 

24 ‘‘(ii) TERMINATION OR MODIFICATION

25 DURING DEMONSTRATION.—The Secretary 


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1 shall terminate or modify the design and 

2 implementation of an Alternative Payment 

3 Model approved under subparagraph 

4 (A)(iii) for a demonstration program, after 

5 testing has begun, unless the Secretary de6 termines (and the Chief Actuary of the Cen7 ters for Medicare & Medicaid Services, with 

8 respect to program spending under this 

9 title, certifies) that the model is expected to 

10 continue to satisfy the requirements de11 scribed in such paragraph relating to qual12 ity of care and reduced spending. Such ter13 mination may occur at any time after such 

14 testing has begun and before completion of 

15 the testing. 

16 ‘‘(C) RULES OF COORDINATION FOR APPLI17 CATION OF PAYMENT ARRANGEMENTS UNDER

18 MODELS.— 

19 ‘‘(i) IN GENERAL.—Rules of coordina20 tion described in this subparagraph for an 

21 Alternative Payment Model shall be de22 signed to determine, for purposes of apply23 ing subsection (a) and section 1848(d)(16), 

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1 sional is treated as having a payment ar2 rangement under a particular model. 

3 ‘‘(ii) NONDUPLICATION OF PAYMENT.— 

4 Such rules of coordination shall ensure co5 ordination and nonduplication of payment 

6 of services that might be covered under more 

7 than one payment arrangement or under 

8 section 1848(d)(16). 

9 ‘‘(iii) APPLICATION TO NON-APM PAY10 MENT.—In applying such rules for purposes 

11 of section 1848(d)(16), an eligible profes12 sional shall not be treated as having a pay13 ment arrangement in effect under such a 

14 model for any covered professional services 

15 not treated as furnished under the model. 

16 ‘‘(3) PARTICIPATING APM PROVIDERS.— 

17 ‘‘(A) IN GENERAL.—To participate under a 

18 demonstration program under this subsection, 

19 with respect to an Alternative Payment Model, 

20 an eligible professional shall enter into a con21 tract with the Administrator of the Centers for 

22 Medicare & Medicaid Services under this sub23 section. For purposes of this section, such an eli24 gible professional who so participates under such 


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1 an Alternative Payment Model in this section is 

2 referred to as a ‘participating APM provider’. 

3 ‘‘(B) REQUIREMENTS.—The Secretary shall 

4 establish criteria for eligible professionals to 

5 enter into contracts under this paragraph for 

6 purposes of participation under a demonstration 

7 program with respect to an Alternative Payment 

8 Model. Such criteria shall ensure participation 

9 under such model of a sufficient number of eligi10 ble professionals for whom the model was de11 signed in order to satisfy the criterion described 

12 in paragraph (2)(A)(iii)(II). 

13 ‘‘(4) REPORTING AND EVALUATION.— 

14 ‘‘(A) INDEPENDENT EVALUATION ENTITY.— 

15 Under this subsection, the Secretary shall enter 

16 into a contract with an independent entity to 

17 evaluate Alternative Payment Models under dem18 onstration programs under this subsection based 

19 on appropriate measures specified under sub20 paragraph (B). In this section, such entity shall 

21 be referred to as the ‘independent evaluation en22 tity’. Such contract shall be entered into in a 

23 timely manner so as to ensure evaluation of an 

24 Alternative Payment Model under a demonstra25 tion program under this subsection may begin as 


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1 soon as possible after the model is approved 

2 under paragraph (2). 

3 ‘‘(B) PERFORMANCE MEASURES.—For pur4 poses of this subsection, the Secretary shall speci5 fy— 

6 ‘‘(i) measures to evaluate Alternative 

7 Payment Models under demonstration pro8 grams under this subsection, which may in9 clude measures suggested under subsection 

10 (c) and shall be sufficient to allow for a 

11 comprehensive assessment of such a model; 

12 and 

13 ‘‘(ii) quality measures on which par14 ticipating APM providers shall report, 

15 which shall be similar to measures applica16 ble under section 1848(k). 

17 ‘‘(C) REPORTING REQUIREMENTS.—A con18 tract entered into with a participating APM 

19 provider under paragraph (3) shall require such 

20 provider to report on appropriate measures spec21 ified under subparagraph (B). 

22 ‘‘(D) PERIODIC REVIEW.—The independent 

23 evaluation entity shall periodically review and 

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1 volved data reported under subparagraph (C) 

2 and such other data as deemed necessary to 

3 evaluate the model. 

4 ‘‘(E) FINAL EVALUATION.—Not later than 6 

5 months after the date of completion of a dem6 onstration program, the independent evaluation 

7 entity shall submit to the Secretary, the Medi8 care Payment Advisory Commission, and the 

9 Chief Actuary of the Centers for Medicare & 

10 Medicaid Services (and make publicly available) 

11 a report on each model evaluated under such 

12 program. Such report shall include— 

13 ‘‘(i) outcomes on the clinical and 

14 claims data received through such program 

15 with respect to such model; 

16 ‘‘(ii) recommendations on— 

17 ‘‘(I) whether or not such model 

18 should be implemented as an eligible 

19 APM under this section; or 

20 ‘‘(II) whether or not the evalua21 tion of such model under the dem22 onstration program should be extended 

23 or expanded; 


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1 ‘‘(iii) the justification for each such 

2 recommendation described in clause (ii); 

3 and 

4 ‘‘(iv) in the case of a recommendation 

5 to implement such model as an eligible 

6 APM, recommendations on standardized 

7 rules for purposes of such implementation. 

8 ‘‘(5) APPROVAL OF EXTENDING EVALUATION

9 UNDER DEMONSTRATION.—Not later than 90 days 

10 after the date of receipt of a submission under para11 graph (4)(E), the Secretary shall, including based on 

12 a recommendation submitted under such paragraph, 

13 determine whether an Alternative Payment Model 

14 may be extended or expanded under the demonstra15 tion program. 

16 ‘‘(6) TERMINATION.—The Secretary shall termi17 nate a demonstration program for a model under this 

18 subsection unless the Secretary determines (and the 

19 Chief Actuary of the Centers for Medicare & Medicaid 

20 Services, with respect to spending under this title, 

21 certifies), after testing has begun, that the model is ex22 pected to— 

23 ‘‘(A) improve the quality of care (as deter24 mined by the Administrator of the Centers for 


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1 Medicare & Medicaid Services) without increas2 ing spending under this title; 

3 ‘‘(B) reduce spending under this title with4 out reducing the quality of care; or 

5 ‘‘(C) improve the quality of care and reduce 

6 spending. 

7 Such termination may occur at any time after such 

8 testing has begun and before completion of the testing. 

9 ‘‘(7) FUNDING.— 

10 ‘‘(A) IN GENERAL.—There are appro11 priated, from amounts in the Federal Supple12 mentary Medical Insurance Trust Fund under 

13 section 1841 not otherwise appropriated and as 

14 of the date of the enactment of this section, 

15 $2,000,000,000 for the purposes described in sub16 paragraph (B), of which no more than 2.5 per17 cent may be used for the purpose described in 

18 clause (iii) of such subparagraph. Amounts ap19 propriated under this subparagraph shall be 

20 available until expended. 

21 ‘‘(B) PURPOSES.—Amounts appropriated 

22 under subparagraph (A) shall be used for— 

23 ‘‘(i) payments for items and services 

24 furnished by participating APM providers 

25 under an Alternative Payment Model under 


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1 a demonstration program under this sub2 section that— 

3 ‘‘(I) would not otherwise be eligi4 ble for payment under this title; or 

5 ‘‘(II) exceed the amount of pay6 ment that would otherwise be made for 

7 such items and services under this title 

8 if such items and services were not fur9 nished under such demonstration pro10 gram; 

11 ‘‘(ii) the evaluations provided for 

12 under this section of models under such a 

13 demonstration program; 

14 ‘‘(iii) payment to the APM contracting 

15 entity for carrying out its duties under this 

16 section; and 

17 ‘‘(iv) for otherwise carrying out this 

18 subsection. 

19 ‘‘(C) LIMITATION.—The amounts appro20 priated under subparagraph (A) are the only 

21 amounts authorized or appropriated to carry out 

22 the purposes described in subparagraph (B). 

23 ‘‘(f) IMPLEMENTATION OF RECOMMENDED MODELS AS

24 ELIGIBLE APMS.— 


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1 ‘‘(1) ASSESSMENT.—With respect to each Alter2 native Payment Model recommended under subsection 

3 (d)(1)(A)(i)(II) or (e)(4)(E)(ii)(I), the Secretary shall 

4 review the basis for such recommendation and assess 

5 and determine, in consultation with the Chief Actu6 ary of the Centers for Medicare & Medicaid Services, 

7 whether the model is significantly likely to continue 

8 to result in meeting the criterion described in sub9 section (e)(2)(A)(iii)(I), with or without a modifica10 tion described in paragraph (5). 

11 ‘‘(2) IMPLEMENTATION THROUGH RULE12 MAKING.— 

13 ‘‘(A) PUBLICATION OF NPRM.—If the Sec14 retary determines that such a model is signifi15 cantly likely to meet such criterion, the Secretary 

16 shall publish as part of the applicable physician 

17 fee schedule rulemaking process (specified in 

18 paragraph (3)) a notice of proposed rulemaking 

19 to implement such model, including as modified 

20 under paragraph (5). 

21 ‘‘(B) COMMENTS BY MEDPAC.—Not later 

22 than 90 days after the date of issuance of such 

23 notice with respect to a model, the Medicare 

24 Payment Advisory Commission shall submit 

25 comments on the proposed rule for such model to 


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1 Congress and to the Secretary. Such comments 

2 shall include an evaluation of the reports from 

3 the contracting entity and independent evalua4 tion entity on such model regarding the model’s 

5 impact on expenditures and quality of care 

6 under this title. 

7 ‘‘(C) FINAL RULE AND CONDITIONS.—The 

8 Secretary shall publish as part of the applicable 

9 physician fee schedule rulemaking process (speci10 fied in paragraph (3)) a final notice imple11 menting such proposed rule, including as modi12 fied under paragraph (5), as an eligible APM 

13 only if— 

14 ‘‘(i) the Secretary determines that such 

15 model is expected to— 

16 ‘‘(I) reduce spending under this 

17 title without reducing the quality of 

18 care; or 

19 ‘‘(II) improve the quality of pa20 tient care without increasing spending; 

21 ‘‘(ii) the Chief Actuary of the Centers 

22 for Medicare & Medicaid Services certifies 

23 that such model would reduce (or would not 

24 result in any increase in) spending under 

25 this title; 


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1 ‘‘(iii) the Secretary determines that 

2 such model would not deny or limit the cov3 erage or provision of benefits under this 

4 title for applicable individuals; 

5 ‘‘(iv) the Secretary determines that the 

6 model is significantly likely to result in the 

7 participation of a sufficient number of ap8 propriate eligible professionals for whom the 

9 model was designed in order to satisfy the 

10 criterion described in subsection 

11 (d)(2)(A)(iii)(II); 

12 ‘‘(v) the Secretary determines that the 

13 model applies rules of coordination de14 scribed in paragraph (6); and 

15 ‘‘(vi) the Secretary determines that 

16 model meets such other criteria as the Sec17 retary may determine. 

18 ‘‘(3) APPLICABLE PHYSICIAN FEE SCHEDULE

19 RULEMAKING PROCESS.—For purposes of paragraph 

20 (2), in the case of an Alternative Payment Model rec21 ommended under subsection (d)(1)(A)(ii) or 

22 (e)(4)(E)(ii)(I)— 

23 ‘‘(A) on or before April 1 of a year, the ap24 plicable physician fee schedule rulemaking proc25 ess is the process for publication by November 1 


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1 of that year of the fee schedule amounts under 

2 this section for the succeeding year; or 

3 ‘‘(B) after April 1 of a year, the applicable 

4 physician fee schedule rulemaking process is the 

5 process for publication by November 1 of the fol6 lowing year of the fee schedule amounts under 

7 this section for the second succeeding year. 

8 ‘‘(4) JUSTIFICATION FOR DISAPPROVALS.—In the 

9 case that an Alternative Payment Model rec10 ommended under subsection (d)(1)(A)(ii) or 

11 (e)(4)(E)(ii)(I) is not implemented as an eligible 

12 APM under this subsection, the Secretary shall make 

13 publicly available the rational, in detail, for such de14 cision. 

15 ‘‘(5) MODIFICATIONS BY SECRETARY.—For pur16 poses of this subsection, the Secretary may modify an 

17 Alternative Payment Model recommended under sub18 section (d)(1)(A)(i)(II) or (e)(4)(E)(ii)(I) to ensure 

19 that the model meets the requirements under para20 graph (1)(B). Such a modification may include one 

21 or more of the following: 

22 ‘‘(A) A change to the payment arrangement 

23 under which eligible professionals participating 

24 in such model would be paid for covered profes25 sional services furnished under such model. 


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1 ‘‘(B) A change to the criteria for eligible 

2 professionals to be eligible to participate under 

3 such model in order to ensure that such require4 ments are satisfied. 

5 ‘‘(C) A change to the rules of coordination 

6 described in paragraph (6). 

7 ‘‘(D) The application of a withhold mecha8 nism under the payment arrangement under 

9 which the distribution of withheld amounts is 

10 based on the success of the model in meeting 

11 spending reduction requirements. 

12 ‘‘(E) Such other change as the Secretary 

13 may specify. 

14 ‘‘(6) RULES OF COORDINATION FOR APPLICATION

15 OF PAYMENT ARRANGEMENTS UNDER MODELS.— 

16 ‘‘(A) IN GENERAL.—Rules of coordination 

17 described in this paragraph for an Alternative 

18 Payment Model shall be designed to determine, 

19 for purposes of applying subsection (a) and sec20 tion 1848(d)(16), under what circumstances an 

21 eligible professional is treated as having a pay22 ment arrangement under a particular model. 

23 ‘‘(B) NONDUPLICATION OF PAYMENT.—Such 

24 rules of coordination shall ensure coordination 

25 and nonduplication of payment of services that 


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1 might be covered under more than one payment 

2 arrangement or under section 1848(d)(16). 

3 ‘‘(C) APPLICATION TO NON-APM PAYMENT.— 

4 In applying such rules for purposes of section 

5 1848(d)(16), an eligible professional shall not be 

6 treated as having a payment arrangement in ef7 fect under such a model for any covered profes8 sional services not treated as furnished under the 

9 model. 

10 ‘‘(g) PERIODIC REVIEW AND TERMINATION.— 

11 ‘‘(1) PERIODIC REVIEW.—In the case of an Alter12 native Payment Model that has been implemented, the 

13 Secretary and the Chief Actuary of the Centers for 

14 Medicare & Medicaid Services shall review such 

15 model every 3 years to determine (and certify, in the 

16 case of the Chief Actuary and spending under this 

17 title), for the previous 3 years, whether the model 

18 has— 

19 ‘‘(A) reduced the quality of care, or 

20 ‘‘(B) increased spending under this title, 

21 compared to the quality of care or spending that 

22 would have resulted if the model had not been imple23 mented. 

24 ‘‘(2) TERMINATION.— 


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1 ‘‘(A) QUALITY OF CARE REDUCTION TERMI2 NATION.—If based upon such review the Sec3 retary determines under paragraph (1)(A) that 

4 the model has reduced the quality of care, the 

5 Secretary may terminate such model. 

6 ‘‘(B) SPENDING INCREASE TERMINATION.— 

7 Unless such Chief Actuary certifies under para8 graph (1)(B) that the expenditures under this 

9 title under the model do not exceed the expendi10 tures that would otherwise have been made if the 

11 model had not been implemented for the period 

12 involved, the Secretary shall terminate such 

13 model. 

14 ‘‘(h) DISSEMINATION OF ELIGIBLE APMS.—Under 

15 this section there shall be established a process for speci16 fying, and making publicly available a list of, all eligible 

17 APMs, which shall include at least those implemented under 

18 subsection (f) and demonstrations carried out with respect 

19 to payments under section 1848 through authority in exist20 ence as of the day before the date of the enactment of this 

21 section. Under such process such list shall be periodically 

22 updated and, beginning with January 1, 2015, and annu23 ally thereafter, such list shall be published in the Federal 

24 Register.’’. 


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1 (2) CONFORMING AMENDMENT.—Section 

2 1848(a)(1) of the Social Security Act (42 U.S.C. 

3 1395w–4(a)(1)) is amended by striking ‘‘shall in4 stead’’ and inserting ‘‘shall, subject to section 1848A, 

5 instead’’. 

6 (d) ADJUSTMENT TO MEDICARE PAYMENT LOCAL7 ITIES.— 

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

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

10 adding at the end the following new paragraph: 

11 ‘‘(6) USE OF MSAS AS FEE SCHEDULE AREAS IN

12 CALIFORNIA.— 

13 ‘‘(A) IN GENERAL.—Subject to the suc14 ceeding provisions of this paragraph and not15 withstanding the previous provisions of this sub16 section, for services furnished on or after Janu17 ary 1, 2017, the fee schedule areas used for pay18 ment under this section applicable to California 

19 shall be the following: 

20 ‘‘(i) Each Metropolitan Statistical 

21 Area (each in this paragraph referred to as 

22 an ‘MSA’), as defined by the Director of the 

23 Office of Management and Budget as of De24 cember 31 of the previous year, shall be a 

25 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 fee 

3 schedule area. 

4 ‘‘(B) TRANSITION FOR MSAS PREVIOUSLY IN

5 REST-OF-STATE PAYMENT LOCALITY OR IN LO6 CALITY 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 subparagraph 

12 (C), the geographic index values to be ap13 plied under this subsection for such year 

14 shall be equal to the sum of the following: 

15 ‘‘(I) CURRENT LAW COMPO16 NENT.—The old weighting factor (de17 scribed in clause (ii)) for such year 

18 multiplied by the geographic index val19 ues under this subsection for the fee 

20 schedule area that included such MSA 

21 that would have applied in such area 

22 (as estimated by the Secretary) if this 

23 paragraph did not apply. 

24 ‘‘(II) MSA-BASED COMPONENT.— 

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1 scribed in clause (iii)) for such year 

2 multiplied by the geographic index val3 ues computed for the fee schedule area 

4 under subparagraph (A) for the year 

5 (determined without regard to this sub6 paragraph). 

7 ‘‘(ii) OLD WEIGHTING FACTOR.—The 

8 old weighting factor described in this 

9 clause— 

‘‘(I) for 2017, is 5 10 ⁄6; and 

11 ‘‘(II) for each succeeding year, is 

12 the old weighting factor described in 

13 this clause for the previous year minus 

1 14 ⁄6. 

15 ‘‘(iii) MSA-BASED WEIGHTING FAC16 TOR.—The MSA-based weighting factor de17 scribed in this clause for a year is 1 minus 

18 the old weighting factor under clause (ii) 

19 for that year. 

20 ‘‘(C) HOLD HARMLESS.—For services fur21 nished in a transition area in California during 

22 a year beginning with 2017, the geographic 

23 index values to be applied under this subsection 

24 for such year shall not be less than the cor25 responding geographic index values that would 


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1 have applied in such transition area (as esti2 mated by the Secretary) if this paragraph did 

3 not apply. 

4 ‘‘(D) TRANSITION AREA DEFINED.—In this 

5 paragraph, the term ‘transition area’ means each 

6 of the following fee schedule areas for 2013: 

7 ‘‘(i) The rest-of-State payment locality. 

8 ‘‘(ii) Payment locality 3. 

9 ‘‘(E) REFERENCES TO FEE SCHEDULE

10 AREAS.—Effective for services furnished on or 

11 after January 1, 2017, for California, any ref12 erence in this section to a fee schedule area shall 

13 be deemed a reference to a fee schedule area es14 tablished in accordance with this paragraph.’’. 

15 (2) CONFORMING AMENDMENT TO DEFINITION OF

16 FEE SCHEDULE AREA.—Section 1848(j)(2) of the So17 cial Security Act (42 U.S.C. 1395w–4(j)(2)) is 

18 amended by striking ‘‘The term’’ and inserting ‘‘Ex19 cept as provided in subsection (e)(6)(D), the term’’. 

20 (e) RELATIVE VALUES UNDER THE MEDICARE PHYSI21 CIAN FEE SCHEDULE.— 

22 (1) ELIGIBLE PHYSICIANS REPORTING SYSTEM

23 TO IMPROVE ACCURACY OF RELATIVE VALUES.—Sec24 tion 1848(c) of the Social Security Act (42 U.S.C. 


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1 1395w–4(c)) is amended by adding at the end the fol2 lowing new paragraph: 

3 ‘‘(7) PHYSICIAN REPORTING SYSTEM TO IMPROVE

4 ACCURACY OF RELATIVE VALUES.— 

5 ‘‘(A) IN GENERAL.—The Secretary shall im6 plement a system for the periodic reporting by 

7 physicians of data on the accuracy of relative 

8 values under this subsection, such as data relat9 ing to service volume and time. Such data shall 

10 be submitted in a form and manner specified by 

11 the Secretary and shall, as appropriate, incor12 porate data from existing sources of data, pa13 tient scheduling systems, cost accounting sys14 tems, and other similar systems. 

15 ‘‘(B) IDENTIFICATION OF REPORTING CO16 HORT.—Not later than January 1, 2015, the 

17 Secretary shall establish a mechanism for physi18 cians to participate under the reporting system 

19 under this paragraph, all of whom shall collec20 tively be referred to under this paragraph as the 

21 ‘reporting group’. The reporting group shall in22 clude physicians across settings that collectively 

23 represent a range of specialties and practitioner 

24 types, furnish a range of physicians’ services, 

25 and serve a range of patient populations. 


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1 ‘‘(C) INCENTIVE TO REPORT.—Under the 

2 system under this paragraph, the Secretary may 

3 provide for such payments under this part to 

4 physicians included in the reporting group as 

5 the Secretary determines appropriate to com6 pensate such physicians for reporting data under 

7 the system. Such payments shall be provided in 

8 such form and manner as specified by the Sec9 retary. In carrying out this subparagraph, re10 porting by such a physician under this para11 graph shall not be treated as the furnishing of 

12 physicians’ services for purposes of applying this 

13 section. 

14 ‘‘(D) FUNDING.—To carry out this para15 graph (other than with respect to payments 

16 made under subparagraph (C)), in addition to 

17 funds otherwise appropriated, the Secretary shall 

18 provide for the transfer from the Federal Supple19 mentary Medical Insurance Trust Fund under 

20 section 1841 of $1,000,000 to the Centers for 

21 Medicare & Medicaid Services Program Manage22 ment Account for each fiscal year beginning with 

23 fiscal year 2014. Amounts transferred under this 

24 subparagraph for a fiscal year shall be available 

25 until expended.’’. 


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1 (2) RELATIVE VALUE ADJUSTMENTS FOR

2 MISVALUED PHYSICIANS’ SERVICES.— 

3 (A) IN GENERAL.—Section 1848(c)(2) of the 

4 Social Security Act (42 U.S.C. 1395w–4(c)(2)) is 

5 amended by adding at the end the following new 

6 subparagraph: 

7 ‘‘(M) ADJUSTMENTS FOR MISVALUED PHYSI8 CIANS’ SERVICES.— 

9 ‘‘(i) IN GENERAL.—Only with respect 

10 to fee schedules established for 2016, 2017, 

11 and 2018 (and not for subsequent years), 

12 the Secretary shall— 

13 ‘‘(I) identify, based on the data 

14 reported under paragraph (8) and 

15 other relevant data, misvalued services 

16 for which adjustments to the relative 

17 values established under this para18 graph would result in a reduction in 

19 expenditures under the fee schedule 

20 under this section, with respect to such 

21 year, of not more than 1 percent of the 

22 projected amount of expenditures under 

23 such fee schedule for such year; and 


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1 ‘‘(II) make such adjustments for 

2 each such year so as only to result in 

3 such a reduction for such year. 

4 ‘‘(ii) NO EFFECT ON SUBSEQUENT

5 YEARS.—A reduction under this subpara6 graph for a year shall not affect any reduc7 tion for any subsequent year. 

8 ‘‘(iii) RULE OF CONSTRUCTION RELAT9 ING TO UNDERVALUED CODES.—Nothing in 

10 this subparagraph shall be construed as pre11 venting the Secretary from increasing the 

12 relative values for codes that are under13 valued.’’. 

14 (B) BUDGET NEUTRALITY.—Section 

15 1848(c)(2)(B)(v) of the Social Security Act (42 

16 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by add17 ing at the end the following new subclause: 

18 ‘‘(VIII) REDUCTIONS FOR

19 MISVALUED PHYSICIANS’ SERVICES.— 

20 Reduced expenditures attributable to 

21 subparagraph (M) for fiscal years 

22 2016, 2017, and 2018.’’. 

23 (3) DISCLOSURE OF DATA USED TO ESTABLISH

24 MULTIPLE PROCEDURE PAYMENT REDUCTION POL25 ICY.—The Secretary of Health and Human Services 


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1 shall make publicly available the data used to estab2 lish the multiple procedure payment reduction policy 

3 to the professional component of imaging services in 

4 the final rule published in the Federal Register, v. 77, 

5 n. 222, November 16, 2012, pages 68891-69380 under 

6 the physician fee schedule under section 1848 of the 

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

8 SEC. 3. EXPANDING AVAILABILITY OF MEDICARE DATA. 

9 (a) EXPANDING USES OF MEDICARE DATA BY QUALI10 FIED ENTITIES.— 

11 (1) IN GENERAL.—To the extent consistent with 

12 applicable information, privacy, security, and disclo13 sure laws, beginning with 2014, notwithstanding 

14 paragraph (4)(B) of section 1874(e) of the Social Se15 curity Act (42 U.S.C. 1395kk(e)) and the second sen16 tence of paragraph (4)(D) of such section, a qualified 

17 entity may use data received by such entity under 

18 such section, and information derived from the eval19 uation described in such paragraph (4)(D), for addi20 tional non-public analyses (as determined appro21 priate by the Secretary of Health and Human Serv22 ices) or provide or sell such data to registered or au23 thorized users and subscribers, including to providers 

24 of services and suppliers, for non-public use (includ25 ing for the purposes of assisting providers of services 


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1 and suppliers to develop and participate in quality 

2 and patient care improvement activities, including 

3 developing new models of care). 

4 (2) DEFINITIONS.—In this section: 

5 (A) The term ‘‘qualified entity’’ has the 

6 meaning given such term in section 1874(e)(2) of 

7 the Social Security Act (42 U.S.C. 1395kk(e)). 

8 (B) The terms ‘‘supplier’’ and ‘‘provider of 

9 services’’ have the meanings given such terms in 

10 subsections (d) and (u), respectively, of section 

11 1861 of the Social Security Act (42 U.S.C. 

12 1395x). 

13 (b) ACCESS TO MEDICARE DATA TO PROVIDERS OF

14 SERVICES AND SUPPLIERS TO FACILITATE DEVELOPMENT

15 OF ALTERNATIVE PAYMENT MODELS AND TO QUALIFIED

16 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY IM17 PROVEMENT.—Consistent with applicable laws and regula18 tions with respect to privacy and other relevant matters, 

19 the Secretary shall provide Medicare claims data (in a form 

20 and manner determined to be appropriate) to— 

21 (1) qualified entities, that may share with pro22 viders of services and suppliers that are registered or 

23 authorized users or subscribers, for non-public use in24 cluding to facilitate the development of new models of 

25 care (including development of Alternate Payment 


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1 Models under section 1848A of the Social Security 

2 Act, models for small group specialty practices, and 

3 care coordination models); and 

4 (2) qualified clinical data registries under sec5 tion 1848(m)(3)(E)) of the Social Security Act (42 

6 U.S.C. 1395w–4(m)(3)(E)) for purposes of linking 

7 such data with clinical outcomes data and performing 

8 and disseminating risk-adjusted, scientifically valid 

9 analysis and research to support quality improvement 

10 or patient safety, provided that any public reporting 

11 of identifiable provider data shall only be conducted 

12 with prior consent of such provider. 

13 SEC. 4. ENCOURAGING CARE COORDINATION AND MEDICAL 

14 HOMES. 

15 Section 1848(b) of the Social Security Act (42 U.S.C. 

16 1395w–4(b)) is amended by adding at the end the following 

17 new paragraph: 

18 ‘‘(8) ENCOURAGING CARE COORDINATION AND

19 MEDICAL HOMES.— 

20 ‘‘(A) IN GENERAL.—In order to promote the 

21 coordination of care by an applicable provider 

22 (as defined in subparagraph (B)) for individuals 

23 with complex chronic care needs who are fur24 nished items and services by multiple physicians 


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1 and other suppliers and providers of services, the 

2 Secretary shall— 

3 ‘‘(i) develop one or more HCPCS codes 

4 for complex chronic care management serv5 ices for individuals with complex chronic 

6 care needs; and 

7 ‘‘(ii) for such services furnished on or 

8 after January 1, 2015, by an applicable 

9 provider, make payment (as the Secretary 

10 determines to be appropriate) under the fee 

11 schedule under this section using such 

12 HCPCS codes. 

13 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

14 For purposes of this paragraph, the term ‘appli15 cable provider’ means a physician (as defined in 

16 section 1861(r)(1)) or a physician assistant or 

17 nurse practitioner (as defined in section 

18 1861(aa)(5)(A)) who— 

19 ‘‘(i) is certified as a medical home (by 

20 achieving an accreditation status of level 3 

21 by the National Committee for Quality As22 surance); 

23 ‘‘(ii) is recognized as a patient-cen24 tered specialty practice by the National 

25 Committee for Quality Assurance; 


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1 ‘‘(iii) has received equivalent certifi2 cation (as determined by the Secretary); or 

3 ‘‘(iv) meets such other comparable 

4 qualifications as the Secretary determines 

5 to be appropriate. 

6 ‘‘(C) BUDGET NEUTRALITY.—The budget 

7 neutrality provision under subsection 

8 (c)(2)(B)(ii)(II) shall apply in establishing the 

9 payment under subparagraph (A)(ii). 

10 ‘‘(D) SINGLE APPLICABLE PROVIDER PAY11 MENT.—In carrying out this paragraph, the Sec12 retary shall only make payment to a single ap13 plicable provider for complex chronic care man14 agement services furnished to an individual.’’. 

15 SEC. 5. MISCELLANEOUS. 

16 (a) SOLICITATIONS, RECOMMENDATIONS, AND RE17 PORTS.— 

18 (1) SOLICITATION FOR RECOMMENDATIONS ON

19 EPISODES OF CARE DEFINITION.—The Administrator 

20 of the Centers for Medicare & Medicaid Services shall 

21 request eligible professional organizations (as defined 

22 in section 1848(k)(3) of the Social Security Act (42 

23 U.S.C. 1395w–4(k)(3))) and other relevant stake24 holders to submit recommendations for defining non25 acute related episodes of care for purposes of applying 


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1 such definition under subsections (k) and (q) of sec2 tion 1848 of the Social Security Act (42 U.S.C. 

3 1395w–4) and section 1848A of such Act, as added by 

4 subsections (b) and (c) of section 2. 

5 (2) SOLICITATION FOR RECOMMENDATIONS ON

6 PROVIDER FEE SCHEDULE PAYMENT BUNDLES.— 

7 (A) IN GENERAL.—The Administrator of the 

8 Centers for Medicare & Medicaid Services shall 

9 solicit from eligible professional organizations 

10 (as defined in section 1848(k)(3) of the Social 

11 Security Act (42 U.S.C. 1395w–4(k)(3))) rec12 ommendations for payment bundles for chronic 

13 conditions and expensive, high volume services 

14 for which payment is made under title XVIII of 

15 such Act. 

16 (B) REPORT TO CONGRESS.—Not later than 

17 24 months after the date of the enactment of this 

18 Act, the Administrator shall submit to Congress 

19 a report on proposals for such payment bundles. 

20 (3) REPORTS ON MODIFIED PFS SYSTEM AND

21 PAYMENT SYSTEM ALTERNATIVES.— 

22 (A) BIANNUAL PROGRESS REPORTS.—Not 

23 later than January 15, 2016, and annually 

24 thereafter, the Secretary of Health and Human 

25 Services shall submit to Congress and post on the 


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1 public Internet website of the Centers for Medi2 care & Medicaid Services a biannual progress re3 port— 

4 (i) on the implementation of para5 graph (9) of section 1848(k) of the Social 

6 Security Act (42 U.S.C. 1395w–4(k)), as 

7 added by section 2(b)(2), and the quality 

8 update incentive program under subsection 

9 (q) of section 1848 of the Social Security 

10 Act (42 U.S.C. 1395w–4), as added by sec11 tion 2(b)(3); 

12 (ii) that includes an evaluation of such 

13 paragraph and such quality update incen14 tive program and recommendations with re15 spect to such program and appropriate up16 date mechanisms; and 

17 (iii) on the actions taken to promote 

18 and fulfill the identification of eligible 

19 APMs under section 1848A of the Social Se20 curity Act, as added by section 2(c), for ap21 plication under such section 1848A. 

22 (B) GAO AND MEDPAC REPORTS.— 

23 (i) GAO REPORT ON INITIAL STAGES

24 OF PROGRAM.—The Comptroller General of 

25 the United States shall submit to Congress 


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1 a report for 2019 and each subsequent year 

2 analyzing the extent to which the system 

3 under section 1848(k)(9) of the Social Secu4 rity Act (42 U.S.C. 1395w–4(k)(9)) and 

5 such quality update incentive program 

6 under section 1848(q) of the Social Security 

7 Act, as added by section 2(b) is successfully 

8 satisfying performance objectives, including 

9 with respect to— 

10 (I) the process for developing and 

11 selecting measures and activities under 

12 subsection (k)(9) of section 1848 of 

13 such Act (42 U.S.C. 1395w–4); 

14 (II) the process for assessing per15 formance against such measures and 

16 activities under subsection (q) of such 

17 section; and 

18 (III) the adequacy of the measures 

19 and activities so selected. 

20 (ii) EVALUATION BY GAO AND MEDPAC

21 ON IMPLEMENTATION OF QUALITY UPDATE

22 INCENTIVE PROGRAM.— 

23 (I) GAO.—The Comptroller Gen24 eral of the United States shall evaluate 

25 the initial phase of the quality update 


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1 incentive program under subsection (q) 

2 of section 1848 of the Social Security 

3 Act (42 U.S.C. 1395w–4) and shall 

4 submit to Congress, not later than 

5 2019, a report with recommendations 

6 for improving such quality update in7 centive program. 

8 (II) MEDPAC.—In the course of 

9 its March Report to Congress on Medi10 care payment policy, MedPAC shall 

11 analyze the initial phase of such qual12 ity update incentive program and 

13 make recommendations, as appro14 priate, for improving such quality up15 date incentive program. 

16 (iii) MEDPAC REPORT ON PAYMENT

17 SYSTEM ALTERNATIVES.— 

18 (I) IN GENERAL.—Not later than 

19 June 15, 2016, the Medicare Payment 

20 Advisory Commission shall submit to 

21 Congress a report that analyzes mul22 tiple options for alternative payment 

23 models in lieu of section 1848 of the 

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

25 4). In analyzing such models, the 


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1 Medicare Payment Advisory Commis2 sion shall examine at least the fol3 lowing models: 

4 (aa) Accountable care orga5 nization payment models. 

6 (bb) Primary care medical 

7 home payment models. 

8 (cc) Bundled or episodic pay9 ments for certain conditions and 

10 services. 

11 (dd) Gainsharing arrange12 ments 

13 (II) ITEMS TO BE INCLUDED.— 

14 Such report shall include information 

15 on how each recommended new pay16 ment model will achieve maximum 

17 flexibility to reward high quality, effi18 cient care. 

19 (C) TRACKING EXPENDITURE GROWTH AND

20 ACCESS.—Beginning in 2015, the Chief Actuary 

21 of the Centers for Medicare & Medicaid Services 

22 shall track expenditure growth and beneficiary 

23 access to physicians’ services under section 1848 

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

25 and shall post on the public Internet website of 


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1 the Centers for Medicare & Medicaid Services 

2 annual reports on such topics. 

3 (4) REPORT ON CLINICAL DECISION SUPPORT

4 MECHANISMS.—Not later than one year after the date 

5 of the enactment of this Act, the Secretary of Health 

6 and Human Services shall submit to Congress a re7 port on the extent to which clinical decision support 

8 mechanisms and other provider support tools could be 

9 used to further program objectives under section 1848 

10 of the Social Security Act (42 U.S.C. 1395w–4)) and 

11 recommendation for how such mechanisms and tools 

12 should be so used. 

13 (b) RULE OF CONSTRUCTION REGARDING HEALTH

14 CARE PROVIDER STANDARDS OF CARE.— 

15 (1) IN GENERAL.—The development, recognition, 

16 or implementation of any guideline or other standard 

17 under any Federal health care provision shall not be 

18 construed to establish the standard of care or duty of 

19 care owed by a health care provider to a patient in 

20 any medical malpractice or medical product liability 

21 action or claim. 

22 (2) DEFINITIONS.—For purposes of this sub23 section: 

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1 tion and Affordable Care Act (Public Law 111– 

2 148), title I and subtitle B of title III of the 

3 Health Care and Education Reconciliation Act 

4 of 2010 (Public Law 111–152), and titles XVIII 

5 and XIX of the Social Security Act. 

6 (B) The term ‘‘health care provider’’ means 

7 any individual or entity— 

8 (i) licensed, registered, or certified 

9 under Federal or State laws or regulations 

10 to provide health care services; or 

11 (ii) required to be so licensed, reg12 istered, or certified but that is exempted by 

13 other statute or regulation. 

14 (C) The term ‘‘medical malpractice or med15 ical liability action or claim’’ means a medical 

16 malpractice action or claim (as defined in sec17 tion 431(7) of the Health Care Quality Improve18 ment Act of 1986 (42 U.S.C. 11151(7))) and in19 cludes a liability action or claim relating to a 

20 health care provider’s prescription or provision 

21 of a drug, device, or biological product (as such 

22 terms are defined in section 201 of the Federal 

23 Food, Drug, and Cosmetic Act or section 351 of 

24 the Public Health Service Act). 


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1 (D) The term ‘‘State’’ includes the District 

2 of Columbia, Puerto Rico, and any other com3 monwealth, possession, or territory of the United 

4 States. 

5 (3) NO PREEMPTION.—No provision of the Pa6 tient Protection and Affordable Care Act (Public Law 

7 111–148), title I or subtitle B of title III of the 

8 Health Care and Education Reconciliation Act of 

9 2010 (Public Law 111–152), or title XVIII or XIX of 

10 the Social Security Act shall be construed to preempt 

11 any State or common law governing medical profes12 sional or medical product liability actions or claims. 

13 SEC. 1. SHORT TITLE; TABLE OF CONTENTS. 

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

15 the ‘‘SGR Repeal and Medicare Beneficiary 

16 Access Act of 2013’’. 

17 (b) TABLE OF CONTENTS.—The table of con18 tents for this Act is as follows: 

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 quality 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 claims data availability to improve care. 

Sec. 9. Reducing administrative burden and other provisions. 


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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 Secu7 rity Act (42 U.S.C. 1395w–4) is amended— 

8 (A) in subsection (d)— 

9 (i) in paragraph (1)(A), by in10 serting ‘‘or a subsequent para11 graph’’ after ‘‘paragraph (4)’’; and 

12 (ii) in paragraph (4)— 

13 (I) in the heading, by in14 serting ‘‘AND ENDING WITH 2013’’ 

15 after ‘‘YEARS BEGINNING WITH

16 2001’’; and 

17 (II) in subparagraph (A), 

18 by inserting ‘‘and ending with 

19 2013’’ after ‘‘a year beginning 

20 with 2001’’; and 

21 (B) in subsection (f)— 

22 (i) in paragraph (1)(B), by in23 serting ‘‘through 2013’’ after ‘‘of 

24 each succeeding year’’; and 


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1 (ii) in paragraph (2), by in2 serting ‘‘and ending with 2013’’ 

3 after ‘‘beginning with 2000’’. 

4 (2) UPDATE OF RATES FOR 2014 AND SUB5 SEQUENT YEARS.—Subsection (d) of section 

6 1848 of the Social Security Act (42 U.S.C. 

7 1395w–4) is amended by adding at the 

8 end the following new paragraphs: 

9 ‘‘(15) UPDATE FOR 2014 THROUGH 2016.— 

10 The update to the single conversion fac11 tor established in paragraph (1)(C) for 

12 each of 2014 through 2016 shall be 0.5 

13 percent. 

14 ‘‘(16) UPDATE FOR 2017 THROUGH 2023.— 

15 The update to the single conversion fac16 tor established in paragraph (1)(C) for 

17 each of 2017 through 2023 shall be zero 

18 percent. 

19 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

20 YEARS.—The update to the single conver21 sion factor established in paragraph 

22 (1)(C) for 2024 and each subsequent year 

23 shall be— 

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1 pant (as defined in section 1833(z)(2)) 

2 for such year, 2 percent; and 

3 ‘‘(B) for other items and services, 

4 1 percent.’’. 

5 (3) MEDPAC REPORTS.— 

6 (A) INITIAL REPORT.—Not later 

7 than July 1, 2016, the Medicare Pay8 ment Advisory Commission shall sub9 mit to Congress a report on the rela10 tionship between— 

11 (i) physician and other health 

12 professional utilization and ex13 penditures (and the rate of in14 crease of such utilization and ex15 penditures) of items and services 

16 for which payment is made under 

17 section 1848 of the Social Security 

18 Act (42 U.S.C. 1395w–4); and 

19 (ii) total utilization and ex20 penditures (and the rate of in21 crease of such utilization and ex22 penditures) under parts A, B, and 

23 D of title XVIII of such Act. 

24 Such report shall include a method25 ology to describe such relationship 


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1 and the impact of changes in such 

2 physician and other health profes3 sional practice and service ordering 

4 patterns on total utilization and ex5 penditures under parts A, B, and D of 

6 such title. 

7 (B) FINAL REPORT.—Not later than 

8 July 1, 2020, the Medicare Payment 

9 Advisory Commission shall submit to 

10 Congress a report on the relationship 

11 described in subparagraph (A), in12 cluding the results determined from 

13 applying the methodology included in 

14 the report submitted under such sub15 paragraph. 

16 (b) CONSOLIDATION OF CERTAIN CURRENT

17 LAW PERFORMANCE PROGRAMS WITH NEW

18 VALUE-BASED PERFORMANCE INCENTIVE PRO19 GRAM.— 

20 (1) EHR MEANINGFUL USE INCENTIVE

21 PROGRAM.— 

22 (A) SUNSETTING SEPARATE MEANING23 FUL USE PAYMENT ADJUSTMENTS.—Sec24 tion 1848(a)(7)(A) of the Social SecuVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00094 Fmt 6652 Sfmt 6202 E:\BILLS\H2810.RH H2810

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1 rity Act (42 U.S.C. 1395w–4(a)(7)(A)) is 

2 amended— 

3 (i) in clause (i), by striking ‘‘or 

4 any subsequent payment year’’ 

5 and inserting ‘‘or 2016’’; 

6 (ii) in clause (ii)— 

7 (I) in the matter pre8 ceding subclause (I), by strik9 ing ‘‘Subject to clause (iii), 

10 for’’ and inserting ‘‘For’’; 

11 (II) in subclause (I), by 

12 adding at the end ‘‘and’’; 

13 (III) in subclause (II), by 

14 striking ‘‘; and’’ and inserting 

15 a period; and 

16 (IV) by striking subclause 

17 (III); and 

18 (iii) by striking clause (iii). 

19 (B) CONTINUATION OF MEANINGFUL

20 USE DETERMINATIONS FOR VBP PRO21 GRAM.—Section 1848(o)(2) of the So22 cial Security Act (42 U.S.C. 1395w– 

23 4(o)(2)) is amended— 

24 (i) in subparagraph (A), in the 

25 matter preceding clause (i)— 


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1 (I) by striking ‘‘For pur2 poses of paragraph (1), an’’ 

3 and inserting ‘‘An’’; and 

4 (II) by inserting ‘‘, or pur5 suant to subparagraph (D) for 

6 purposes of subsection (q), for 

7 a performance period under 

8 such subsection for a year’’ 

9 after ‘‘under such subsection 

10 for a year’’; and 

11 (ii) by adding at the end the 

12 following new subparagraph: 

13 ‘‘(D) CONTINUED APPLICATION FOR

14 PURPOSES OF VBP PROGRAM.—With re15 spect to 2017 and each subsequent 

16 payment year, the Secretary shall, for 

17 purposes of subsection (q) and in ac18 cordance with paragraph (1)(F) of 

19 such subsection, determine whether 

20 an eligible professional who is a VBP 

21 eligible professional (as defined in 

22 subsection (q)(1)(C)) for such year is a 

23 meaningful EHR user under this 

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1 riod under subsection (q) for such 

2 year.’’. 

3 (2) QUALITY REPORTING.— 

4 (A) SUNSETTING SEPARATE QUALITY

5 REPORTING INCENTIVES.—Section 

6 1848(a)(8)(A) of the Social Security 

7 Act (42 U.S.C. 1395w–4(a)(8)(A)) is 

8 amended— 

9 (i) in clause (i), by striking ‘‘or 

10 any subsequent year’’ and insert11 ing ‘‘or 2016’’; and 

12 (ii) in clause (ii)(II), by strik13 ing ‘‘and each subsequent year’’. 

14 (B) CONTINUATION OF QUALITY

15 MEASURES AND PROCESSES FOR VBP PRO16 GRAM.—Section 1848 of the Social Se17 curity Act (42 U.S.C. 1395w–4) is 

18 amended— 

19 (i) in subsection (k), by adding 

20 at the end the following new 

21 paragraph: 

22 ‘‘(9) CONTINUED APPLICATION FOR PUR23 POSES OF VBP PROGRAM.—The Secretary 

24 shall, in accordance with subsection 

25 (q)(1)(F), carry out the provisions of this 


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1 subsection for purposes of subsection 

2 (q).’’; and 

3 (ii) in subsection (m)— 

4 (I) by redesignating the 

5 paragraph (7) added by sec6 tion 10327(a) of Public Law 

7 111-148 as paragraph (8); and 

8 (II) by adding at the end 

9 the following new paragraph: 

10 ‘‘(9) CONTINUED APPLICATION FOR PUR11 POSES OF VBP PROGRAM.—The Secretary 

12 shall, in accordance with subsection 

13 (q)(1)(F), carry out the processes under 

14 this subsection for purposes of subsection 

15 (q).’’. 

16 (3) VALUE-BASED PAYMENTS.— 

17 (A) SUNSETTING SEPARATE VALUE18 BASED PAYMENTS.—Clause (iii) of sec19 tion 1848(p)(4)(B) of the Social Secu20 rity Act (42 U.S.C. 1395w–4(p)(4)(B)) is 

21 amended to read as follows: 

22 ‘‘(iii) APPLICATION.—The Sec23 retary shall apply the payment 

24 modifier established under this 

25 subsection for items and services 


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1 furnished on or after January 1, 

2 2015, but before January 1, 2017, 

3 with respect to specific physi4 cians and groups of physicians 

5 the Secretary determines appro6 priate. Such payment modifier 

7 shall not be applied for items and 

8 services furnished on or after 

9 January 1, 2017.’’. 

10 (B) CONTINUATION OF VALUE-BASED

11 PAYMENT MODIFIER MEASURES FOR VBP

12 PROGRAM.—Section 1848(p) of the So13 cial Security Act (42 U.S.C. 1395w– 

14 4(p)) is amended— 

15 (i) in paragraph (2), by adding 

16 at the end the following new sub17 paragraph: 

18 ‘‘(C) CONTINUED APPLICATION FOR

19 PURPOSES OF VBP PROGRAM.—The Sec20 retary shall, in accordance with sub21 section (q)(1)(F), carry out subpara22 graph (B) for purposes of subsection 

23 (q).’’ ; and 

24 (ii) in paragraph (3), by add25 ing at the end the following: 


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1 ‘‘With respect to 2017 and each 

2 subsequent year, the Secretary 

3 shall, in accordance with sub4 section (q)(1)(F), carry out this 

5 paragraph for purposes of sub6 section (q).’’. 

7 (c) VALUE-BASED PERFORMANCE INCENTIVE

8 PROGRAM.— 

9 (1) IN GENERAL.—Section 1848 of the 

10 Social Security Act (42 U.S.C. 1395w–4) is 

11 amended by adding at the end the fol12 lowing new subsection: 

13 ‘‘(q) VALUE-BASED PERFORMANCE INCENTIVE

14 PROGRAM.— 

15 ‘‘(1) ESTABLISHMENT.— 

16 ‘‘(A) IN GENERAL.—Subject to the 

17 succeeding provisions of this sub18 section, the Secretary shall establish 

19 an eligible professional value-based 

20 performance incentive program (in 

21 this subsection referred to as the 

22 ‘VBP program’) under which the Sec23 retary shall— 

24 ‘‘(i) develop a methodology for 

25 assessing the total performance of 


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1 each VBP eligible professional ac2 cording to performance standards 

3 under paragraph (3) for a per4 formance period (as established 

5 under paragraph (4)) for a year; 

6 ‘‘(ii) using such methodology, 

7 provide for a composite perform8 ance score in accordance with 

9 paragraph (5) for each such pro10 fessional for each performance 

11 period; and 

12 ‘‘(iii) use such composite per13 formance score of the VBP eligi14 ble professional for a perform15 ance period for a year to make 

16 VBP program incentive payments 

17 under paragraph (7) to the profes18 sional for the year. 

19 ‘‘(B) PROGRAM IMPLEMENTATION.— 

20 The VBP program shall apply to pay21 ments for items and services fur22 nished on or after January 1, 2017. 

23 ‘‘(C) VBP ELIGIBLE PROFESSIONAL

24 DEFINED.— 


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1 ‘‘(i) IN GENERAL.—For purposes 

2 of this subsection, subject to 

3 clauses (ii) and (iv), the term ‘VBP 

4 eligible professional’ means— 

5 ‘‘(I) for the first and sec6 ond years for which the VBP 

7 program applies to payments 

8 (and for the performance pe9 riod for such first and second 

10 year), a physician (as defined 

11 in section 1861(r)(1)), a physi12 cian assistant, nurse practi13 tioner, and clinical nurse spe14 cialist (as such terms are de15 fined in section 1861(aa)(5)), 

16 and a certified registered 

17 nurse anesthetist (as defined 

18 in section 1861(bb)(2)); and 

19 ‘‘(II) for the third year for 

20 which the VBP program ap21 plies to payments (and for the 

22 performance period for such 

23 third year) and for each suc24 ceeding year (and for the per25 formance period for each 


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1 such year), the professionals 

2 described in subclause (I) and 

3 such other eligible profes4 sionals (as defined in sub5 section (k)(3)(B)) as specified 

6 by the Secretary. 

7 ‘‘(ii) EXCLUSIONS.—For pur8 poses of clause (i), the term ‘VBP 

9 eligible professional’ does not in10 clude, with respect to a year, an 

11 eligible professional (as defined 

12 in subsection (k)(3)(B))— 

13 ‘‘(I) who is a qualifying 

14 APM participant (as defined 

15 in section 1833(z)(2)); 

16 ‘‘(II) who, subject to clause 

17 (vii), is a partial qualifying 

18 APM participant (as defined 

19 in clause (iii)) for the most re20 cent period for which data 

21 are available and who, for the 

22 performance period with re23 spect to such year, does not 

24 report on applicable measures 

25 and activities described in 


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1 paragraph (2)(B) that are re2 quired to be reported by such 

3 a professional under the VBP 

4 program; or 

5 ‘‘(III) who, for the per6 formance period with respect 

7 to such year, does not exceed 

8 the low-volume threshold 

9 measurement selected under 

10 clause (iv). 

11 ‘‘(iii) PARTIAL QUALIFYING APM

12 PARTICIPANT.—For purposes of 

13 this subparagraph, the term ‘par14 tial qualifying APM participant’ 

15 means, with respect to a year, an 

16 eligible professional for whom the 

17 Secretary determines the min18 imum payment percentage (or 

19 percentages), as applicable, de20 scribed in paragraph (2) of sec21 tion 1833(z) for such year have 

22 not been satisfied, but who would 

23 be considered a qualifying APM 

24 participant (as defined in such 

25 paragraph) for such year if— 


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1 ‘‘(I) with respect to 2017 

2 and 2018, the reference in 

3 subparagraph (A) of such 

4 paragraph to 25 percent was 

5 instead a reference to 20 per6 cent; 

7 ‘‘(II) with respect to 2019 

8 and 2020— 

9 ‘‘(aa) the reference in 

10 subparagraph (B)(i) of 

11 such paragraph to 50 per12 cent was instead a ref13 erence to 40 percent; and 

14 ‘‘(bb) the references in 

15 subparagraph (B)(ii) of 

16 such paragraph to 50 per17 cent and 25 percent of 

18 such paragraph were in19 stead references to 40 per20 cent and 20 percent, re21 spectively; and 

22 ‘‘(III) with respect to 2021 

23 and subsequent years— 

24 ‘‘(aa) the reference in 

25 subparagraph (C)(i) of 


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1 such paragraph to 75 per2 cent was instead a ref3 erence to 50 percent; and 

4 ‘‘(bb) the references in 

5 subparagraph (C)(ii) of 

6 such paragraph to 75 per7 cent and 25 percent of 

8 such paragraph were in9 stead references to 50 per10 cent and 20 percent, re11 spectively. 

12 ‘‘(iv) SELECTION OF LOW-VOL13 UME THRESHOLD MEASUREMENT.— 

14 The Secretary shall select one of 

15 the following low-volume thresh16 old measurements to apply for 

17 purposes of clause (ii)(III): 

18 ‘‘(I) The minimum number 

19 (as determined by the Sec20 retary) of individuals enrolled 

21 under this part who are treat22 ed by the VBP eligible profes23 sional for the performance pe24 riod involved. 


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1 ‘‘(II) The minimum num2 ber (as determined by the Sec3 retary) of items and services 

4 furnished to individuals en5 rolled under this part by such 

6 professional for such perform7 ance period. 

8 ‘‘(III) The minimum 

9 amount (as determined by the 

10 Secretary) of allowed charges 

11 billed by such professional 

12 under this part for such per13 formance period. 

14 ‘‘(v) TREATMENT OF NEW MEDI15 CARE ENROLLED ELIGIBLE PROFES16 SIONALS.—In the case of a profes17 sional who first becomes a Medi18 care enrolled eligible professional 

19 during the performance period 

20 for a year (and had not previously 

21 submitted claims under this title 

22 such as a person, an entity, or a 

23 part of a physician group or 

24 under a different billing number 

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1 sional shall not be treated under 

2 this subsection as a VBP eligible 

3 professional until the subsequent 

4 year and performance period for 

5 such subsequent year. 

6 ‘‘(vi) CLARIFICATION.—In the 

7 case of items and services fur8 nished during a year by an indi9 vidual who is not a VBP eligible 

10 professional (including pursuant 

11 to clauses (ii) and (v)) with re12 spect to a year, in no case shall a 

13 reduction under paragraph (6) or 

14 a VBP program incentive pay15 ment under paragraph (7) apply 

16 to such individual for such year. 

17 ‘‘(vii) PARTIAL QUALIFYING APM

18 PARTICIPANT CLARIFICATION.—In 

19 the case of an eligible profes20 sional who is a partial qualifying 

21 APM participant, with respect to 

22 a year, and who for the perform23 ance period for such year reports 

24 on applicable measures and ac25 tivities described in paragraph 


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1 (2)(B) that are required to be re2 ported by such a professional 

3 under the VBP program, such eli4 gible professional is considered to 

5 be a VBP eligible professional 

6 with respect to such year. 

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

9 ‘‘(i) IN GENERAL.—Under the 

10 VBP program: 

11 ‘‘(I) QUALITY PERFORMANCE

12 CATEGORY.—The Secretary 

13 shall establish and apply a 

14 process that includes features 

15 of the provisions of sub16 section (m)(3)(C) for VBP eli17 gible professionals in a group 

18 practice with respect to as19 sessing performance of such 

20 group with respect to the per21 formance category described 

22 in clause (i) of paragraph 

23 (2)(A). 

24 ‘‘(II) OTHER PERFORMANCE

25 CATEGORIES.—The Secretary 


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1 may establish and apply a 

2 process that includes features 

3 of the provisions of sub4 section (m)(3)(C) for VBP eli5 gible professionals in a group 

6 practice with respect to as7 sessing the performance of 

8 such group with respect to 

9 the performance categories 

10 described in clauses (ii) 

11 through (iv) of such para12 graph. 

13 ‘‘(ii) ENSURING COMPREHENSIVE14 NESS OF GROUP PRACTICE ASSESS15 MENT.—The process established 

16 under clause (i) shall to the ex17 tent practicable reflect the full 

18 range of items and services fur19 nished by the VBP eligible profes20 sionals in the group practice in21 volved. 

22 ‘‘(iii) CLARIFICATION.—VBP eli23 gible professionals electing to be 

24 a virtual group under paragraph 

25 (5)(J) shall not be considered VBP 


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1 eligible professionals in a group 

2 practice for purposes of applying 

3 this subparagraph. 

4 ‘‘(E) USE OF REGISTRIES.—Under 

5 the VBP program, the Secretary shall 

6 encourage the use of qualified clin7 ical data registries pursuant to sub8 section (m)(3)(E) in carrying out this 

9 subsection. 

10 ‘‘(F) APPLICATION OF CERTAIN PRO11 VISIONS.—In applying a provision of 

12 subsection (k), (m), (o), or (p) for pur13 poses of this subsection, the Sec14 retary shall— 

15 ‘‘(i) adjust the application of 

16 such provision to ensure the pro17 vision is consistent with the pro18 visions of this subsection; and 

19 ‘‘(ii) not apply such provision 

20 to the extent that the provision is 

21 duplicative with a provision of 

22 this subsection. 

23 ‘‘(2) MEASURES AND ACTIVITIES UNDER

24 PERFORMANCE CATEGORIES.— 


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1 ‘‘(A) PERFORMANCE CATEGORIES.— 

2 Under the VBP program, the Sec3 retary shall use the following per4 formance categories (each of which is 

5 referred to in this subsection as a 

6 performance category) in deter7 mining the composite performance 

8 score under paragraph (5): 

9 ‘‘(i) Quality. 

10 ‘‘(ii) Resource use. 

11 ‘‘(iii) Clinical practice im12 provement activities. 

13 ‘‘(iv) Meaningful use of cer14 tified EHR technology. 

15 ‘‘(B) MEASURES AND ACTIVITIES

16 SPECIFIED FOR EACH CATEGORY.—For 

17 purposes of paragraph (3)(A) and sub18 ject to subparagraph (C), measures 

19 and activities specified for a perform20 ance period (as established under 

21 paragraph (4)) for a year are as fol22 lows: 

23 ‘‘(i) QUALITY.—For the per24 formance category described in 

25 subparagraph (A)(i), the quality 


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1 measures established for such pe2 riod under subsections (k) and 

3 (m), including under subsection 

4 (m)(3)(E), and the measures of 

5 quality of care established for 

6 such period under subsection 

7 (p)(2). 

8 ‘‘(ii) RESOURCE USE.—For the 

9 performance category described 

10 in subparagraph (A)(ii), the meas11 urement of resource use for such 

12 period under subsection (p)(3), 

13 using the methodology under sub14 section (r), as appropriate, and, as 

15 feasible and applicable, account16 ing for the cost of covered part D 

17 drugs. 

18 ‘‘(iii) CLINICAL PRACTICE IM19 PROVEMENT ACTIVITIES.—For the 

20 performance category described 

21 in subparagraph (A)(iii), clinical 

22 practice improvement activities 

23 under subcategories specified by 

24 the Secretary for such period, 


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1 which shall include at least the 

2 following: 

3 ‘‘(I) The subcategory of ex4 panded practice access, which 

5 shall include activities such 

6 as same day appointments for 

7 urgent needs and after hours 

8 access to clinician advice. 

9 ‘‘(II) The subcategory of 

10 population management, 

11 which shall include activities 

12 such as monitoring health 

13 conditions of individuals to 

14 provide timely health care 

15 interventions or participation 

16 in a qualified clinical data 

17 registry. 

18 ‘‘(III) The subcategory of 

19 care coordination, which shall 

20 include activities such as 

21 timely communication of test 

22 results, timely exchange of 

23 clinical information to pa24 tients and other providers, 


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1 and use of remote monitoring 

2 or telehealth. 

3 ‘‘(IV) The subcategory of 

4 beneficiary engagement, 

5 which shall include activities 

6 such as the establishment of 

7 care plans for individuals 

8 with complex care needs, ben9 eficiary self-management 

10 training, and using shared de11 cision-making mechanisms. 

12 ‘‘(V) The subcategory of 

13 patient safety and practice as14 sessment, such as through use 

15 of clinical or surgical check16 lists and practice assessments 

17 related to maintaining certifi18 cation. 

19 ‘‘(VI) The subcategory of 

20 participation in an alternative 

21 payment model (as defined in 

22 section 1833(z)(3)(C)). 

23 In establishing activities under 

24 this clause, the Secretary shall 

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1 cumstances of small practices 

2 (consisting of fewer than 20 pro3 fessionals) and practices located 

4 in rural areas and in health pro5 fessional shortage areas (as des6 ignated under section 332(a)(1)(A) 

7 of the Public Health Service Act). 

8 ‘‘(iv) MEANINGFUL EHR USE.— 

9 For the performance category de10 scribed in subparagraph (A)(iv), 

11 the requirements established for 

12 such period under subsection 

13 (o)(2) for determining whether an 

14 eligible professional is a meaning15 ful EHR user. 

16 ‘‘(C) ADDITIONAL PROVISIONS.— 

17 ‘‘(i) EMPHASIZING OUTCOME

18 MEASURES UNDER QUALITY PER19 FORMANCE CATEGORY.—In applying 

20 subparagraph (B)(i), the Sec21 retary shall, as feasible, empha22 size the application of outcome 

23 measures. 

24 ‘‘(ii) APPLICATION OF ADDI25 TIONAL SYSTEM MEASURES.—The 


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1 Secretary may use measures used 

2 for a payment system other than 

3 for physicians for purposes of the 

4 performance category described 

5 in subparagraph (A)(i). 

6 ‘‘(iii) GLOBAL AND POPULATION7 BASED MEASURES.—The Secretary 

8 may use global measures, such as 

9 global outcome measures, and 

10 population-based measures for 

11 purposes of the performance cat12 egory described in subparagraph 

13 (A)(i). 

14 ‘‘(iv) REQUEST FOR INFORMA15 TION FOR CLINICAL PRACTICE IM16 PROVEMENT ACTIVITIES.—In ini17 tially applying subparagraph 

18 (B)(iii), the Secretary shall use a 

19 request for information to solicit 

20 recommendations from stake21 holders for identifying activities 

22 described in such subparagraph 

23 and specifying criteria for such 

24 activities. 


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1 ‘‘(v) CONTRACT AUTHORITY FOR

2 CLINICAL PRACTICE IMPROVEMENT

3 ACTIVITIES PERFORMANCE CAT4 EGORY.—In applying subpara5 graph (B)(iii), the Secretary may 

6 contract with entities to assist the 

7 Secretary in— 

8 ‘‘(I) identifying activities 

9 described in subparagraph 

10 (B)(iii); 

11 ‘‘(II) specifying criteria for 

12 such activities; and 

13 ‘‘(III) determining wheth14 er a VBP eligible professional 

15 meets such criteria. 

16 ‘‘(vi) APPLICATION OF MEASURES

17 AND ACTIVITIES TO NON-PATIENT18 FACING PROVIDERS.—In carrying 

19 out this paragraph, with respect 

20 to measures and activities speci21 fied in subparagraph (B) for per22 formance categories described in 

23 subparagraph (A), the Secretary— 

24 ‘‘(I) shall give consider25 ation to the circumstances of 


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1 professional types (or subcat2 egories of those types deter3 mined by practice character4 istics) who typically provide 

5 services that do not involve 

6 face-to-face interaction with a 

7 patient; and 

8 ‘‘(II) may, to the extent 

9 feasible and appropriate, take 

10 into account such cir11 cumstances and apply under 

12 this subsection with respect 

13 to VBP eligible professionals 

14 of such professional types or 

15 subcategories, in lieu of such 

16 a measure or activity, a com17 parable measure or activity 

18 that fulfills the goals of the 

19 applicable performance cat20 egory. 

21 In carrying out the previous sen22 tence, the Secretary shall consult 

23 with professionals of such profes24 sional types or subcategories. 

25 ‘‘(3) PERFORMANCE STANDARDS.— 


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1 ‘‘(A) ESTABLISHMENT.—Under the 

2 VBP program, the Secretary shall es3 tablish performance standards with 

4 respect to measures and activities 

5 specified under paragraph (2)(B) for a 

6 performance period (as established 

7 under paragraph (4)) for a year. 

8 ‘‘(B) CONSIDERATIONS IN ESTAB9 LISHING STANDARDS.—In establishing 

10 such performance standards with re11 spect to measures and activities spec12 ified under paragraph (2)(B), the Sec13 retary shall take into account the fol14 lowing: 

15 ‘‘(i) Historical performance 

16 standards. 

17 ‘‘(ii) Improvement rates. 

18 ‘‘(iii) The opportunity for con19 tinued improvement. 

20 ‘‘(4) PERFORMANCE PERIOD.—The Sec21 retary shall establish a performance pe22 riod (or periods) for a year (beginning 

23 with the year described in paragraph 

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1 ginning of such year and be as close as 

2 possible to such year. In this subsection, 

3 such performance period (or periods) for 

4 a year shall be referred to as the per5 formance period for the year. 

6 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

7 ‘‘(A) IN GENERAL.—Subject to the 

8 succeeding provisions of this para9 graph and consistent with section 

10 2(g)(2) of the SGR Repeal and Medi11 care Beneficiary Access Act of 2013, 

12 the Secretary shall develop a method13 ology for assessing the total perform14 ance of each VBP eligible profes15 sional according to performance 

16 standards under paragraph (3) with 

17 respect to applicable measures and 

18 activities specified in paragraph 

19 (2)(B) with respect to each perform20 ance category applicable to such pro21 fessional for a performance period (as 

22 established under paragraph (4)) for 

23 a year. Using such methodology, the 

24 Secretary shall provide for a com25 posite assessment (in this subsection 


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1 referred to as the ‘composite perform2 ance score’) for each such profes3 sional for each performance period. 

4 ‘‘(B) WEIGHTING PERFORMANCE CAT5 EGORIES, MEASURES, AND ACTIVITIES.— 

6 Under the methodology under sub7 paragraph (A), the Secretary— 

8 ‘‘(i) may assign different scor9 ing weights (including a weight of 

10 0) for— 

11 ‘‘(I) each performance cat12 egory based on the extent to 

13 which the category is applica14 ble to the type of eligible pro15 fessional involved; and 

16 ‘‘(II) each measure and ac17 tivity specified under para18 graph (2)(B) with respect to 

19 each such category based on 

20 the extent to which the meas21 ure or activity is applicable to 

22 the type of eligible profes23 sional involved; and 


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1 ‘‘(ii) with respect to the per2 formance category described in 

3 paragraph (2)(A)(i)— 

4 ‘‘(I) shall assign a higher 

5 scoring weight to outcomes 

6 measures than to other meas7 ures and increase the scoring 

8 weight for outcome measures 

9 over time; and 

10 ‘‘(II) may assign a higher 

11 scoring weight to patient ex12 perience measures. 

13 ‘‘(C) INCENTIVE TO REPORT; EN14 COURAGING USE OF CERTIFIED EHR

15 TECHNOLOGY FOR REPORTING QUALITY

16 MEASURES.— 

17 ‘‘(i) INCENTIVE TO REPORT.— 

18 Under the methodology estab19 lished under subparagraph (A), 

20 the Secretary shall provide that 

21 in the case of a VBP eligible pro22 fessional who fails to report on an 

23 applicable measure or activity 

24 that is required to be reported by 

25 the professional, the professional 


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1 shall be treated as achieving the 

2 lowest potential score applicable 

3 to such measure or activity. 

4 ‘‘(ii) ENCOURAGING USE OF CER5 TIFIED EHR TECHNOLOGY FOR RE6 PORTING QUALITY MEASURES.— 

7 Under the methodology estab8 lished under subparagraph (A), 

9 the Secretary shall— 

10 ‘‘(I) encourage VBP eligi11 ble professionals to report on 

12 applicable measures with re13 spect to the performance cat14 egory described in paragraph 

15 (2)(A)(i) through the use of 

16 certified EHR technology; and 

17 ‘‘(II) with respect to a per18 formance period, with respect 

19 to a year, for which a VBP eli20 gible professional reports 

21 such measures through the 

22 use of such EHR technology, 

23 treat such professional as sat24 isfying the clinical quality 

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1 ment described in subsection 

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

3 ‘‘(D) CLINICAL PRACTICE IMPROVE4 MENT ACTIVITIES PERFORMANCE

5 SCORE.— 

6 ‘‘(i) RULE FOR ACCREDITA7 TION.—A VBP eligible professional 

8 who is in a practice that is cer9 tified as a patient-centered med10 ical home or comparable specialty 

11 practice pursuant to subsection 

12 (b)(8)(B)(i) with respect to a per13 formance period shall be given 

14 the highest potential score for the 

15 performance category described 

16 in paragraph (2)(A)(iii) for such 

17 period. 

18 ‘‘(ii) APM PARTICIPATION.—Par19 ticipation by a VBP eligible pro20 fessional in an alternative pay21 ment model (as defined in section 

22 1833(z)(3)(C)) with respect to a 

23 performance period shall earn 

24 such eligible professional one-half 

25 of the highest potential score for 


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1 the performance category de2 scribed in paragraph (2)(A)(iii) 

3 for such performance period. 

4 Nothing in the previous sentence 

5 shall prevent such professional 

6 from earning more than one-half 

7 of such highest potential score for 

8 such performance period by per9 forming additional activities with 

10 respect to such performance cat11 egory. 

12 ‘‘(iii) SUBCATEGORIES.—A VBP 

13 eligible professional shall not be 

14 required to perform activities in 

15 each subcategory under para16 graph (2)(B)(iii) to achieve the 

17 highest potential score for the 

18 performance category described 

19 in paragraph (2)(A)(iii). 

20 ‘‘(E) DISTRIBUTION.—The Secretary 

21 shall ensure that the application of 

22 the methodology developed under 

23 subparagraph (A) results in a contin24 uous distribution of performance 


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1 scores, which shall result in differen2 tial payments under paragraph (7). 

3 ‘‘(F) ACHIEVEMENT AND IMPROVE4 MENT.— 

5 ‘‘(i) TAKING INTO ACCOUNT IM6 PROVEMENT.—Beginning with the 

7 second year to which the VBP 

8 program applies, in addition to 

9 the achievement score of a VBP 

10 eligible professional, the method11 ology developed under subpara12 graph (A)— 

13 ‘‘(I) in the case of the per14 formance score for the per15 formance category described 

16 in clauses (i) and (ii) of para17 graph (2)(A), shall take into 

18 account the improvement of 

19 the professional; and 

20 ‘‘(II) in the case of per21 formance scores for other per22 formance categories, may take 

23 into account the improvement 

24 of the professional. 


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1 ‘‘(ii) ASSIGNING HIGHER WEIGHT

2 FOR ACHIEVEMENT.—Beginning 

3 with the fourth year to which the 

4 VBP program applies, under the 

5 methodology developed under 

6 subparagraph (A), the Secretary 

7 may assign a higher scoring 

8 weight under subparagraph (B) 

9 with respect to the achievement 

10 score of a VBP eligible profes11 sional with respect to a measure 

12 or activity specified under para13 graph (2)(B) (or with respect to 

14 such a measure or activity and 

15 with respect to categories de16 scribed in paragraph (2)(A)) than 

17 to any improvement score applied 

18 under clause (i) with respect to 

19 such measure or activity (or such 

20 measure or activity and cat21 egories). 

22 ‘‘(G) WEIGHTS FOR THE PERFORM23 ANCE CATEGORIES.— 

24 ‘‘(i) IN GENERAL.—Under the 

25 methodology developed under 


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1 subparagraph (A), subject to 

2 clauses (ii) and (iii), the com3 posite performance score shall be 

4 determined as follows: 

5 ‘‘(I) QUALITY.— 

6 ‘‘(aa) IN GENERAL.— 

7 Subject to item (bb), 30 

8 percent of such score 

9 shall be based on perform10 ance with respect to the 

11 category described in 

12 clause (i) of paragraph 

13 (2)(A). 

14 ‘‘(bb) FIRST 2 YEARS

15 AND TEST YEAR.—For the 

16 first and second years for 

17 which the VBP program 

18 applies to payments, 60 

19 percent of such score 

20 shall be based on perform21 ance with respect to the 

22 category described in 

23 clause (i) of paragraph 

24 (2)(A). With respect to the 

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1 cent described in item 

2 (aa) of such score shall be 

3 based on performance 

4 with respect to such cat5 egory only for purposes of 

6 feedback and 60 percent 

7 of such score shall be 

8 based on performance 

9 with respect to such cat10 egory for any other pur11 pose under this sub12 section. 

13 ‘‘(II) RESOURCE USE.— 

14 ‘‘(aa) IN GENERAL.— 

15 Subject to item (bb), 30 

16 percent of such score 

17 shall be based on perform18 ance with respect to the 

19 category described in 

20 clause (ii) of paragraph 

21 (2)(A). 

22 ‘‘(bb) FIRST 2 YEARS

23 AND TEST YEAR.—For the 

24 first and second years for 

25 which the VBP program 


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1 applies to payments, zero 

2 percent of such score 

3 shall be based on perform4 ance with respect to the 

5 category described in 

6 clause (ii) of paragraph 

7 (2)(A). With respect to the 

8 subsequent year, the per9 cent described in item 

10 (aa) of such score shall be 

11 based on performance 

12 with respect to such cat13 egory only for purposes of 

14 feedback and zero percent 

15 of such score shall be 

16 based on performance 

17 with respect to such cat18 egory for any other pur19 pose under this sub20 section. 

21 ‘‘(III) CLINICAL PRACTICE

22 IMPROVEMENT ACTIVITIES.—Fif23 teen percent of such score 

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1 egory described in clause (iii) 

2 of paragraph (2)(A). 

3 ‘‘(IV) MEANINGFUL USE OF

4 CERTIFIED EHR TECHNOLOGY.— 

5 Twenty-five percent of such 

6 score shall be based on per7 formance with respect to the 

8 category described in clause 

9 (iv) of paragraph (2)(A). 

10 ‘‘(ii) AUTHORITY TO ADJUST PER11 CENTAGES IN CASE OF HIGH EHR

12 MEANINGFUL USE ADOPTION.—In 

13 any year in which the Secretary 

14 estimates that the proportion of 

15 eligible professionals (as defined 

16 in subsection (o)(5)) who are 

17 meaningful EHR users (as deter18 mined under subsection (o)(2)) is 

19 75 percent or greater, the Sec20 retary may reduce the percent ap21 plicable under clause (i)(IV), but 

22 not below 15 percent. If the Sec23 retary makes such reduction for a 

24 year, the percentages applicable 

25 under one or more of subclauses 


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1 (I), (II), and (III) of clause (i) for 

2 such year (or, in the case of a 

3 year described in clause 

4 (i)(II)(bb), applicable under one 

5 or more of subclauses (I) and 

6 (III)) shall be increased in a man7 ner such that the total percentage 

8 points of the increase under this 

9 clause for such year equals the 

10 total number of percentage points 

11 reduced under the preceding sen12 tence for such year. 

13 ‘‘(iii) AUTHORITY TO ADJUST

14 PERCENTAGES FOR QUALITY AND RE15 SOURCE USE.—Other than for a 

16 year described in clause 

17 (i)(II)(bb), the percentages de18 scribed in subclauses (I) and (II) 

19 of clause (i), including after appli20 cation of clause (ii), shall be 

21 equal. 

22 ‘‘(H) RESOURCE USE.—Analysis of 

23 the performance category described 

24 in paragraph (2)(A)(ii) shall include 

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

3 ‘‘(I) INCLUSION OF QUALITY MEASURE

4 DATA FROM MULTIPLE PAYERS.—In ap5 plying subsections (k), (m), and (p) 

6 with respect to measures described in 

7 paragraph (2)(B)(i), analysis of the 

8 performance category described in 

9 paragraph (2)(A)(i) may include data 

10 submitted by VBP eligible profes11 sionals with respect to multiple pay12 ers. 

13 ‘‘(J) USE OF VOLUNTARY VIRTUAL

14 GROUPS FOR CERTAIN ASSESSMENT PUR15 POSES.— 

16 ‘‘(i) IN GENERAL.—In the case 

17 of VBP eligible professionals 

18 electing to be a virtual group 

19 under clause (ii) with respect to a 

20 performance period for a year, for 

21 purposes of applying the method22 ology under subparagraph (A)— 

23 ‘‘(I) the assessment of per24 formance provided under 

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1 spect to the performance cat2 egories described in clauses 

3 (i) and (ii) of paragraph (2)(A) 

4 that is to be applied to each 

5 such professional in such 

6 group for such performance 

7 period shall be with respect to 

8 the combined performance of 

9 all such professionals in such 

10 group for such period; and 

11 ‘‘(II) the composite score 

12 provided under this para13 graph for such performance 

14 period with respect to each 

15 such performance category 

16 for each such VBP eligible 

17 professional in such virtual 

18 group shall be based on the 

19 assessment of the combined 

20 performance under subclause 

21 (I) for the performance cat22 egory and performance pe23 riod. 

24 ‘‘(ii) ELECTION OF PRACTICES TO

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1 retary shall, in accordance with 

2 clause (iii), establish and have in 

3 place a process to allow an indi4 vidual VBP eligible professional 

5 or a group practice consisting of 

6 not more than 10 VBP eligible 

7 professionals to elect, with re8 spect to a performance period for 

9 a year, for such individual VBP 

10 eligible professional or all such 

11 VBP eligible professionals in such 

12 group practice, respectively, to be 

13 a virtual group under this sub14 paragraph with at least one other 

15 such individual VBP eligible pro16 fessional or group practice mak17 ing such an election. 

18 ‘‘(iii) REQUIREMENTS.—The 

19 process under clause (ii) shall 

20 provide that— 

21 ‘‘(I) an election under 

22 such clause, with respect to a 

23 performance period, shall be 

24 made before the beginning of 

25 such performance period and 


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1 may not be changed during 

2 such performance period; and 

3 ‘‘(II) a practice described 

4 in such clause, and each VBP 

5 eligible professional in such 

6 practice, may elect to be in no 

7 more than one virtual group 

8 for a performance period. 

9 ‘‘(6) FUNDING FOR VBP PROGRAM INCEN10 TIVE PAYMENTS.— 

11 ‘‘(A) TOTAL AMOUNT FOR INCENTIVE

12 PAYMENTS.—The total amount for VBP 

13 program incentive payments under 

14 paragraph (7) for all VBP eligible pro15 fessionals for a year shall be equal to 

16 the total amount of the performance 

17 funding pool for all VBP eligible pro18 fessionals under subparagraph (B) for 

19 such year, as estimated by the Sec20 retary. 

21 ‘‘(B) PERFORMANCE FUNDING

22 POOL.— 

23 ‘‘(i) IN GENERAL.—In the case 

24 of items and services furnished by 

25 a VBP eligible professional during 


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1 a year (beginning with 2017), the 

2 otherwise applicable fee schedule 

3 amount (as defined in clause (iii)) 

4 with respect to such items and 

5 services and eligible professional 

6 for such year shall be reduced by 

7 the applicable percent under 

8 clause (ii). The total amount of 

9 such reductions for a year shall 

10 be referred to in this subsection 

11 as the ‘performance funding pool’ 

12 for such year. 

13 ‘‘(ii) APPLICABLE PERCENT DE14 FINED.—For purposes of clause (i), 

15 the term ‘applicable percent’ 

16 means— 

17 ‘‘(I) for 2017, 4 percent; 

18 ‘‘(II) for 2018, 6 percent; 

19 ‘‘(III) for 2019, 8 percent; 

20 ‘‘(IV) for 2020, 10 percent; 

21 and 

22 ‘‘(V) for 2021 and subse23 quent years, a percent speci24 fied by the Secretary (but in 


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1 no case less than 10 percent 

2 or more than 12 percent). 

3 ‘‘(iii) OTHERWISE APPLICABLE

4 FEE SCHEDULE AMOUNT.—For pur5 poses of this subparagraph and 

6 paragraph (7), the term ‘other7 wise applicable fee schedule 

8 amount’ means, with respect to 

9 items and services furnished by a 

10 VBP eligible professional during a 

11 year, the fee schedule amount for 

12 such items and services and year 

13 that would otherwise apply (with14 out application of this subpara15 graph or paragraph (7)) with re16 spect to such eligible professional 

17 under subsection (b), after appli18 cation of subsection (a)(3), or 

19 under another fee schedule under 

20 this part. 

21 ‘‘(7) VBP PROGRAM INCENTIVE PAY22 MENTS.— 

23 ‘‘(A) VBP PROGRAM INCENTIVE PAY24 MENT ADJUSTMENT FACTOR.—Con25 sistent with section 2(g)(2) of the SGR 


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1 Repeal and Medicare Beneficiary Ac2 cess Act of 2013, the Secretary shall 

3 specify a VBP program incentive pay4 ment adjustment factor for each VBP 

5 eligible professional for a year. Such 

6 VBP program incentive payment ad7 justment factor for a VBP eligible 

8 professional for a year shall be deter9 mined— 

10 ‘‘(i) by the composite perform11 ance score of the eligible profes12 sional for such year; 

13 ‘‘(ii) in a manner such that the 

14 adjustment factors specified 

15 under this subparagraph for a 

16 year results in differential pay17 ments under this paragraph re18 flecting the full range of the dis19 tribution of composite perform20 ance scores of VBP eligible pro21 fessionals determined under para22 graph (5)(E) for such year, with 

23 such professionals having higher 

24 composite performance scores re25 ceiving higher payment; and 


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1 ‘‘(iii) in a manner such that 

2 the adjustment factors specified 

3 under this subparagraph for a 

4 year— 

5 ‘‘(I) does not result in a 

6 payment reduction for such 

7 year by an amount that ex8 ceeds the applicable percent 

9 described in paragraph 

10 (6)(B)(ii) for such year; and 

11 ‘‘(II) does not result in a 

12 payment increase for such 

13 year by an amount that ex14 ceeds the applicable percent 

15 described in paragraph 

16 (6)(B)(ii) for such year. 

17 ‘‘(B) CALCULATION OF VBP PROGRAM

18 INCENTIVE PAYMENT AMOUNTS.—The 

19 VBP program incentive payment 

20 amount with respect to items and 

21 services furnished by a VBP eligible 

22 professional during a year shall be 

23 equal to the difference between— 

24 ‘‘(i) the product of— 


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1 ‘‘(I) the VBP program in2 centive payment adjustment 

3 factor determined under sub4 paragraph (A) for such VBP 

5 eligible professional for such 

6 year; and 

7 ‘‘(II) the otherwise appli8 cable fee schedule amount (as 

9 defined in paragraph 

10 (6)(B)(iii)) with respect to 

11 such items and services and 

12 eligible professional for such 

13 year; and 

14 ‘‘(ii) the otherwise applicable 

15 fee schedule amount, as reduced 

16 under paragraph (6)(B), with re17 spect to such items and services, 

18 eligible professional, and year. 

19 The application of the preceding sen20 tence may result in the VBP program 

21 incentive payment amount being 0.0 

22 with respect to an item or service fur23 nished by a VBP eligible professional. 

24 ‘‘(C) APPLICATION OF VBP PROGRAM

25 INCENTIVE PAYMENT AMOUNT.—In the 


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1 case of items and services furnished 

2 by a VBP eligible professional during 

3 a year (beginning with 2017), the oth4 erwise applicable fee schedule 

5 amount, as reduced under paragraph 

6 (6)(B), with respect to such items and 

7 services and eligible professional for 

8 such year shall be increased, if appli9 cable, by the VBP program incentive 

10 payment amount determined under 

11 subparagraph (B) with respect to 

12 such items and services, professional, 

13 and year. 

14 ‘‘(D) BUDGET NEUTRALITY.—In 

15 specifying the VBP program incentive 

16 payment adjustment factor for each 

17 VBP eligible professional for a year 

18 under subparagraph (A), the Sec19 retary shall ensure that the total 

20 amount of VBP program incentive 

21 payment amounts under this para22 graph for all VBP eligible profes23 sionals in a year shall be equal to the 

24 performance funding pool for such 


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1 year under paragraph (6), as esti2 mated by the Secretary. 

3 ‘‘(8) ANNOUNCEMENT OF RESULT OF AD4 JUSTMENTS.—Under the VBP program, the 

5 Secretary shall, not later than 60 days 

6 prior to the year involved, make avail7 able to each VBP eligible professional the 

8 VBP program incentive payment adjust9 ment factor under paragraph (7) and the 

10 payment reduction under paragraph (6) 

11 applicable to the eligible professional for 

12 items and services furnished by the pro13 fessional in such year. The Secretary may 

14 include such information in the confiden15 tial feedback under paragraph (13). 

16 ‘‘(9) NO EFFECT IN SUBSEQUENT YEARS.— 

17 The VBP program incentive payment 

18 under paragraph (7) and the payment re19 duction under paragraph (6) shall each 

20 apply only with respect to the year in21 volved, and the Secretary shall not take 

22 into account such VBP program incentive 

23 payment or payment reduction in making 

24 payments to a VBP eligible professional 

25 under this part in a subsequent year. 


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1 ‘‘(10) PUBLIC REPORTING.— 

2 ‘‘(A) IN GENERAL.—The Secretary 

3 shall, in an easily understandable for4 mat, make available on the Physician 

5 Compare Internet website under sub6 section (t) the following: 

7 ‘‘(i) Information regarding the 

8 performance of VBP eligible pro9 fessionals under the VBP pro10 gram, which— 

11 ‘‘(I) shall include the com12 posite score for each such 

13 VBP eligible professional and 

14 the performance of each such 

15 VBP eligible professional with 

16 respect to each performance 

17 category; and 

18 ‘‘(II) may include the per19 formance of each such VBP el20 igible professional with re21 spect to each measure or ac22 tivity specified in paragraph 

23 (2)(B). 

24 ‘‘(ii) The names of eligible pro25 fessionals in eligible alternative 


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1 payment models (as defined in 

2 section 1833(z)(3)(D)) and, to the 

3 extent feasible, the names of such 

4 eligible alternative payment mod5 els and performance of such mod6 els. 

7 ‘‘(B) DISCLOSURE.—The informa8 tion made available under this para9 graph shall indicate, where appro10 priate, that publicized information 

11 may not be representative of the eli12 gible professional’s entire patient 

13 population, the variety of services 

14 furnished by the eligible professional, 

15 or the health conditions of individ16 uals treated. 

17 ‘‘(C) OPPORTUNITY TO REVIEW AND

18 SUBMIT CORRECTIONS.—The Secretary 

19 shall provide for an opportunity for a 

20 professional described in subpara21 graph (A) to review, and submit cor22 rections for, the information to be 

23 made public with respect to the pro24 fessional under such subparagraph 


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1 prior to such information being made 

2 public. 

3 ‘‘(D) AGGREGATE INFORMATION.— 

4 The Secretary shall periodically post 

5 on the Physician Compare Internet 

6 website aggregate information on the 

7 VBP program, including the range of 

8 composite scores for all VBP eligible 

9 professionals and the range of the 

10 performance of all VBP eligible pro11 fessionals with respect to each per12 formance category. 

13 ‘‘(11) CONSULTATION.—The Secretary 

14 shall consult with stakeholders in car15 rying out the VBP program, including for 

16 the identification of measures and activi17 ties under paragraph (2)(B) and the 

18 methodologies developed under para19 graphs (5)(A) and (7). Such consultation 

20 shall include the use of a request for in21 formation or other mechanisms deter22 mined appropriate. 

23 ‘‘(12) TECHNICAL ASSISTANCE TO SMALL

24 PRACTICES AND PRACTICES IN HEALTH PRO25 FESSIONAL SHORTAGE AREAS.— 


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1 ‘‘(A) IN GENERAL.—The Secretary 

2 shall enter into contracts or agree3 ments with appropriate entities (such 

4 as quality improvement organiza5 tions, regional extension centers (as 

6 described in section 3012(c) of the 

7 Public Health Service Act), or re8 gional health collaboratives) to offer 

9 guidance and assistance to VBP eligi10 ble professionals in practices of fewer 

11 than 20 professionals (with priority 

12 given to such practices located in 

13 rural areas, health professional short14 age areas (as designated under in sec15 tion 332(a)(1)(A) of the Public Health 

16 Service Act), or practices with low 

17 composite scores) with respect to— 

18 ‘‘(i) the performance cat19 egories described in clauses (i) 

20 through (iv) of paragraph (2)(A); 

21 or 

22 ‘‘(ii) how to transition to the 

23 implementation of and participa24 tion in an alternative payment 


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1 model as described in section 

2 1833(z)(3)(C). 

3 ‘‘(B) FUNDING FOR IMPLEMENTA4 TION.—For purposes of implementing 

5 subparagraph (A), the Secretary shall 

6 provide for the transfer from the Fed7 eral Supplementary Medical Insur8 ance Trust Fund established under 

9 section 1841 to the Centers for Medi10 care & Medicaid Services Program 

11 Management Account of $50,000,000 

12 for each of fiscal years 2014 through 

13 2018. Amounts transferred under this 

14 subparagraph for a fiscal year shall 

15 be available until expended. 

16 ‘‘(13) FEEDBACK AND INFORMATION TO

17 IMPROVE PERFORMANCE.— 

18 ‘‘(A) PERFORMANCE FEEDBACK.— 

19 ‘‘(i) IN GENERAL.—Beginning 

20 July 1, 2015, the Secretary— 

21 ‘‘(I) shall make available 

22 timely (such as quarterly) 

23 confidential feedback to each 

24 VBP eligible professional on 

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1 fessional with respect to the 

2 performance categories under 

3 clauses (i) and (ii) of para4 graph (2)(A); and 

5 ‘‘(II) may make available 

6 confidential feedback to each 

7 such professional on the per8 formance of such professional 

9 with respect to the perform10 ance categories under clauses 

11 (iii) and (iv) of such para12 graph. 

13 ‘‘(ii) MECHANISMS.—The Sec14 retary may use one or more mech15 anisms to make feedback avail16 able under clause (i), which may 

17 include use of a web-based portal 

18 or other mechanisms determined 

19 appropriate by the Secretary. The 

20 Secretary shall encourage provi21 sion of feedback through quali22 fied clinical data registries as de23 scribed in subsection (m)(3)(E)). 

24 ‘‘(iii) USE OF DATA.—For pur25 poses of clause (i), the Secretary 


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1 may use data, with respect to a 

2 VBP eligible professional, from 

3 periods prior to the current per4 formance period and may use 

5 rolling periods in order to make 

6 illustrative calculations about the 

7 performance of such professional. 

8 ‘‘(iv) DISCLOSURE EXEMPTION.— 

9 Feedback made available under 

10 this subparagraph shall be ex11 empt from disclosure under sec12 tion 552 of title 5, United States 

13 Code. 

14 ‘‘(v) RECEIPT OF INFORMA15 TION.—The Secretary may use the 

16 mechanisms established under 

17 clause (ii) to receive information 

18 from professionals, such as infor19 mation with respect to this sub20 section. 

21 ‘‘(B) ADDITIONAL INFORMATION.— 

22 ‘‘(i) IN GENERAL.—Beginning 

23 July 1, 2016, the Secretary shall 

24 make available to each VBP eligi25 ble professional information, with 


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1 respect to individuals who are pa2 tients of such VBP eligible profes3 sional, about items and services 

4 for which payment is made under 

5 this title that are furnished to 

6 such individuals by other sup7 pliers and providers of services, 

8 which may include information 

9 described in clause (ii). Such in10 formation shall be made available 

11 under the previous sentence to 

12 such VBP eligible professionals 

13 by mechanisms determined ap14 propriate by the Secretary, which 

15 may include use of a web-based 

16 portal. Such information shall be 

17 made available in accordance 

18 with the same or similar terms as 

19 data are made available to ac20 countable care organizations 

21 under section 1899, including a 

22 beneficiary opt-out. 

23 ‘‘(ii) TYPE OF INFORMATION.— 

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1 formation described in this 

2 clause, is the following: 

3 ‘‘(I) With respect to se4 lected items and services (as 

5 determined appropriate by 

6 the Secretary) for which pay7 ment is made under this title 

8 and that are furnished to indi9 viduals, who are patients of a 

10 VBP eligible professional, by 

11 another supplier or provider 

12 of services during the most re13 cent period for which data 

14 are available (such as the 

15 most recent three-month pe16 riod), the name of such pro17 viders furnishing such items 

18 and services to such patients 

19 during such period, the types 

20 of such items and services so 

21 furnished, and the dates such 

22 items and services were so 

23 furnished. 

24 ‘‘(II) Historical averages 

25 (and other measures of the 


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1 distribution if appropriate) of 

2 the total, and components of, 

3 allowed charges (and other 

4 figures as determined appro5 priate by the Secretary) for 

6 care episodes for such period. 

7 ‘‘(14) REVIEW.— 

8 ‘‘(A) TARGETED REVIEW.—The Sec9 retary shall establish a process under 

10 which a VBP eligible professional 

11 may seek an informal review of the 

12 calculation of the VBP program in13 centive payment adjustment factor 

14 applicable to such eligible profes15 sional under this subsection for a 

16 year. The results of a review con17 ducted pursuant to the previous sen18 tence shall not be taken into account 

19 for purposes of paragraph (7) with re20 spect to a year (other than with re21 spect to the calculation of such eligi22 ble professional’s VBP program in23 centive payment adjustment factor 

24 for such year) after the factors deter25 mined in subparagraph (A) of such 


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1 paragraph have been determined for 

2 such year. 

3 ‘‘(B) LIMITATION.—Except as pro4 vided for in subparagraph (A), there 

5 shall be no administrative or judicial 

6 review under section 1869, section 

7 1878, or otherwise of the following: 

8 ‘‘(i) The methodology used to 

9 determine the amount of the VBP 

10 program incentive payment ad11 justment factor under paragraph 

12 (7) and the determination of such 

13 amount. 

14 ‘‘(ii) The determination of the 

15 amount of funding available for 

16 such VBP program incentive pay17 ments under paragraph (6)(A) and 

18 the payment reduction under 

19 paragraph (6)(B)(i). 

20 ‘‘(iii) The establishment of the 

21 performance standards under 

22 paragraph (3) and the perform23 ance period under paragraph (4). 

24 ‘‘(iv) The identification of 

25 measures and activities specified 


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1 under paragraph (2)(B) and infor2 mation made public or posted on 

3 the Physician Compare Internet 

4 website of the Centers for Medi5 care & Medicaid Services under 

6 paragraph (10). 

7 ‘‘(v) The methodology devel8 oped under paragraph (5) that is 

9 used to calculate performance 

10 scores and the calculation of such 

11 scores, including the weighting of 

12 measures and activities under 

13 such methodology.’’. 

14 (2) GAO REPORTS.— 

15 (A) EVALUATION OF ELIGIBLE PRO16 FESSIONAL VBP PROGRAM.—Not later 

17 than October 1, 2018, and October 1, 

18 2021, the Comptroller General of the 

19 United States shall submit to Con20 gress a report evaluating the eligible 

21 professional value-based performance 

22 incentive program under subsection 

23 (q) of section 1848 of the Social Secu24 rity Act (42 U.S.C. 1395w–4), as added 

25 by paragraph (1). Such report shall— 


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1 (i) examine the distribution of 

2 the performance and incentive 

3 payments for VBP eligible profes4 sionals (as defined in subsection 

5 (q)(1)(C) of such section) under 

6 such program, and patterns relat7 ing to such performance and in8 centive payments, including 

9 based on type of provider, prac10 tice size, geographic location, and 

11 patient mix; and 

12 (ii) provide recommendations 

13 for improving such program. 

14 (B) STUDY TO EXAMINE ALIGNMENT

15 OF QUALITY MEASURES USED IN PUBLIC

16 AND PRIVATE PROGRAMS.—Not later 

17 than 18 months after the date of the 

18 enactment of this Act, the Comp19 troller General of the United States 

20 shall submit to Congress a report 

21 that— 

22 (i) compares the similarities 

23 and differences in the use of qual24 ity measures under the original 

25 medicare fee-for-service program 


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1 under parts A and B of title XVIII 

2 of the Social Security Act, the 

3 Medicare Advantage program 

4 under part C of such title, and 

5 private payer arrangements; and 

6 (ii) makes recommendations 

7 on how to reduce the administra8 tive burden involved in applying 

9 such quality measures. 

10 (3) FUNDING FOR IMPLEMENTATION.— 

11 For purposes of implementing the provi12 sions of and the amendments made by 

13 this section, the Secretary of Health and 

14 Human Services shall provide for the 

15 transfer of $50,000,000 from the Supple16 mentary Medical Insurance Trust Fund 

17 established under section 1841 of the So18 cial Security Act (42 U.S.C. 1395t) to the 

19 Centers for Medicare & Medicaid Pro20 gram Management Account for each of 

21 the fiscal years 2014 through 2017. 

22 Amounts transferred under this para23 graph shall be available until expended. 

24 (d) IMPROVING QUALITY REPORTING FOR

25 COMPOSITE SCORES.— 


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1 (1) CHANGES FOR GROUP REPORTING OP2 TION.— 

3 (A) IN GENERAL.—Section 

4 1848(m)(3)(C)(ii)) of the Social Secu5 rity Act (42 U.S.C. 1395w– 

6 4(m)(3)(C)(ii)) is amended by insert7 ing ‘‘and, for 2014 and subsequent 

8 years, may provide’’ after ‘‘shall pro9 vide’’. 

10 (B) CLARIFICATION OF QUALIFIED

11 CLINICAL DATA REGISTRY REPORTING TO

12 GROUP PRACTICES.—Section 

13 1848(m)(3)(D) of the Social Security 

14 Act (42 U.S.C. 1395w–4(m)(3)(D)) is 

15 amended by inserting ‘‘and, for 2015 

16 and subsequent years, subparagraph 

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

18 (2) CHANGES FOR MULTIPLE REPORTING

19 PERIODS AND ALTERNATIVE CRITERIA FOR

20 SATISFACTORY REPORTING.—Section 

21 1848(m)(5)(F)) of the Social Security Act 

22 (42 U.S.C. 1395w–4(m)(5)(F)) is amended— 

23 (A) by striking ‘‘and subsequent 

24 years’’ and inserting ‘‘through report25 ing periods occurring in 2013’’; and 


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1 (B) by inserting ‘‘and, for report2 ing periods occurring in 2014 and 

3 subsequent years, the Secretary may 

4 establish’’ following ‘‘shall establish’’. 

5 (3) PHYSICIAN FEEDBACK PROGRAM RE6 PORTS SUCCEEDED BY REPORTS UNDER VBP

7 PROGRAM.—Section 1848(n) of the Social 

8 Security Act (42 U.S.C. 1395w–4(n)) is 

9 amended by adding at the end the fol10 lowing new paragraph: 

11 ‘‘(11) REPORTS ENDING WITH 2016.—Re12 ports under the Program shall not be 

13 provided after December 31, 2016. See 

14 subsection (q)(13) for reports beginning 

15 with 2017.’’. 

16 (4) COORDINATION WITH SATISFYING

17 MEANINGFUL EHR USE CLINICAL QUALITY

18 MEASURE REPORTING REQUIREMENT.—Sec19 tion 1848(o)(2)(A)(iii) of the Social Secu20 rity Act (42 U.S.C. 1395w–4(o)(2)(A)(iii)) is 

21 amended by inserting ‘‘and subsection 

22 (q)(5)(C)(ii)(II)’’ after ‘‘Subject to subpara23 graph (B)(ii)’’. 

24 (e) PROMOTING ALTERNATIVE PAYMENT

25 MODELS.— 


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1 (1) INCENTIVE PAYMENTS FOR PARTICI2 PATION IN ELIGIBLE ALTERNATIVE PAYMENT

3 MODELS.—Section 1833 of the Social Secu4 rity Act (42 U.S.C. 1395l) is amended by 

5 adding at the end the following new sub6 section: 

7 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPA8 TION IN ELIGIBLE ALTERNATIVE PAYMENT MOD9 ELS.— 

10 ‘‘(1) PAYMENT INCENTIVE.— 

11 ‘‘(A) IN GENERAL.—In the case of 

12 covered professional services fur13 nished by an eligible professional 

14 during a year that is in the period be15 ginning with 2017 and ending with 

16 2022 and for which the professional is 

17 a qualifying APM participant, in addi18 tion to the amount of payment that 

19 would otherwise be made for such 

20 covered professional services under 

21 this part for such year, there also 

22 shall be paid to such professional an 

23 amount equal to 5 percent of the pay24 ment amount for the covered profes25 sional services under this part for the 


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1 preceding year. For purposes of the 

2 previous sentence, the payment 

3 amount for the preceding year may 

4 be an estimation for the full pre5 ceding year based on a period of such 

6 preceding year that is less than the 

7 full year. The Secretary shall estab8 lish policies to implement this sub9 paragraph in cases where payment 

10 for covered professional services fur11 nished by a qualifying APM partici12 pant in an alternative payment model 

13 is made to an entity participating in 

14 the alternative payment model rather 

15 than directly to the qualifying APM 

16 participant. 

17 ‘‘(B) FORM OF PAYMENT.—Payments 

18 under this subsection shall be made 

19 in a lump sum, on an annual basis, as 

20 soon as practicable. 

21 ‘‘(C) TREATMENT OF PAYMENT IN22 CENTIVE.—Payments under this sub23 section shall not be taken into ac24 count for purposes of determining ac25 tual expenditures under an alterVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00162 Fmt 6652 Sfmt 6202 E:\BILLS\H2810.RH H2810

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1 native payment model and for pur2 poses of determining or rebasing any 

3 benchmarks used under the alter4 native payment model. 

5 ‘‘(D) COORDINATION.—The amount 

6 of the additional payment for an item 

7 or service under this subsection or 

8 subsection (m) shall be determined 

9 without regard to any additional pay10 ment for the item or service under 

11 subsection (m) and this subsection, 

12 respectively. The amount of the addi13 tional payment for an item or service 

14 under this subsection or subsection 

15 (x) shall be determined without re16 gard to any additional payment for 

17 the item or service under subsection 

18 (x) and this subsection, respectively. 

19 The amount of the additional pay20 ment for an item or service under 

21 this subsection or subsection (y) shall 

22 be determined without regard to any 

23 additional payment for the item or 

24 service under subsection (y) and this 

25 subsection, respectively. 


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1 ‘‘(2) QUALIFYING APM PARTICIPANT.— 

2 For purposes of this subsection, the term 

3 ‘qualifying APM participant’ means the 

4 following: 

5 ‘‘(A) 2017 AND 2018.—With respect 

6 to 2017 and 2018, an eligible profes7 sional for whom the Secretary deter8 mines that at least 25 percent of pay9 ments under this part for covered 

10 professional services furnished by 

11 such professional during the most re12 cent period for which data are avail13 able (which may be less than a year) 

14 were attributable to such services 

15 furnished under this part through an 

16 entity that participates in an eligible 

17 alternative payment model with re18 spect to such services. 

19 ‘‘(B) 2019 AND 2020.—With respect 

20 to 2019 and 2020, an eligible profes21 sional described in either of the fol22 lowing clauses: 

23 ‘‘(i) MEDICARE REVENUE

24 THRESHOLD OPTION.—An eligible 

25 professional for whom the SecVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00164 Fmt 6652 Sfmt 6202 E:\BILLS\H2810.RH H2810

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1 retary determines that at least 50 

2 percent of payments under this 

3 part for covered professional 

4 services furnished by such profes5 sional during the most recent pe6 riod for which data are available 

7 (which may be less than a year) 

8 were attributable to such services 

9 furnished under this part through 

10 an entity that participates in an 

11 eligible alternative payment 

12 model with respect to such serv13 ices. 

14 ‘‘(ii) COMBINATION ALL-PAYER

15 AND MEDICARE REVENUE THRESHOLD

16 OPTION.—An eligible profes17 sional— 

18 ‘‘(I) for whom the Sec19 retary determines, with re20 spect to items and services 

21 furnished by such profes22 sional during the most recent 

23 period for which data are 

24 available (which may be less 


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1 than a year), that at least 50 

2 percent of the sum of— 

3 ‘‘(aa) payments de4 scribed in clause (i); and 

5 ‘‘(bb) all other pay6 ments, regardless of payer 

7 (other than payments 

8 made by the Secretary of 

9 Defense or the Secretary 

10 of Veterans Affairs under 

11 chapter 55 of title 10, 

12 United States Code, or 

13 title 38, United States 

14 Code, or any other provi15 sion of law), 

16 meet the requirement de17 scribed in clause (iii)(I) with 

18 respect to payments described 

19 in item (aa) and meet the re20 quirement described in clause 

21 (iii)(II) with respect to pay22 ments described in item (bb); 

23 ‘‘(II) for whom the Sec24 retary determines at least 25 

25 percent of payments under 


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1 this part for covered profes2 sional services furnished by 

3 such professional during the 

4 most recent period for which 

5 data are available (which may 

6 be less than a year) were at7 tributable to such services 

8 furnished under this part 

9 through an entity that partici10 pates in an eligible alter11 native payment model with 

12 respect to such services; and 

13 ‘‘(III) who provides to the 

14 Secretary such information as 

15 is necessary for the Secretary 

16 to make a determination 

17 under subclause (I), with re18 spect to such professional. 

19 ‘‘(iii) REQUIREMENT.—For pur20 poses of clause (ii)(I)— 

21 ‘‘(I) the requirement de22 scribed in this subclause, with 

23 respect to payments described 

24 in item (aa) of such clause, is 

25 that such payments are made 


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1 under an eligible alternative 

2 payment model; and 

3 ‘‘(II) the requirement de4 scribed in this subclause, with 

5 respect to payments described 

6 in item (bb) of such clause, is 

7 that such payments are made 

8 under an arrangement in 

9 which— 

10 ‘‘(aa) quality measures 

11 comparable to measures 

12 under the performance 

13 category described in sec14 tion 1848(q)(2)(B)(i) apply; 

15 ‘‘(bb) certified EHR 

16 technology is used; and 

17 ‘‘(cc) the eligible pro18 fessional bears more than 

19 nominal financial risk if 

20 actual aggregate expendi21 tures exceeds expected ag22 gregate expenditures. 

23 ‘‘(C) BEGINNING IN 2021.—With re24 spect to 2021 and each subsequent 

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1 scribed in either of the following 

2 clauses: 

3 ‘‘(i) MEDICARE REVENUE

4 THRESHOLD OPTION.—An eligible 

5 professional for whom the Sec6 retary determines that at least 75 

7 percent of payments under this 

8 part for covered professional 

9 services furnished by such profes10 sional during the most recent pe11 riod for which data are available 

12 (which may be less than a year) 

13 were attributable to such services 

14 furnished under this part through 

15 an entity that participates in an 

16 eligible alternative payment 

17 model with respect to such serv18 ices. 

19 ‘‘(ii) COMBINATION ALL-PAYER

20 AND MEDICARE REVENUE THRESHOLD

21 OPTION.—An eligible profes22 sional— 

23 ‘‘(I) for whom the Sec24 retary determines, with re25 spect to items and services 


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1 furnished by such profes2 sional during the most recent 

3 period for which data are 

4 available (which may be less 

5 than a year), that at least 75 

6 percent of the sum of— 

7 ‘‘(aa) payments de8 scribed in clause (i); and 

9 ‘‘(bb) all other pay10 ments, regardless of payer 

11 (other than payments 

12 made by the Secretary of 

13 Defense or the Secretary 

14 of Veterans Affairs under 

15 chapter 55 of title 10, 

16 United States Code, or 

17 title 38, United States 

18 Code, or any other provi19 sion of law), 

20 meet the requirement de21 scribed in clause (iii)(I) with 

22 respect to payments described 

23 in item (aa) and meet the re24 quirement described in clause 


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1 (iii)(II) with respect to pay2 ments described in item (bb); 

3 ‘‘(II) for whom the Sec4 retary determines at least 25 

5 percent of payments under 

6 this part for covered profes7 sional services furnished by 

8 such professional during the 

9 most recent period for which 

10 data are available (which may 

11 be less than a year) were at12 tributable to such services 

13 furnished under this part 

14 through an entity that partici15 pates in an eligible alter16 native payment model with 

17 respect to such services; and 

18 ‘‘(III) who provides to the 

19 Secretary such information as 

20 is necessary for the Secretary 

21 to make a determination 

22 under subclause (I), with re23 spect to such professional. 

24 ‘‘(iii) REQUIREMENT.—For pur25 poses of clause (ii)(I)— 


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1 ‘‘(I) the requirement de2 scribed in this subclause, with 

3 respect to payments described 

4 in item (aa) of such clause, is 

5 that such payments are made 

6 under an eligible alternative 

7 payment model; and 

8 ‘‘(II) the requirement de9 scribed in this subclause, with 

10 respect to payments described 

11 in item (bb) of such clause, is 

12 that such payments are made 

13 under an arrangement in 

14 which— 

15 ‘‘(aa) quality measures 

16 comparable to measures 

17 under the performance 

18 category described in sec19 tion 1848(q)(2)(B)(i) apply; 

20 ‘‘(bb) certified EHR 

21 technology is used; and 

22 ‘‘(cc) the eligible pro23 fessional bears more than 

24 nominal financial risk if 

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1 tures exceeds expected ag2 gregate expenditures. 

3 ‘‘(2) ADDITIONAL DEFINITIONS.—In this 

4 subsection: 

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

7 services’ has the meaning given that 

8 term in section 1848(k)(3)(A). 

9 ‘‘(B) ELIGIBLE PROFESSIONAL.—The 

10 term ‘eligible professional’ has the 

11 meaning given that term in section 

12 1848(k)(3)(B). 

13 ‘‘(C) ALTERNATIVE PAYMENT MODEL

14 (APM).—The term ‘alternative payment 

15 model’ means any of the following: 

16 ‘‘(i) A model under section 

17 1115A (other than a health care 

18 innovation award). 

19 ‘‘(ii) An accountable care or20 ganization under section 1899. 

21 ‘‘(iii) A demonstration under 

22 section 1866C. 

23 ‘‘(iv) A demonstration re24 quired by Federal law. 


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1 ‘‘(D) ELIGIBLE ALTERNATIVE PAY2 MENT MODEL (APM).— 

3 ‘‘(i) IN GENERAL.—The term ‘el4 igible alternative payment model’ 

5 means, with respect to a year, an 

6 alternative payment model— 

7 ‘‘(I) that requires use of 

8 certified EHR technology (as 

9 defined in subsection (o)(4)); 

10 ‘‘(II) that provides for pay11 ment for covered professional 

12 services based on quality 

13 measures comparable to 

14 measures under the perform15 ance category described in 

16 section 1848(q)(2)(B)(i); and 

17 ‘‘(III) that satisfies the re18 quirement described in clause 

19 (ii). 

20 ‘‘(ii) ADDITIONAL REQUIRE21 MENT.—For purposes of clause 

22 (i)(III), the requirement described 

23 in this clause, with respect to a 

24 year and an alternative payment 


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1 model, is that the alternative pay2 ment model— 

3 ‘‘(I) is one in which one or 

4 more entities bear financial 

5 risk for monetary losses 

6 under such model that are in 

7 excess of a nominal amount; 

8 or 

9 ‘‘(II) is a medical home ex10 panded under section 

11 1115A(c). 

12 ‘‘(3) LIMITATION.—There shall be no 

13 administrative or judicial review under 

14 section 1869, 1878, or otherwise, of the 

15 following: 

16 ‘‘(A) The determination that an el17 igible professional is a qualifying 

18 APM participant under paragraph (2) 

19 and the determination that an alter20 native payment model is an eligible 

21 alternative payment model under 

22 paragraph (3)(D). 

23 ‘‘(B) The determination of the 

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1 cluding any estimation as part of 

2 such determination.’’. 

3 (2) COORDINATION CONFORMING AMEND4 MENTS.—Section 1833 of the Social Secu5 rity Act (42 U.S.C. 1395l) is further 

6 amended— 

7 (A) in subsection (x)(3), by adding 

8 at the end the following new sen9 tence: ‘‘The amount of the additional 

10 payment for a service under this sub11 section and subsection (z) shall be de12 termined without regard to any addi13 tional payment for the service under 

14 subsection (z) and this subsection, re15 spectively.’’; and 

16 (B) in subsection (y)(3), by adding 

17 at the end the following new sen18 tence: ‘‘The amount of the additional 

19 payment for a service under this sub20 section and subsection (z) shall be de21 termined without regard to any addi22 tional payment for the service under 

23 subsection (z) and this subsection, re24 spectively.’’. 


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1 (3) ENCOURAGING DEVELOPMENT AND

2 TESTING OF CERTAIN MODELS.—Section 

3 1115A(b)(2) of the Social Security Act (42 

4 U.S.C. 1315a(b)(2)) is amended— 

5 (A) in subparagraph (B), by add6 ing at the end the following new 

7 clauses: 

8 ‘‘(xxi) Focusing primarily on 

9 physicians’ services (as defined in 

10 section 1848(j)(3)) furnished by 

11 physicians who are not primary 

12 care practitioners. 

13 ‘‘(xxii) Focusing on practices 

14 of fewer than 20 professionals.’’; 

15 and 

16 (B) in subparagraph (C)(viii), by 

17 striking ‘‘other public sector or pri18 vate sector payers’’ and inserting 

19 ‘‘other public sector payers, private 

20 sector payers, or Statewide payment 

21 models’’. 

22 (f) STUDY AND REPORT ON FRAUD RELATED

23 TO ALTERNATIVE PAYMENT MODELS UNDER THE

24 MEDICARE PROGRAM.— 


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1 (1) STUDY.—The Secretary of Health 

2 and Human Services, in consultation 

3 with the Inspector General of the Depart4 ment of Health and Human Services, 

5 shall conduct a study that— 

6 (A) examines the applicability of 

7 the Federal fraud prevention laws to 

8 items and services furnished under 

9 title XVIII of the Social Security Act 

10 for which payment is made under an 

11 alternative payment model (as de12 fined in section 1833(z)(3)(C) of such 

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

14 (B) identifies aspects of such al15 ternative payment models that are 

16 vulnerable to fraudulent activity; and 

17 (C) examines the implications of 

18 waivers to such laws granted in sup19 port of such alternative payment 

20 models, including under any poten21 tial expansion of such models. 

22 (2) REPORT.—Not later than 2 years 

23 after the date of the enactment of this 

24 Act, the Secretary shall submit to Con25 gress a report containing the results of 


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1 the study conducted under paragraph (1). 

2 Such report shall include recommenda3 tions for actions to be taken to reduce 

4 the vulnerability of such alternative pay5 ment models to fraudulent activity. Such 

6 report also shall include, as appropriate, 

7 recommendations of the Inspector Gen8 eral for changes in Federal fraud preven9 tion laws to reduce such vulnerability. 

10 (g) IMPROVING PAYMENT ACCURACY.— 

11 (1) STUDIES AND REPORTS OF EFFECT OF

12 CERTAIN INFORMATION ON QUALITY AND RE13 SOURCE USE .— 

14 (A) STUDY USING EXISTING MEDI15 CARE DATA.— 

16 (i) STUDY.—The Secretary of 

17 Health and Human Services (in 

18 this subsection referred to as the 

19 ‘‘Secretary’’) shall conduct a study 

20 that examines the effect of indi21 viduals’ socioeconomic status on 

22 quality and resource use outcome 

23 measures for individuals under 

24 the Medicare program (such as to 

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1 viduals may require more inten2 sive interventions). The study 

3 shall use information collected on 

4 such individuals in carrying out 

5 such program, such as urban and 

6 rural location, eligibility for Med7 icaid (recognizing and accounting 

8 for varying Medicaid eligibility 

9 across States), and eligibility for 

10 benefits under the supplemental 

11 security income (SSI) program. 

12 The Secretary shall carry out this 

13 paragraph acting through the As14 sistant Secretary for Planning 

15 and Evaluation. 

16 (ii) REPORT.—Not later than 2 

17 years after the date of the enact18 ment of this Act, the Secretary 

19 shall submit to Congress a report 

20 on the study conducted under 

21 clause (i). 

22 (B) STUDY USING OTHER DATA.— 

23 (i) STUDY.—The Secretary 

24 shall conduct a study that exam25 ines the impact of risk factors, 


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1 such as those described in section 

2 1848(p)(3) of the Social Security 

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

4 health literacy, limited English 

5 proficiency (LEP), and patient ac6 tivation, on quality and resource 

7 use outcome measures under the 

8 Medicare program (such as to rec9 ognize that less healthy individ10 uals may require more intensive 

11 interventions). In conducting 

12 such study the Secretary may use 

13 existing Federal data and collect 

14 such additional data as may be 

15 necessary to complete the study. 

16 (ii) REPORT.—Not later than 5 

17 years after the date of the enact18 ment of this Act, the Secretary 

19 shall submit to Congress a report 

20 on the study conducted under 

21 clause (i). 

22 (C) EXAMINATION OF DATA IN CON23 DUCTING STUDIES.—In conducting the 

24 studies under subparagraphs (A) and 

25 (B), the Secretary shall examine what 


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1 non-Medicare data sets, such as data 

2 from the American Community Sur3 vey (ACS), can be useful in con4 ducting the types of studies under 

5 such paragraphs and how such data 

6 sets that are identified as useful can 

7 be coordinated with Medicare admin8 istrative data in order to improve the 

9 overall data set available to do such 

10 studies and for the administration of 

11 the Medicare program. 

12 (D) RECOMMENDATIONS TO ACCOUNT

13 FOR INFORMATION IN PAYMENT ADJUST14 MENT MECHANISMS.—If the studies con15 ducted under subparagraphs (A) and 

16 (B) find a relationship between the 

17 factors examined in the studies and 

18 quality and resource use outcome 

19 measures, then the Secretary shall 

20 also provide recommendations for 

21 how the Centers for Medicare & Med22 icaid Services should— 

23 (i) obtain access to the nec24 essary data (if such data is not al25 ready being collected) on such 


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1 factors, including recommenda2 tions on how to address barriers 

3 to the Centers in accessing such 

4 data; and 

5 (ii) account for such factors in 

6 determining payment adjust7 ments based on quality and re8 source use outcome measures 

9 under the eligible professional 

10 value-based performance incen11 tive program under section 

12 1848(q) of the Social Security Act 

13 (42 U.S.C. 1395w–4(q)) and, as the 

14 Secretary determines appro15 priate, other similar provisions of 

16 title XVIII of such Act. 

17 (E) FUNDING.—There are hereby 

18 appropriated from the Federal Sup19 plemental Medical Insurance Trust 

20 Fund to the Secretary to carry out 

21 this paragraph $6,000,000, to remain 

22 available until expended. 

23 (2) CMS ACTIVITIES.— 

24 (A) HIERARCHAL CONDITION CAT25 EGORY (HCC) IMPROVEMENT.—Taking 


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1 into account the relevant studies con2 ducted and recommendations made 

3 in reports under paragraph (1), the 

4 Secretary, on an ongoing basis, shall 

5 estimate how an individual’s health 

6 status and other risk factors affect 

7 quality and resource use outcome 

8 measures and, as feasible, shall incor9 porate information from quality and 

10 resource use outcome measurement 

11 (including care episode and patient 

12 condition groups) into the eligible 

13 professional value-based performance 

14 incentive program under section 

15 1848(q) of the Social Security Act and, 

16 as the Secretary determines appro17 priate, other similar provisions of 

18 title XVIII of such Act. 

19 (B) ACCOUNTING FOR OTHER FAC20 TORS IN PAYMENT ADJUSTMENT MECHA21 NISMS.— 

22 (i) IN GENERAL.—Taking into 

23 account the studies conducted 

24 and recommendations made in re25 ports under paragraph (1), the 


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1 Secretary shall account for identi2 fied factors (other than those ap3 plied under subparagraph (A)) 

4 with an effect on quality and re5 source use outcome measures 

6 when determining payment ad7 justments under the eligible pro8 fessional value-based perform9 ance incentive program under 

10 section 1848(q) of the Social Secu11 rity Act and, as the Secretary de12 termines appropriate, other simi13 lar provisions of title XVIII of 

14 such Act. 

15 (ii) ACCESSING DATA.—The Sec16 retary shall collect or otherwise 

17 obtain access to the data nec18 essary to carry out this para19 graph through existing and new 

20 data sources. 

21 (iii) PERIODIC ANALYSES.—The 

22 Secretary shall carry out periodic 

23 analyses, at least every 3 years, 

24 based on the factors referred to in 


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1 clause (i) so as to monitor 

2 changes in possible relationships. 

3 (C) FUNDING.—There are hereby 

4 appropriated from the Federal Sup5 plemental Medical Insurance Trust 

6 Fund to the Secretary to carry out 

7 this paragraph $10,000,000, to remain 

8 available until expended. 

9 (3) STRATEGIC PLAN FOR ACCESSING

10 RACE AND ETHNICITY DATA.—Not later than 

11 18 months after the date of the enactment 

12 of this Act, the Secretary shall develop 

13 and report to Congress on a strategic 

14 plan for collecting or otherwise accessing 

15 data on race and ethnicity for purposes 

16 of carrying out the eligible professional 

17 value-based performance incentive pro18 gram under section 1848(q) of the Social 

19 Security Act and, as the Secretary deter20 mines appropriate, other similar provi21 sions of title XVIII of such Act. 

22 (h) COLLABORATING WITH THE PHYSICIAN, 

23 PRACTITIONER, AND OTHER STAKEHOLDER COM24 MUNITIES TO IMPROVE RESOURCE USE MEASURE25 MENT.—Section 1848 of the Social Security Act 


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1 (42 U.S.C. 1395w–4), as amended by subsection 

2 (c), is further amended by adding at the end 

3 the following new subsection: 

4 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, 

5 PRACTITIONER, AND OTHER STAKEHOLDER COM6 MUNITIES TO IMPROVE RESOURCE USE MEASURE7 MENT.— 

8 ‘‘(1) IN GENERAL.—In order to involve 

9 the physician, practitioner, and other 

10 stakeholder communities in enhancing 

11 the infrastructure for resource use meas12 urement, including for purposes of the 

13 value-based performance incentive pro14 gram under subsection (q) and alter15 native payment models under section 

16 1833(z), the Secretary shall undertake the 

17 steps described in the succeeding provi18 sions of this subsection. 

19 ‘‘(2) DEVELOPMENT OF CARE EPISODE

20 AND PATIENT CONDITION GROUPS AND CLAS21 SIFICATION CODES.— 

22 ‘‘(A) IN GENERAL.—In order to clas23 sify similar patients into distinct care 

24 episode groups and distinct patient 

25 condition groups, the Secretary shall 


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1 undertake the steps described in the 

2 succeeding provisions of this para3 graph. 

4 ‘‘(B) PUBLIC AVAILABILITY OF EXIST5 ING EFFORTS TO DESIGN AN EPISODE

6 GROUPER.—Not later than 60 days 

7 after the date of the enactment of this 

8 subsection, the Secretary shall post 

9 on the Internet website of the Cen10 ters for Medicare & Medicaid Serv11 ices a list of the episode groups devel12 oped pursuant to subsection (n)(9)(A) 

13 and related descriptive information. 

14 ‘‘(C) STAKEHOLDER INPUT.—The 

15 Secretary shall accept, through the 

16 date that is 60 days after the day the 

17 Secretary posts the list pursuant to 

18 subparagraph (B), suggestions from 

19 physician specialty societies, applica20 ble practitioner organizations, and 

21 other stakeholders for episode groups 

22 in addition to those posted pursuant 

23 to such subparagraph, and specific 

24 clinical criteria and patient charac25 teristics to classify patients into— 


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1 ‘‘(i) distinct care episode 

2 groups; and 

3 ‘‘(ii) distinct patient condition 

4 groups. 

5 ‘‘(D) DEVELOPMENT OF PROPOSED

6 CLASSIFICATION CODES.— 

7 ‘‘(i) IN GENERAL.—Taking into 

8 account the information de9 scribed in subparagraph (B) and 

10 the information received under 

11 subparagraph (C), the Secretary 

12 shall— 

13 ‘‘(I) establish distinct care 

14 episode groups and distinct 

15 patient condition groups, 

16 which account for at least an 

17 estimated two-thirds of ex18 penditures under parts A and 

19 B; and 

20 ‘‘(II) assign codes to such 

21 groups. 

22 ‘‘(ii) CARE EPISODE GROUPS.—In 

23 establishing the care episode 

24 groups under clause (i), the Sec25 retary shall take into account— 


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1 ‘‘(I) the patient’s clinical 

2 problems at the time items 

3 and services are furnished 

4 during an episode of care, 

5 such as the clinical conditions 

6 or diagnoses, whether or not 

7 inpatient hospitalization is 

8 anticipated or occurs, and the 

9 principal procedures or serv10 ices planned or furnished; 

11 and 

12 ‘‘(II) other factors deter13 mined appropriate by the Sec14 retary. 

15 ‘‘(iii) PATIENT CONDITION

16 GROUPS.—In establishing the pa17 tient condition groups under 

18 clause (i), the Secretary shall take 

19 into account— 

20 ‘‘(I) the patient’s clinical 

21 history at the time of each 

22 medical visit, such as the pa23 tient’s combination of chronic 

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1 tory (such as hospitalization 

2 and major surgery during a 

3 previous period, such as 3 

4 months); and 

5 ‘‘(II) other factors deter6 mined appropriate by the Sec7 retary, such as eligibility sta8 tus under this title (including 

9 eligibility under section 

10 226(a), 226(b), or 226A, and 

11 dual eligibility under this title 

12 and title XIX). 

13 ‘‘(E) DRAFT CARE EPISODE AND PA14 TIENT CONDITION GROUPS AND CLASSI15 FICATION CODES.—Not later than 120 

16 days after the end of the comment pe17 riod described in subparagraph (C), 

18 the Secretary shall post on the Inter19 net website of the Centers for Medi20 care & Medicaid Services a draft list 

21 of the care episode and patient condi22 tion codes established under subpara23 graph (D) (and the criteria and char24 acteristics assigned to such code). 


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1 ‘‘(F) SOLICITATION OF INPUT.—The 

2 Secretary shall seek, through the date 

3 that is 60 days after the Secretary 

4 posts the list pursuant to subpara5 graph (E), comments from physician 

6 specialty societies, applicable practi7 tioner organizations, and other stake8 holders, including representatives of 

9 individuals entitled to benefits under 

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

12 condition groups (and codes) posted 

13 under subparagraph (E). In seeking 

14 such comments, the Secretary shall 

15 use one or more mechanisms (other 

16 than notice and comment rule17 making) that may include use of open 

18 door forums, town hall meetings, or 

19 other appropriate mechanisms. 

20 ‘‘(G) OPERATIONAL LIST OF CARE

21 EPISODE AND PATIENT CONDITION

22 GROUPS AND CODES.—Not later than 

23 120 days after the end of the com24 ment period described in subpara25 graph (F), taking into account the 


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1 comments received under such sub2 paragraph, the Secretary shall post 

3 on the Internet website of the Cen4 ters for Medicare & Medicaid Serv5 ices an operational list of care epi6 sode and patient condition codes (and 

7 the criteria and characteristics as8 signed to such code). 

9 ‘‘(H) SUBSEQUENT REVISIONS.—Not 

10 later than November 1 of each year 

11 (beginning with 2016), the Secretary 

12 shall, through rulemaking, make revi13 sions to the operational lists of care 

14 episode and patient condition codes 

15 as the Secretary determines may be 

16 appropriate. Such revisions may be 

17 based on experience, new information 

18 developed pursuant to subsection 

19 (n)(9)(A), and input from the physi20 cian specialty societies, applicable 

21 practitioner organizations, and other 

22 stakeholders, including representa23 tives of individuals entitled to bene24 fits under part A or enrolled under 

25 this part. 


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1 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHY2 SICIANS OR PRACTITIONERS.— 

3 ‘‘(A) IN GENERAL.—In order to fa4 cilitate the attribution of patients 

5 and episodes (in whole or in part) to 

6 one or more physicians or applicable 

7 practitioners furnishing items and 

8 services, the Secretary shall under9 take the steps described in the suc10 ceeding provisions of this paragraph. 

11 ‘‘(B) DEVELOPMENT OF PATIENT RE12 LATIONSHIP CATEGORIES AND CODES.— 

13 The Secretary shall develop patient 

14 relationship categories and codes 

15 that define and distinguish the rela16 tionship and responsibility of a physi17 cian or applicable practitioner with a 

18 patient at the time of furnishing an 

19 item or service. Such patient relation20 ship categories shall include different 

21 relationships of the physician or ap22 plicable practitioner to the patient 

23 (and the codes may reflect combina24 tions of such categories), such as a 


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1 physician or applicable practitioner 

2 who— 

3 ‘‘(i) considers themself to have 

4 the primary responsibility for the 

5 general and ongoing care for the 

6 patient over extended periods of 

7 time; 

8 ‘‘(ii) considers themself to be 

9 the lead physician or practitioner 

10 and who furnishes items and 

11 services and coordinates care fur12 nished by other physicians or 

13 practitioners for the patient dur14 ing an acute episode; 

15 ‘‘(iii) furnishes items and serv16 ices to the patient on a con17 tinuing basis during an acute epi18 sode of care, but in a supportive 

19 rather than a lead role; 

20 ‘‘(iv) furnishes items and serv21 ices to the patient on an occa22 sional basis, usually at the re23 quest of another physician or 

24 practitioner; or 


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1 ‘‘(v) furnishes items and serv2 ices only as ordered by another 

3 physician or practitioner. 

4 ‘‘(C) DRAFT LIST OF PATIENT RELA5 TIONSHIP CATEGORIES AND CODES.—Not 

6 later than 180 days after the date of 

7 the enactment of this subsection, the 

8 Secretary shall post on the Internet 

9 website of the Centers for Medicare & 

10 Medicaid Services a draft list of the 

11 patient relationship categories and 

12 codes developed under subparagraph 

13 (B). 

14 ‘‘(D) STAKEHOLDER INPUT.—The 

15 Secretary shall seek, through the date 

16 that is 60 days after the Secretary 

17 posts the list pursuant to subpara18 graph (C), comments from physician 

19 specialty societies, applicable practi20 tioner organizations, and other stake21 holders, including representatives of 

22 individuals entitled to benefits under 

23 part A or enrolled under this part, re24 garding the patient relationship cat25 egories and codes posted under subVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00196 Fmt 6652 Sfmt 6202 E:\BILLS\H2810.RH H2810

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1 paragraph (C). In seeking such com2 ments, the Secretary shall use one or 

3 more mechanisms (other than notice 

4 and comment rulemaking) that may 

5 include open door forums, town hall 

6 meetings, or other appropriate mech7 anisms. 

8 ‘‘(E) OPERATIONAL LIST OF PATIENT

9 RELATIONSHIP CATEGORIES AND

10 CODES.—Not later than 120 days after 

11 the end of the comment period de12 scribed in subparagraph (D), taking 

13 into account the comments received 

14 under such subparagraph, the Sec15 retary shall post on the Internet 

16 website of the Centers for Medicare & 

17 Medicaid Services an operational list 

18 of patient relationship categories and 

19 codes. 

20 ‘‘(F) SUBSEQUENT REVISIONS.—Not 

21 later than November 1 of each year 

22 (beginning with 2016), the Secretary 

23 shall, through rulemaking, make revi24 sions to the operational list of patient 

25 relationship categories and codes as 


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1 the Secretary determines appro2 priate. Such revisions may be based 

3 on experience, new information de4 veloped pursuant to subsection 

5 (n)(9)(A), and input from the physi6 cian specialty societies, applicable 

7 practitioner organizations, and other 

8 stakeholders, including representa9 tives of individuals entitled to bene10 fits under part A or enrolled under 

11 this part. 

12 ‘‘(4) REPORTING OF INFORMATION FOR

13 RESOURCE USE MEASUREMENT.—Claims sub14 mitted for items and services furnished 

15 by a physician or applicable practitioner 

16 on or after January 1, 2016, shall, as de17 termined appropriate by the Secretary, 

18 include— 

19 ‘‘(A) applicable codes established 

20 under paragraphs (2) and (3); and 

21 ‘‘(B) the national provider identi22 fier of the ordering physician or ap23 plicable practitioner (if different 

24 from the billing physician or applica25 ble practitioner). 


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1 ‘‘(5) METHODOLOGY FOR RESOURCE USE

2 ANALYSIS.— 

3 ‘‘(A) IN GENERAL.—In order to 

4 evaluate the resources used to treat 

5 patients (with respect to care episode 

6 and patient condition groups), the 

7 Secretary shall— 

8 ‘‘(i) use the patient relation9 ship codes reported on claims 

10 pursuant to paragraph (4) to at11 tribute patients (in whole or in 

12 part) to one or more physicians 

13 and applicable practitioners; 

14 ‘‘(ii) use the care episode and 

15 patient condition codes reported 

16 on claims pursuant to paragraph 

17 (4) as a basis to compare similar 

18 patients and care episodes and 

19 patient condition groups; and 

20 ‘‘(iii) conduct an analysis of 

21 resource use (with respect to care 

22 episodes and patient condition 

23 groups of such patients), as the 

24 Secretary determines appro25 priate. 


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1 ‘‘(B) ANALYSIS OF PATIENTS OF PHY2 SICIANS AND PRACTITIONERS.—In con3 ducting the analysis described in sub4 paragraph (A)(iii) with respect to pa5 tients attributed to physicians and 

6 applicable practitioners, the Sec7 retary shall, as feasible— 

8 ‘‘(i) use the claims data expe9 rience of such patients by patient 

10 condition codes during a common 

11 period, such as 12 months; and 

12 ‘‘(ii) use the claims data expe13 rience of such patients by care 

14 episode codes— 

15 ‘‘(I) in the case of episodes 

16 without a hospitalization, 

17 during periods of time (such 

18 as the number of days) deter19 mined appropriate by the Sec20 retary; and 

21 ‘‘(II) in the case of epi22 sodes with a hospitalization, 

23 during periods of time (such 

24 as the number of days) before, 


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1 during, and after the hos2 pitalization. 

3 ‘‘(C) MEASUREMENT OF RESOURCE

4 USE.—In measuring such resource 

5 use, the Secretary— 

6 ‘‘(i) shall use per patient total 

7 allowed amounts for all services 

8 under part A and this part (and, if 

9 the Secretary determines appro10 priate, part D) for the analysis of 

11 patient resource use, by care epi12 sode codes and by patient condi13 tion codes; and 

14 ‘‘(ii) may, as determined ap15 propriate, use other measures of 

16 allowed amounts (such as sub17 totals for categories of items and 

18 services) and measures of utiliza19 tion of items and services (such as 

20 frequency of specific items and 

21 services and the ratio of specific 

22 items and services among attrib23 uted patients or episodes). 

24 ‘‘(D) STAKEHOLDER INPUT.—The 

25 Secretary shall seek comments from 


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1 the physician specialty societies, ap2 plicable practitioner organizations, 

3 and other stakeholders, including 

4 representatives of individuals enti5 tled to benefits under part A or en6 rolled under this part, regarding the 

7 resource use methodology established 

8 pursuant to this paragraph. In seek9 ing comments the Secretary shall use 

10 one or more mechanisms (other than 

11 notice and comment rulemaking) that 

12 may include open door forums, town 

13 hall meetings, or other appropriate 

14 mechanisms. 

15 ‘‘(6) LIMITATION.—There shall be no 

16 administrative or judicial review under 

17 section 1869, section 1878, or otherwise 

18 of— 

19 ‘‘(A) care episode and patient con20 dition groups and codes established 

21 under paragraph (2); 

22 ‘‘(B) patient relationship cat23 egories and codes established under 

24 paragraph (3); and 


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1 ‘‘(C) measurement of, and anal2 yses of resource use with respect to, 

3 care episode and patient condition 

4 codes and patient relationship codes 

5 pursuant to paragraph (5). 

6 ‘‘(7) ADMINISTRATION.—Chapter 35 of 

7 title 44, United States Code, shall not 

8 apply to this section. 

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

10 ‘‘(A) PHYSICIAN.—The term ‘physi11 cian’ has the meaning given such 

12 term in section 1861(r)(1). 

13 ‘‘(B) APPLICABLE PRACTITIONER.— 

14 The term ‘applicable practitioner’ 

15 means— 

16 ‘‘(i) a physician assistant, 

17 nurse practitioner, and clinical 

18 nurse specialist (as such terms 

19 are defined in section 

20 1861(aa)(5)); and 

21 ‘‘(ii) beginning January 1, 

22 2017, such other eligible profes23 sionals (as defined in subsection 

24 (k)(3)(B)) as specified by the Sec25 retary. 


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1 ‘‘(9) CLARIFICATION.—The provisions of 

2 sections 1890(b)(7) and 1890A shall not 

3 apply to this subsection.’’. 

4 SEC. 3. PRIORITIES AND FUNDING FOR QUALITY MEASURE 

5 DEVELOPMENT. 

6 Section 1848 of the Social Security Act (42 

7 U.S.C. 1395w–4), as amended by subsections 

8 (c) and (h) of section 2, is further amended by 

9 inserting at the end the following new sub10 section: 

11 ‘‘(s) PRIORITIES AND FUNDING FOR QUALITY

12 MEASURE DEVELOPMENT.— 

13 ‘‘(1) PLAN IDENTIFYING MEASURE DEVEL14 OPMENT PRIORITIES AND TIMELINES.— 

15 ‘‘(A) DRAFT MEASURE DEVELOPMENT

16 PLAN.— 

17 ‘‘(i) DRAFT PLAN.— 

18 ‘‘(I) IN GENERAL.—Not later 

19 than October 1, 2014, the Sec20 retary shall develop, and post 

21 on the Internet website of the 

22 Centers for Medicare & Med23 icaid Services, a draft plan for 

24 the development of quality 

25 measures for application 


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1 under the applicable provi2 sions. 

3 ‘‘(II) REQUIREMENT.—Such 

4 plan shall address how meas5 ures used by private payers 

6 and integrated delivery sys7 tems could be incorporated 

8 under such subsection. 

9 ‘‘(ii) CONSIDERATION.—In devel10 oping the draft plan under sub11 paragraph (A), the Secretary shall 

12 consider— 

13 ‘‘(I) gap analyses con14 ducted by the entity with a 

15 contract under section 1890(a) 

16 or other contractors or enti17 ties; and 

18 ‘‘(II) whether measures 

19 are applicable across health 

20 care settings. 

21 ‘‘(iii) PRIORITIES.—In devel22 oping the draft plan under sub23 paragraph (A), the Secretary shall 

24 give priority to the following 

25 types of measures: 


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1 ‘‘(I) Outcome measures in2 cluding patient reported out3 come and functional status 

4 measures. 

5 ‘‘(II) Patient experience 

6 measures. 

7 ‘‘(III) Care coordination 

8 measures. 

9 ‘‘(IV) Measures of appro10 priate use of services, includ11 ing measures of over use. 

12 ‘‘(iv) DEFINITION OF APPLICABLE

13 PROVISIONS.—In this subsection, 

14 the term ‘applicable provisions’ 

15 means the following provisions: 

16 ‘‘(I) Subsection (q)(2)(B)(i). 

17 ‘‘(II) Section 1833(z)(2)(C). 

18 ‘‘(B) STAKEHOLDER INPUT.—The 

19 Secretary shall accept through De20 cember 1, 2014, comments on the 

21 draft plan posted under paragraph 

22 (1)(A) from the public, including 

23 health care providers, payers, con24 sumers, and other stakeholders. 


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1 ‘‘(C) OPERATIONAL MEASURE DEVEL2 OPMENT PLAN.—Not later than Feb3 ruary 1, 2015, taking into account the 

4 comments received under subpara5 graph (B), the Secretary shall post on 

6 the Internet website of the Centers 

7 for Medicare & Medicaid Services an 

8 operational plan for the development 

9 of quality measures for use under 

10 subsection (q)(2)(A)(i). 

11 ‘‘(2) CONTRACTS AND OTHER ARRANGE12 MENTS FOR QUALITY MEASURE DEVELOP13 MENT.— 

14 ‘‘(A) IN GENERAL.—The Secretary 

15 shall enter into contracts or other ar16 rangements with entities for the pur17 pose of developing, improving, updat18 ing, or expanding quality measures 

19 for application under the applicable 

20 provisions. Such entities may include 

21 physician specialty societies and 

22 other practitioner organizations. 

23 ‘‘(B) PRIORITIZATION.— 

24 ‘‘(i) IN GENERAL.—In entering 

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1 ments under subparagraph (A), 

2 the Secretary shall give priority 

3 to the development of the types of 

4 measures described in paragraph 

5 (1)(A)(iii). 

6 ‘‘(ii) CONSIDERATION.—In se7 lecting measures for development 

8 under this subsection, the Sec9 retary shall consider whether 

10 such measures would be elec11 tronically specified. 

12 ‘‘(3) ANNUAL REPORT BY THE SEC13 RETARY.— 

14 ‘‘(A) IN GENERAL.—Not later than 

15 February 1, 2016, and annually there16 after, the Secretary shall post on the 

17 Internet website of the Centers for 

18 Medicare & Medicaid Services a re19 port on the progress made in devel20 oping quality measures for applica21 tion under the applicable provisions. 

22 ‘‘(B) REQUIREMENTS.—Each report 

23 submitted pursuant to paragraph (1) 

24 shall include the following: 


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1 ‘‘(i) A description of the Sec2 retary’s efforts to implement this 

3 subsection. 

4 ‘‘(ii) With respect to the meas5 ures developed during the pre6 vious year— 

7 ‘‘(I) a description of the 

8 total number of quality meas9 ures developed and the types 

10 of such measures, such as an 

11 outcome or patient experi12 ence measure; 

13 ‘‘(II) the name of each 

14 measure developed; 

15 ‘‘(III) the name of the de16 veloper and steward of each 

17 measure; 

18 ‘‘(IV) with respect to each 

19 type of measure, an estimate 

20 of the total amount expended 

21 under this title to develop all 

22 measures of such type; and 

23 ‘‘(V) whether the measure 

24 would be electronically speci25 fied. 


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1 ‘‘(iii) With respect to measures 

2 in development at the time of the 

3 report— 

4 ‘‘(I) the information de5 scribed in clause (ii), if avail6 able; and 

7 ‘‘(II) a timeline for comple8 tion of the development of 

9 such measures. 

10 ‘‘(iv) An update on the 

11 progress in developing the types 

12 of measures described in para13 graph (1)(A)(iii), including a de14 scription of issues affecting such 

15 progress. 

16 ‘‘(v) A list of quality topics 

17 and concepts that are being con18 sidered for development of meas19 ures and the rationale for the se20 lection of topics and concepts in21 cluding their relationship to gap 

22 analyses. 

23 ‘‘(vi) A description of any up24 dates to the plan under para25 graph (1) (including newly identiVerDate Mar 15 2010 02:44 Mar 15, 2014 Jkt 039200 PO 00000 Frm 00210 Fmt 6652 Sfmt 6202 E:\BILLS\H2810.RH H2810

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1 fied gaps and the status of pre2 viously identified gaps) and the 

3 inventory of measures applicable 

4 under the applicable provisions. 

5 ‘‘(vii) Other information the 

6 Secretary determines to be appro7 priate. 

8 ‘‘(4) STAKEHOLDER INPUT.—With re9 spect to measures applicable under the 

10 applicable provisions, the Secretary shall 

11 seek stakeholder input with respect to— 

12 ‘‘(A) the identification of gaps 

13 where no quality measures exist, par14 ticularly with respect to the types of 

15 measures described in paragraph 

16 (1)(A)(iii); 

17 ‘‘(B) prioritizing quality measure 

18 development to address such gaps; 

19 and 

20 ‘‘(C) other areas related to quality 

21 measure development determined ap22 propriate by the Secretary. 

23 ‘‘(5) FUNDING.—For purposes of car24 rying out this subsection, the Secretary 

25 shall provide for the transfer, from the 


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1 Federal Supplementary Medical Insur2 ance Trust Fund under section 1841, of 

3 $15,000,000 to the Centers for Medicare & 

4 Medicaid Services Program Management 

5 Account for each of fiscal years 2014 

6 through 2018. Amounts transferred under 

7 this paragraph shall remain available 

8 through the end of fiscal year 2021.’’. 

9 SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVID10 UALS WITH CHRONIC CARE NEEDS. 

11 Section 1848(b) of the Social Security Act 

12 (42 U.S.C. 1395w–4(b)) is amended by adding 

13 at the end the following new paragraph: 

14 ‘‘(8) ENCOURAGING CARE MANAGEMENT

15 FOR INDIVIDUALS WITH CHRONIC CARE

16 NEEDS.— 

17 ‘‘(A) IN GENERAL.—In order to en18 courage the management of care by 

19 an applicable provider (as defined in 

20 subparagraph (B)) for individuals 

21 with chronic care needs the Sec22 retary shall— 

23 ‘‘(i) establish one or more 

24 HCPCS codes for chronic care 


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1 management services for such in2 dividuals; and 

3 ‘‘(ii) subject to subparagraph 

4 (D), make payment (as the Sec5 retary determines to be appro6 priate) under this section for such 

7 management services furnished 

8 on or after January 1, 2015, by an 

9 applicable provider. 

10 ‘‘(B) APPLICABLE PROVIDER DE11 FINED.—For purposes of this para12 graph, the term ‘applicable provider’ 

13 means a physician (as defined in sec14 tion 1861(r)(1)), physician assistant or 

15 nurse practitioner (as defined in sec16 tion 1861(aa)(5)(A)), or clinical nurse 

17 specialist (as defined in section 

18 1861(aa)(5)(B)) who furnishes services 

19 as part of a patient-centered medical 

20 home or a comparable specialty prac21 tice that— 

22 ‘‘(i) is recognized as such a 

23 medical home or comparable spe24 cialty practice by an organization 

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1 retary for purposes of such rec2 ognition as such a medical home 

3 or practice; or 

4 ‘‘(ii) meets such other com5 parable qualifications as the Sec6 retary determines to be appro7 priate. 

8 ‘‘(C) BUDGET NEUTRALITY.—The 

9 budget neutrality provision under 

10 subsection (c)(2)(B)(ii)(II) shall apply 

11 in establishing the payment under 

12 subparagraph (A)(ii). 

13 ‘‘(D) POLICIES RELATING TO PAY14 MENT.—In carrying out this para15 graph, with respect to chronic care 

16 management services, the Secretary 

17 shall— 

18 ‘‘(i) make payment to only one 

19 applicable provider for such serv20 ices furnished to an individual 

21 during a period; 

22 ‘‘(ii) not make payment under 

23 subparagraph (A) if such payment 

24 would be duplicative of payment 

25 that is otherwise made under this 


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1 title for such services (such as in 

2 the case of hospice care or home 

3 health services); and 

4 ‘‘(iii) not require that an an5 nual wellness visit (as defined in 

6 section 1861(hhh)) or an initial 

7 preventive physical examination 

8 (as defined in section 1861(ww)) 

9 be furnished as a condition of 

10 payment for such management 

11 services.’’. 

12 SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES 

13 UNDER THE PHYSICIAN FEE SCHEDULE. 

14 (a) AUTHORITY TO COLLECT AND USE INFOR15 MATION ON PHYSICIANS’ SERVICES IN THE DETER16 MINATION OF RELATIVE VALUES.— 

17 (1) IN GENERAL.—Section 1848(c)(2) of 

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

19 4(c)(2)) is amended by adding at the end 

20 the following new subparagraph: 

21 ‘‘(M) AUTHORITY TO COLLECT AND

22 USE INFORMATION ON PHYSICIANS’ SERV23 ICES IN THE DETERMINATION OF REL24 ATIVE VALUES.— 


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1 ‘‘(i) COLLECTION OF INFORMA2 TION.—Notwithstanding any other 

3 provision of law, the Secretary 

4 may collect or obtain information 

5 on the resources directly or indi6 rectly related to furnishing serv7 ices for which payment is made 

8 under the fee schedule estab9 lished under subsection (b). Such 

10 information may be collected or 

11 obtained from any eligible profes12 sional or any other source. 

13 ‘‘(ii) USE OF INFORMATION.— 

14 Notwithstanding any other provi15 sion of law, subject to clause (v), 

16 the Secretary may (as the Sec17 retary determines appropriate) 

18 use information collected or ob19 tained pursuant to clause (i) in 

20 the determination of relative val21 ues for services under this sec22 tion. 

23 ‘‘(iii) TYPES OF INFORMATION.— 

24 The types of information de25 scribed in clauses (i) and (ii) may, 


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1 at the Secretary’s discretion, in2 clude any or all of the following: 

3 ‘‘(I) Time involved in fur4 nishing services. 

5 ‘‘(II) Amounts and types of 

6 practice expense inputs in7 volved with furnishing serv8 ices. 

9 ‘‘(III) Prices (net of any 

10 discounts) for practice ex11 pense inputs, which may in12 clude paid invoice prices or 

13 other documentation or 

14 records. 

15 ‘‘(IV) Overhead and ac16 counting information for 

17 practices of physicians and 

18 other suppliers. 

19 ‘‘(V) Any other element 

20 that would improve the valu21 ation of services under this 

22 section. 

23 ‘‘(iv) INFORMATION COLLECTION

24 MECHANISMS.—Information may be 

25 collected or obtained pursuant to 


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1 this subparagraph from any or all 

2 of the following: 

3 ‘‘(I) Surveys of physicians, 

4 other suppliers, providers of 

5 services, manufacturers, and 

6 vendors. 

7 ‘‘(II) Surgical logs, billing 

8 systems, or other practice or 

9 facility records. 

10 ‘‘(III) Electronic health 

11 records. 

12 ‘‘(IV) Any other mecha13 nism determined appropriate 

14 by the Secretary. 

15 ‘‘(v) TRANSPARENCY OF USE OF

16 INFORMATION.— 

17 ‘‘(I) IN GENERAL.—Subject 

18 to subclauses (II) and (III), if 

19 the Secretary uses informa20 tion collected or obtained 

21 under this subparagraph in 

22 the determination of relative 

23 values under this subsection, 

24 the Secretary shall disclose 

25 the information source and 


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1 discuss the use of such infor2 mation in such determination 

3 of relative values through no4 tice and comment rulemaking. 

5 ‘‘(II) THRESHOLDS FOR

6 USE.—The Secretary may es7 tablish thresholds in order to 

8 use such information, includ9 ing the exclusion of informa10 tion collected or obtained 

11 from eligible professionals 

12 who use very high resources 

13 (as determined by the Sec14 retary) in furnishing a serv15 ice. 

16 ‘‘(III) DISCLOSURE OF IN17 FORMATION.—The Secretary 

18 shall make aggregate informa19 tion available under this sub20 paragraph but shall not dis21 close information in a form or 

22 manner that identifies an eli23 gible professional or a group 

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1 lected or obtained pursuant 

2 to a nondisclosure agreement. 

3 ‘‘(vi) INCENTIVE TO PARTICI4 PATE.—The Secretary may provide 

5 for such payments under this part 

6 to an eligible professional that 

7 submits such solicited informa8 tion under this subparagraph as 

9 the Secretary determines appro10 priate in order to compensate 

11 such eligible professional for such 

12 submission. Such payments shall 

13 be provided in a form and man14 ner specified by the Secretary. 

15 ‘‘(vii) ADMINISTRATION.—Chap16 ter 35 of title 44, United States 

17 Code, shall not apply to informa18 tion collected or obtained under 

19 this subparagraph. 

20 ‘‘(viii) DEFINITION OF ELIGIBLE

21 PROFESSIONAL.—In this subpara22 graph, the term ‘eligible profes23 sional’ has the meaning given 

24 such term in subsection (k)(3)(B). 


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1 ‘‘(ix) FUNDING.—For purposes 

2 of carrying out this subpara3 graph, in addition to funds other4 wise appropriated, the Secretary 

5 shall provide for the transfer, 

6 from the Federal Supplementary 

7 Medical Insurance Trust Fund 

8 under section 1841, of $2,000,000 

9 to the Centers for Medicare & 

10 Medicaid Services Program Man11 agement Account for each fiscal 

12 year beginning with fiscal year 

13 2014. Amounts transferred under 

14 the preceding sentence for a fis15 cal year shall be available until 

16 expended.’’. 

17 (2) LIMITATION ON REVIEW.—Section 

18 1848(i)(1) of the Social Security Act (42 

19 U.S.C. 1395w–4(i)(1)) is amended— 

20 (A) in subparagraph (D), by strik21 ing ‘‘and’’ at the end; 

22 (B) in subparagraph (E), by strik23 ing the period at the end and insert24 ing ‘‘, and’’; and 


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1 (C) by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(F) the collection and use of in4 formation in the determination of rel5 ative values under subsection 

6 (c)(2)(M).’’. 

7 (b) AUTHORITY FOR ALTERNATIVE AP8 PROACHES TO ESTABLISHING PRACTICE EXPENSE

9 RELATIVE VALUES.—Section 1848(c)(2) of the 

10 Social Security Act (42 U.S.C. 1395w–4(c)(2)), 

11 as amended by subsection (a), is amended by 

12 adding at the end the following new subpara13 graph: 

14 ‘‘(N) AUTHORITY FOR ALTERNATIVE

15 APPROACHES TO ESTABLISHING PRACTICE

16 EXPENSE RELATIVE VALUES.—The Sec17 retary may establish or adjust prac18 tice expense relative values under 

19 this subsection using cost, charge, or 

20 other data from suppliers or pro21 viders of services, including informa22 tion collected or obtained under sub23 paragraph (M).’’. 

24 (c) REVISED AND EXPANDED IDENTIFICATION

25 OF POTENTIALLY MISVALUED CODES.—Section 


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1 1848(c)(2)(K)(ii) of the Social Security Act (42 

2 U.S.C. 1395w–4(c)(2)(K)(ii)) is amended to read 

3 as follows: 

4 ‘‘(ii) IDENTIFICATION OF POTEN5 TIALLY MISVALUED CODES.—For 

6 purposes of identifying poten7 tially misvalued codes pursuant 

8 to clause (i)(I), the Secretary shall 

9 examine codes (and families of 

10 codes as appropriate) based on 

11 any or all of the following cri12 teria: 

13 ‘‘(I) Codes that have expe14 rienced the fastest growth. 

15 ‘‘(II) Codes that have expe16 rienced substantial changes 

17 in practice expenses. 

18 ‘‘(III) Codes that describe 

19 new technologies or services 

20 within an appropriate time 

21 period (such as 3 years) after 

22 the relative values are ini23 tially established for such 

24 codes. 


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1 ‘‘(IV) Codes which are 

2 multiple codes that are fre3 quently billed in conjunction 

4 with furnishing a single serv5 ice. 

6 ‘‘(V) Codes with low rel7 ative values, particularly 

8 those that are often billed 

9 multiple times for a single 

10 treatment. 

11 ‘‘(VI) Codes that have not 

12 been subject to review since 

13 implementation of the fee 

14 schedule. 

15 ‘‘(VII) Codes that account 

16 for the majority of spending 

17 under the physician fee 

18 schedule. 

19 ‘‘(VIII) Codes for services 

20 that have experienced a sub21 stantial change in the hospital 

22 length of stay or procedure 

23 time. 

24 ‘‘(IX) Codes for which 

25 there may be a change in the 


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1 typical site of service since 

2 the code was last valued. 

3 ‘‘(X) Codes for which there 

4 is a significant difference in 

5 payment for the same service 

6 between different sites of 

7 service. 

8 ‘‘(XI) Codes for which 

9 there may be anomalies in rel10 ative values within a family of 

11 codes. 

12 ‘‘(XII) Codes for services 

13 where there may be effi14 ciencies when a service is fur15 nished at the same time as 

16 other services. 

17 ‘‘(XIII) Codes with high 

18 intra-service work per unit of 

19 time. 

20 ‘‘(XIV) Codes with high 

21 practice expense relative 

22 value units. 

23 ‘‘(XV) Codes with high 

24 cost supplies. 


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1 ‘‘(XVI) Codes as deter2 mined appropriate by the Sec3 retary.’’. 

4 (d) TARGET FOR RELATIVE VALUE ADJUST5 MENTS FOR MISVALUED SERVICES.— 

6 (1) IN GENERAL.—Section 1848(c)(2) of 

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

8 4(c)(2)), as amended by subsections (a) 

9 and (b), is amended by adding at the end 

10 the following new subparagraph: 

11 ‘‘(O) TARGET FOR RELATIVE VALUE

12 ADJUSTMENTS FOR MISVALUED SERV13 ICES.—With respect to fee schedules 

14 established for each of 2015 through 

15 2018, the following shall apply: 

16 ‘‘(i) DETERMINATION OF NET RE17 DUCTION IN EXPENDITURES.—For 

18 each year, the Secretary shall de19 termine the estimated net reduc20 tion in expenditures under the fee 

21 schedule under this section with 

22 respect to the year as a result of 

23 adjustments to the relative values 

24 established under this paragraph 

25 for misvalued codes. 


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1 ‘‘(ii) BUDGET NEUTRAL REDIS2 TRIBUTION OF FUNDS IF TARGET MET

3 AND COUNTING OVERAGES TOWARDS

4 THE TARGET FOR THE SUCCEEDING

5 YEAR.—If the estimated net reduc6 tion in expenditures determined 

7 under clause (i) for the year is 

8 equal to or greater than the tar9 get for the year— 

10 ‘‘(I) reduced expenditures 

11 attributable to such adjust12 ments shall be redistributed 

13 for the year in a budget neu14 tral manner in accordance 

15 with subparagraph (B)(ii)(II); 

16 and 

17 ‘‘(II) the amount by which 

18 such reduced expenditures 

19 exceeds the target for the 

20 year shall be treated as a re21 duction in expenditures de22 scribed in clause (i) for the 

23 succeeding year, for purposes 

24 of determining whether the 

25 target has or has not been 


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1 met under this subparagraph 

2 with respect to that year. 

3 ‘‘(iii) EXEMPTION FROM BUDGET

4 NEUTRALITY IF TARGET NOT MET.—If 

5 the estimated net reduction in ex6 penditures determined under 

7 clause (i) for the year is less than 

8 the target for the year, reduced 

9 expenditures in an amount equal 

10 to the target recapture amount 

11 shall not be taken into account in 

12 applying subparagraph (B)(ii)(II) 

13 with respect to fee schedules be14 ginning with 2015. 

15 ‘‘(iv) TARGET RECAPTURE

16 AMOUNT.—For purposes of clause 

17 (iii), the target recapture amount 

18 is, with respect to a year, an 

19 amount equal to the difference 

20 between— 

21 ‘‘(I) the target for the year; 

22 and 

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1 mined under clause (i) for the 

2 year. 

3 ‘‘(v) TARGET.—For purposes of 

4 this subparagraph, with respect 

5 to a year, the target is calculated 

6 as 0.5 percent of the estimated 

7 amount of expenditures under the 

8 fee schedule under this section 

9 for the year.’’. 

10 (2) CONFORMING AMENDMENT.—Section 

11 1848(c)(2)(B)(v) of the Social Security Act 

12 (42 U.S.C. 1395w–4(c)(2)(B)(v)) is amended 

13 by adding at the end the following new 

14 subclause: 

15 ‘‘(VIII) REDUCTIONS FOR

16 MISVALUED SERVICES IF TARGET

17 NOT MET.—Effective for fee 

18 schedules beginning with 

19 2015, reduced expenditures 

20 attributable to the application 

21 of the target recapture 

22 amount described in subpara23 graph (O)(iii).’’. 

24 (e) PHASE-IN OF SIGNIFICANT RELATIVE

25 VALUE UNIT (RVU) REDUCTIONS.— 


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1 (1) IN GENERAL.—Section 1848(c) of the 

2 Social Security Act (42 U.S.C. 1395w–4(c)) 

3 is amended by adding at the end the fol4 lowing new paragraph: 

5 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

6 VALUE UNIT (RVU) REDUCTIONS.—Effective 

7 for fee schedules established beginning 

8 with 2015, if the total relative value units 

9 for a service for a year would otherwise 

10 be decreased by an estimated amount 

11 equal to or greater than 20 percent as 

12 compared to the total relative value units 

13 for the previous year, the applicable ad14 justments in work, practice expense, and 

15 malpractice relative value units shall be 

16 phased-in over a 2-year period.’’. 

17 (2) CONFORMING AMENDMENTS.—Sec18 tion 1848(c)(2) of the Social Security Act 

19 (42 U.S.C. 1395w–4(c)(2)) is amended— 

20 (A) in subparagraph (B)(ii)(I), by 

21 striking ‘‘subclause (II)’’ and inserting 

22 ‘‘subclause (II) and paragraph (7)’’; 

23 and 

24 (B) in subparagraph (K)(iii)(VI)— 


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1 (i) by striking ‘‘provisions of 

2 subparagraph (B)(ii)(II)’’ and in3 serting ‘‘provisions of subpara4 graph (B)(ii)(II) and paragraph 

5 (7)’’; and 

6 (ii) by striking ‘‘under sub7 paragraph (B)(ii)(II)’’ and insert8 ing ‘‘under subparagraph 

9 (B)(ii)(I)’’. 

10 (f) AUTHORITY TO SMOOTH RELATIVE VAL11 UES WITHIN GROUPS OF SERVICES.—Section 

12 1848(c)(2)(C) of the Social Security Act (42 

13 U.S.C. 1395w–4(c)(2)(C)) is amended— 

14 (1) in each of clauses (i) and (iii), by 

15 striking ‘‘the service’’ and inserting ‘‘the 

16 service or group of services’’ each place it 

17 appears; and 

18 (2) in the first sentence of clause (ii), 

19 by inserting ‘‘or group of services’’ before 

20 the period. 

21 (g) GAO STUDY AND REPORT ON RELATIVE

22 VALUE SCALE UPDATE COMMITTEE.— 

23 (1) STUDY.—The Comptroller General 

24 of the United States (in this subsection 

25 referred to as the ‘‘Comptroller General’’) 


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1 shall conduct a study of the processes 

2 used by the Relative Value Scale Update 

3 Committee (RUC) to provide rec4 ommendations to the Secretary of Health 

5 and Human Services regarding relative 

6 values for specific services under the 

7 Medicare physician fee schedule under 

8 section 1848 of the Social Security Act (42 

9 U.S.C. 1395w–4). 

10 (2) REPORT.—Not later than 1 year 

11 after the date of the enactment of this 

12 Act, the Comptroller General shall submit 

13 to Congress a report containing the re14 sults of the study conducted under para15 graph (1). 

16 (h) ADJUSTMENT TO MEDICARE PAYMENT LO17 CALITIES.— 

18 (1) IN GENERAL.—Section 1848(e) of the 

19 Social Security Act (42 U.S.C. 1395w–4(e)) 

20 is amended by adding at the end the fol21 lowing new paragraph: 

22 ‘‘(6) USE OF MSAS AS FEE SCHEDULE

23 AREAS IN CALIFORNIA.— 

24 ‘‘(A) IN GENERAL.—Subject to the 

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1 graph and notwithstanding the pre2 vious provisions of this subsection, 

3 for services furnished on or after Jan4 uary 1, 2017, the fee schedule areas 

5 used for payment under this section 

6 applicable to California shall be the 

7 following: 

8 ‘‘(i) Each Metropolitan Statis9 tical Area (each in this paragraph 

10 referred to as an ‘MSA’), as de11 fined by the Director of the Office 

12 of Management and Budget as of 

13 December 31 of the previous year, 

14 shall be a fee schedule area. 

15 ‘‘(ii) All areas not included in 

16 an MSA shall be treated as a sin17 gle rest-of-State fee schedule area. 

18 ‘‘(B) TRANSITION FOR MSAS PRE19 VIOUSLY IN REST-OF-STATE PAYMENT LO20 CALITY OR IN LOCALITY 3.— 

21 ‘‘(i) IN GENERAL.—For services 

22 furnished in California during a 

23 year beginning with 2017 and 

24 ending with 2021 in an MSA in a 

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1 paragraph (D)), subject to sub2 paragraph (C), the geographic 

3 index values to be applied under 

4 this subsection for such year shall 

5 be equal to the sum of the fol6 lowing: 

7 ‘‘(I) CURRENT LAW COMPO8 NENT.—The old weighting fac9 tor (described in clause (ii)) 

10 for such year multiplied by 

11 the geographic index values 

12 under this subsection for the 

13 fee schedule area that in14 cluded such MSA that would 

15 have applied in such area (as 

16 estimated by the Secretary) if 

17 this paragraph did not apply. 

18 ‘‘(II) MSA-BASED COMPO19 NENT.—The MSA-based 

20 weighting factor (described in 

21 clause (iii)) for such year mul22 tiplied by the geographic 

23 index values computed for the 

24 fee schedule area under sub25 paragraph (A) for the year 


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1 (determined without regard 

2 to this subparagraph). 

3 ‘‘(ii) OLD WEIGHTING FACTOR.— 

4 The old weighting factor de5 scribed in this clause— 

‘‘(I) for 2017, is 5 6 ⁄6; and 

7 ‘‘(II) for each succeeding 

8 year, is the old weighting fac9 tor described in this clause 

10 for the previous year minus 

1 11 ⁄6. 

12 ‘‘(iii) MSA-BASED WEIGHTING

13 FACTOR.—The MSA-based 

14 weighting factor described in this 

15 clause for a year is 1 minus the 

16 old weighting factor under clause 

17 (ii) for that year. 

18 ‘‘(C) HOLD HARMLESS.—For serv19 ices furnished in a transition area in 

20 California during a year beginning 

21 with 2017, the geographic index val22 ues to be applied under this sub23 section for such year shall not be less 

24 than the corresponding geographic 

25 index values that would have applied 


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1 in such transition area (as estimated 

2 by the Secretary) if this paragraph 

3 did not apply. 

4 ‘‘(D) TRANSITION AREA DEFINED.—In 

5 this paragraph, the term ‘transition 

6 area’ means each of the following fee 

7 schedule areas for 2013: 

8 ‘‘(i) The rest-of-State payment 

9 locality. 

10 ‘‘(ii) Payment locality 3. 

11 ‘‘(E) REFERENCES TO FEE SCHEDULE

12 AREAS.—Effective for services fur13 nished on or after January 1, 2017, 

14 for California, any reference in this 

15 section to a fee schedule area shall be 

16 deemed a reference to a fee schedule 

17 area established in accordance with 

18 this paragraph.’’. 

19 (2) CONFORMING AMENDMENT TO DEFINI20 TION OF FEE SCHEDULE AREA.—Section 

21 1848(j)(2) of the Social Security Act (42 

22 U.S.C. 1395w–4(j)(2)) is amended by strik23 ing ‘‘The term’’ and inserting ‘‘Except as 

24 provided in subsection (e)(6)(D), the 

25 term’’. 


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1 SEC. 6. PROMOTING EVIDENCE-BASED CARE. 

2 (a) RECOGNIZING APPROPRIATE USE CRI3 TERIA FOR CERTAIN IMAGING SERVICES.— 

4 (1) IN GENERAL.—Section 1834 of the 

5 Social Security Act (42 U.S.C. 1395m) is 

6 amended by adding at the end the fol7 lowing new subsection: 

8 ‘‘(p) RECOGNIZING APPROPRIATE USE CRI9 TERIA FOR CERTAIN IMAGING SERVICES.— 

10 ‘‘(1) PROGRAM ESTABLISHED.— 

11 ‘‘(A) IN GENERAL.—The Secretary 

12 shall establish a program to promote 

13 the use of appropriate use criteria (as 

14 defined in subparagraph (B)) for ap15 plicable imaging services (as defined 

16 in subparagraph (C)) furnished in an 

17 applicable setting (as defined in sub18 paragraph (D)) by ordering profes19 sionals and furnishing professionals 

20 (as defined in subparagraphs (E) and 

21 (F), respectively). 

22 ‘‘(B) APPROPRIATE USE CRITERIA DE23 FINED.—In this subsection, the term 

24 ‘appropriate use criteria’ means cri25 teria to assist ordering professionals 

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1 ing the most appropriate treatment 

2 decision for a specific clinical condi3 tion. To the extent feasible, such cri4 teria shall be evidence-based. 

5 ‘‘(C) APPLICABLE IMAGING SERVICE

6 DEFINED.—In this subsection, the term 

7 ‘applicable imaging service’ means an 

8 advanced diagnostic imaging service 

9 (as defined in subsection (e)(1)(B)) for 

10 which the Secretary determines— 

11 ‘‘(i) one or more applicable ap12 propriate use criteria specified 

13 under paragraph (2) apply; 

14 ‘‘(ii) there are one or more 

15 qualified clinical decision support 

16 mechanisms listed under para17 graph (3)(C); and 

18 ‘‘(iii) one or more of such 

19 mechanisms is available free of 

20 charge. 

21 ‘‘(D) APPLICABLE SETTING DE22 FINED.—In this subsection, the term 

23 ‘applicable setting’ means a physi24 cian’s office, a hospital outpatient de25 partment (including an emergency 


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1 department), an ambulatory surgical 

2 center, and any other outpatient set3 ting determined appropriate by the 

4 Secretary. 

5 ‘‘(E) ORDERING PROFESSIONAL DE6 FINED.—In this subsection, the term 

7 ‘ordering professional’ means a physi8 cian (as defined in section 1861(r)) or 

9 a practitioner described in section 

10 1842(b)(18)(C) who orders an applica11 ble imaging service for an individual. 

12 ‘‘(F) FURNISHING PROFESSIONAL DE13 FINED.—In this subsection, the term 

14 ‘furnishing professional’ means a phy15 sician (as defined in section 1861(r)) 

16 or a practitioner described in section 

17 1842(b)(18)(C) who furnishes an appli18 cable imaging service for an indi19 vidual. 

20 ‘‘(2) ESTABLISHMENT OF APPLICABLE AP21 PROPRIATE USE CRITERIA.— 

22 ‘‘(A) IN GENERAL.—Not later than 

23 November 15, 2015, the Secretary 

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1 tioners, and other stakeholders, 

2 specify applicable appropriate use 

3 criteria for applicable imaging serv4 ices from among appropriate use cri5 teria developed or endorsed by na6 tional professional medical specialty 

7 societies or other entities. 

8 ‘‘(B) CONSIDERATIONS.—In speci9 fying applicable appropriate use cri10 teria under subparagraph (A), the 

11 Secretary shall take into account 

12 whether the criteria— 

13 ‘‘(i) have stakeholder con14 sensus; 

15 ‘‘(ii) have been determined to 

16 be scientifically valid and are evi17 dence based; and 

18 ‘‘(iii) are in the public domain. 

19 ‘‘(C) REVISIONS.—The Secretary 

20 shall periodically update and revise 

21 (as appropriate) such specification of 

22 applicable appropriate use criteria. 

23 ‘‘(D) TREATMENT OF MULTIPLE AP24 PLICABLE APPROPRIATE USE CRITERIA.— 

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1 termines that more than one appro2 priate use criteria applies with re3 spect to an applicable imaging serv4 ice, the Secretary shall specify one or 

5 more applicable appropriate use cri6 teria under this paragraph for the 

7 service. 

8 ‘‘(3) MECHANISMS FOR CONSULTATION

9 WITH APPLICABLE APPROPRIATE USE CRI10 TERIA.— 

11 ‘‘(A) IDENTIFICATION OF MECHA12 NISMS TO CONSULT WITH APPLICABLE AP13 PROPRIATE USE CRITERIA.— 

14 ‘‘(i) IN GENERAL.—The Sec15 retary shall specify one or more 

16 qualified clinical decision support 

17 mechanisms that could be used by 

18 ordering professionals to consult 

19 with applicable appropriate use 

20 criteria for applicable imaging 

21 services. 

22 ‘‘(ii) CONSULTATION.—The Sec23 retary shall consult with physi24 cians, practitioners, and other 


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1 stakeholders in specifying mecha2 nisms under this paragraph. 

3 ‘‘(iii) INCLUSION OF CERTAIN

4 MECHANISMS.—Mechanisms speci5 fied under this paragraph may in6 clude any or all of the following 

7 that meet the requirements de8 scribed in subparagraph (B)(ii): 

9 ‘‘(I) Use of clinical deci10 sion support modules in cer11 tified EHR technology (as de12 fined in section 1848(o)(4)). 

13 ‘‘(II) Use of private sector 

14 clinical decision support 

15 mechanisms that are inde16 pendent from certified EHR 

17 technology, which may in18 clude use of clinical decision 

19 support mechanisms available 

20 from medical specialty organi21 zations. 

22 ‘‘(III) Use of a clinical de23 cision support mechanism es24 tablished by the Secretary. 


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1 ‘‘(B) QUALIFIED CLINICAL DECISION

2 SUPPORT MECHANISMS.— 

3 ‘‘(i) IN GENERAL.—For purposes 

4 of this subsection, a qualified 

5 clinical decision support mecha6 nism is a mechanism that the Sec7 retary determines meets the re8 quirements described in clause 

9 (ii). 

10 ‘‘(ii) REQUIREMENTS.—The re11 quirements described in this 

12 clause are the following: 

13 ‘‘(I) The mechanism makes 

14 available to the ordering pro15 fessional applicable appro16 priate use criteria specified 

17 under paragraph (2) and the 

18 supporting documentation for 

19 the applicable imaging serv20 ice ordered. 

21 ‘‘(II) In the case where 

22 there are more than one ap23 plicable appropriate use cri24 teria specified under such 

25 paragraph for an applicable 


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1 imaging service, the mecha2 nism indicates the criteria 

3 that it uses for the service. 

4 ‘‘(III) The mechanism de5 termines the extent to which 

6 an applicable imaging service 

7 ordered is consistent with the 

8 applicable appropriate use 

9 criteria so specified. 

10 ‘‘(IV) The mechanism gen11 erates and provides to the or12 dering professional a certifi13 cation or documentation that 

14 documents that the qualified 

15 clinical decision support 

16 mechanism was consulted by 

17 the ordering professional. 

18 ‘‘(V) The mechanism is up19 dated on a timely basis to re20 flect revisions to the speci21 fication of applicable appro22 priate use criteria under such 

23 paragraph. 

24 ‘‘(VI) The mechanism 

25 meets privacy and security 


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1 standards under applicable 

2 provisions of law. 

3 ‘‘(VII) The mechanism per4 forms such other functions as 

5 specified by the Secretary, 

6 which may include a require7 ment to provide aggregate 

8 feedback to the ordering pro9 fessional. 

10 ‘‘(C) LIST OF MECHANISMS FOR CON11 SULTATION WITH APPLICABLE APPRO12 PRIATE USE CRITERIA.— 

13 ‘‘(i) INITIAL LIST.—Not later 

14 than April 1, 2016, the Secretary 

15 shall publish a list of mechanisms 

16 specified under this paragraph. 

17 ‘‘(ii) PERIODIC UPDATING OF

18 LIST.—The Secretary shall periodi19 cally update the list of qualified 

20 clinical decision support mecha21 nisms specified under this para22 graph. 

23 ‘‘(4) CONSULTATION WITH APPLICABLE

24 APPROPRIATE USE CRITERIA.— 


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1 ‘‘(A) CONSULTATION BY ORDERING

2 PROFESSIONAL.—Beginning with Janu3 ary 1, 2017, subject to subparagraph 

4 (C), with respect to an applicable im5 aging service ordered by an ordering 

6 professional that would be furnished 

7 in an applicable setting and paid for 

8 under an applicable payment system 

9 (as defined in subparagraph (D)), an 

10 ordering professional shall— 

11 ‘‘(i) consult with a qualified 

12 decision support mechanism list13 ed under paragraph (3)(C); and 

14 ‘‘(ii) provide to the furnishing 

15 professional the information de16 scribed in clauses (i) through (iii) 

17 of subparagraph (B). 

18 ‘‘(B) REPORTING BY FURNISHING

19 PROFESSIONAL.—Beginning with Janu20 ary 1, 2017, subject to subparagraph 

21 (C), with respect to an applicable im22 aging service furnished in an applica23 ble setting and paid for under an ap24 plicable payment system (as defined 

25 in subparagraph (D)), payment for 


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1 such service may only be made if the 

2 claim for the service includes the fol3 lowing: 

4 ‘‘(i) Information about which 

5 qualified clinical decision support 

6 mechanism was consulted by the 

7 ordering professional for the 

8 service. 

9 ‘‘(ii) Information regarding— 

10 ‘‘(I) whether the service 

11 ordered would adhere to the 

12 applicable appropriate use 

13 criteria specified under para14 graph (2); 

15 ‘‘(II) whether the service 

16 ordered would not adhere to 

17 such criteria; or 

18 ‘‘(III) whether such cri19 teria was not applicable to the 

20 service ordered. 

21 ‘‘(iii) The national provider 

22 identifier of the ordering profes23 sional (if different from the fur24 nishing professional). 


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1 ‘‘(C) EXCEPTIONS.—The provisions 

2 of subparagraphs (A) and (B) and 

3 paragraph (6)(A) shall not apply to 

4 the following: 

5 ‘‘(i) EMERGENCY SERVICES.—An 

6 applicable imaging service or7 dered for an individual with an 

8 emergency medical condition (as 

9 defined in section 1867(e)(1)). 

10 ‘‘(ii) INPATIENT SERVICES.—An 

11 applicable imaging service or12 dered for an inpatient and for 

13 which payment is made under 

14 part A. 

15 ‘‘(iii) ALTERNATIVE PAYMENT

16 MODELS.—An applicable imaging 

17 service ordered by an ordering 

18 professional with respect to an in19 dividual attributed to an alter20 native payment model (as defined 

21 in section 1833(z)(3)(C)). 

22 ‘‘(iv) SIGNIFICANT HARDSHIP.— 

23 An applicable imaging service or24 dered by an ordering professional 

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1 by-case basis, exempt from the ap2 plication of such provisions if the 

3 Secretary determines, subject to 

4 annual renewal, that consultation 

5 with applicable appropriate use 

6 criteria would result in a signifi7 cant hardship, such as in the case 

8 of a professional who practices in 

9 a rural area without sufficient 

10 Internet access. 

11 ‘‘(D) APPLICABLE PAYMENT SYSTEM

12 DEFINED.—In this subsection, the term 

13 ‘applicable payment system’ means 

14 the following: 

15 ‘‘(i) The physician fee sched16 ule established under section 

17 1848(b). 

18 ‘‘(ii) The prospective payment 

19 system for hospital outpatient de20 partment services under section 

21 1833(t). 

22 ‘‘(iii) The ambulatory surgical 

23 center payment systems under 

24 section 1833(i). 


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1 ‘‘(5) IDENTIFICATION OF OUTLIER ORDER2 ING PROFESSIONALS.— 

3 ‘‘(A) IN GENERAL.—With respect to 

4 applicable imaging services furnished 

5 beginning with 2017, the Secretary 

6 shall determine, on a periodic basis 

7 (which may be annually), ordering 

8 professionals who are outlier order9 ing professionals. 

10 ‘‘(B) OUTLIER ORDERING PROFES11 SIONALS.—The determination of an 

12 outlier ordering professional shall— 

13 ‘‘(i) be based on low adher14 ence to applicable appropriate 

15 use criteria specified under para16 graph (2), which may be based on 

17 comparison to other ordering pro18 fessionals; and 

19 ‘‘(ii) include data for ordering 

20 professionals for whom prior au21 thorization under paragraph 

22 (6)(A) applies. 

23 ‘‘(C) USE OF TWO YEARS OF DATA.— 

24 The Secretary shall use two years of 


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1 data to identify outlier ordering pro2 fessionals under this paragraph. 

3 ‘‘(D) CONSULTATION WITH STAKE4 HOLDERS.—The Secretary shall con5 sult with physicians, practitioners 

6 and other stakeholders in developing 

7 methods to identify outlier ordering 

8 professionals under this paragraph. 

9 ‘‘(6) PRIOR AUTHORIZATION FOR ORDER10 ING PROFESSIONALS WHO ARE OUTLIERS.— 

11 ‘‘(A) IN GENERAL.—Beginning Jan12 uary 1, 2020, subject to paragraph 

13 (4)(C), with respect to services fur14 nished during a year, the Secretary 

15 shall, for a period determined appro16 priate by the Secretary, apply prior 

17 authorization for applicable imaging 

18 services that are ordered by an 

19 outlier ordering professional identi20 fied under paragraph (5). 

21 ‘‘(B) FUNDING.—For purposes of 

22 carrying out this paragraph, the Sec23 retary shall provide for the transfer, 

24 from the Federal Supplementary 

25 Medical Insurance Trust Fund under 


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1 section 1841, of $5,000,000 to the Cen2 ters for Medicare & Medicaid Serv3 ices Program Management Account 

4 for each of fiscal years 2019 through 

5 2021. Amounts transferred under the 

6 preceding sentence shall remain 

7 available until expended.’’. 

8 (2) CONFORMING AMENDMENT.—Section 

9 1833(t)(16) of the Social Security Act (42 

10 U.S.C. 1395l(t)(16)) is amended by adding 

11 at the end the following new subpara12 graph: 

13 ‘‘(E) APPLICATION OF APPROPRIATE

14 USE CRITERIA FOR CERTAIN IMAGING

15 SERVICES.—For provisions relating to 

16 the application of appropriate use 

17 criteria for certain imaging services, 

18 see section 1834(p).’’. 

19 (b) ESTABLISHMENT OF APPROPRIATE USE

20 PROGRAM FOR OTHER PART B SERVICES.—Sec21 tion 1834 of the Social Security Act (42 U.S.C. 

22 1395m), as amended by subsection (a), is 

23 amended by adding at the end the following 

24 new subsection: 


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1 ‘‘(q) ESTABLISHMENT OF APPROPRIATE USE

2 PROGRAM FOR OTHER PART B SERVICES.— 

3 ‘‘(1) ESTABLISHMENT.— 

4 ‘‘(A) IN GENERAL.—The Secretary 

5 may establish an appropriate use pro6 gram for services under this part 

7 (other than applicable imaging serv8 ices under subsection (p)) using a 

9 process similar to the process under 

10 such subsection. 

11 ‘‘(B) REQUIREMENTS.—In deter12 mining whether to establish a pro13 gram under subparagraph (A), the 

14 Secretary shall take into consider15 ation— 

16 ‘‘(i) the implementation of ap17 propriate use criteria for applica18 ble imaging services under sub19 section (p); and 

20 ‘‘(ii) the report under para21 graph (2). 

22 ‘‘(C) INPUT FROM STAKEHOLDERS IN

23 ADVANCE OF RULEMAKING.—Before 

24 issuing a notice of proposed rule25 making to establish a program under 


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1 subparagraph (A), the Secretary shall 

2 issue an advance notice of proposed 

3 rulemaking. 

4 ‘‘(2) REPORT ON EXPERIENCE OF IMAGING

5 APPROPRIATE USE CRITERIA PROGRAM.—Not 

6 later than 18 months after the date of the 

7 enactment of this subsection, the Comp8 troller General of the United States shall 

9 submit to Congress a report that includes 

10 a description of the extent to which ap11 propriate use criteria could be used for 

12 other services under this part, such as ra13 diation therapy and clinical diagnostic 

14 laboratory services.’’. 

15 SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH 

16 ACCESS TO INFORMATION ON PHYSICIANS’ 

17 SERVICES. 

18 (a) TRANSFERRING FREESTANDING PHYSI19 CIAN COMPARE PROVISION TO THE SOCIAL SECU20 RITY ACT.— 

21 (1) IN GENERAL.—Section 10331 of Pub22 lic Law 111–148 is transferred and redes23 ignated as subsection (t) of section 1848 

24 of the Social Security Act (42 U.S.C. 


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1 1395w–4), as amended by subsections (c) 

2 and (h) of section 2 and by section 3. 

3 (2) CONFORMING REDESIGNATIONS.— 

4 Section 1848(t) of the Social Security Act 

5 (42 U.S.C. 1395w–4(t)), as transferred and 

6 redesignated by paragraph (1), is further 

7 amended— 

8 (A) by striking the subsection 

9 heading and inserting the following 

10 new subsection heading: ‘‘PUBLIC RE11 PORTING OF PERFORMANCE AND OTHER

12 INFORMATION ON PHYSICIAN COM13 PARE.—’’; 

14 (B) by redesignating subsections 

15 (a) through (i) as paragraphs (1) 

16 through (9), respectively, and indent17 ing appropriately; 

18 (C) in paragraph (1), as redesig19 nated by subparagraph (B)— 

20 (i) by redesignating para21 graphs (1) and (2) as subpara22 graphs (A) and (B), respectively, 

23 and indenting appropriately; 

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1 ignating subparagraphs (A) 

2 through (G) as clauses (i) through 

3 (vii), respectively, and indenting 

4 appropriately; 

5 (D) in paragraph (2), as redesig6 nated by subparagraph (B), by redes7 ignating paragraphs (1) through (7) 

8 as subparagraphs (A) through (G), re9 spectively, and indenting appro10 priately; and 

11 (E) in paragraph (9), as redesig12 nated by subparagraph (B), by redes13 ignating paragraphs (1) through (4) 

14 as subparagraphs (A) through (D), re15 spectively, and indenting appro16 priately. 

17 (3) CONFORMING AMENDMENTS.—Sec18 tion 1848(t) of the Social Security Act (42 

19 U.S.C. 1395w–4(t)), as amended by para20 graph (2), is further amended— 

21 (A) in paragraph (1)— 

22 (i) in subparagraph (A)— 

23 (I) by striking ‘‘the Medi24 care program under section 

25 1866(j) of the Social Security 


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1 Act (42 U.S.C. 1395cc(j))’’ and 

2 inserting ‘‘the program under 

3 this title under section 

4 1866(j)’’; and 

5 (II) by striking ‘‘of such 

6 Act (42 U.S.C. 1395w–4)’’; and 

7 (ii) in subparagraph (B), in 

8 the matter preceding clause (i)— 

9 (I) by striking ‘‘subsection 

10 (c)’’ and inserting ‘‘paragraph 

11 (3)’’; 

12 (II) by striking ‘‘the Medi13 care program under such sec14 tion 1866(j)’’ and inserting 

15 ‘‘the program under this title 

16 under section 1866(j)’’; and 

17 (III) by striking ‘‘this sec18 tion’’ and inserting ‘‘this sub19 section’’; 

20 (B) in paragraph (2)— 

21 (i) in the matter preceding 

22 subparagraph (A), by striking 

23 ‘‘subsection (a)(2)’’ and inserting 

24 ‘‘paragraph (1)(B)’’; 


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1 (ii) in subparagraph (D), by 

2 striking ‘‘the Medicare program’’ 

3 and inserting ‘‘the program under 

4 this title’’; and 

5 (iii) in each of subparagraphs 

6 (F) and (G), by striking ‘‘this sec7 tion’’ and inserting ‘‘this sub8 section’’; 

9 (C) in paragraph (3), by striking 

10 ‘‘this section’’ and inserting ‘‘this sub11 section’’; 

12 (D) in paragraph (4)— 

13 (i) by striking ‘‘of the Social 

14 Security Act, as added by section 

15 3014 of this Act’’; and 

16 (ii) by striking ‘‘this section’’ 

17 and inserting ‘‘this subsection’’; 

18 (E) in paragraph (5)— 

19 (i) by striking ‘‘this subsection 

20 (a)(2)’’ and inserting ‘‘paragraph 

21 (1)(B)’’; and 

22 (ii) by striking ‘‘(Public Law 

23 110–275)’’; 


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1 (F) in paragraph (6), by striking 

2 ‘‘subsection (a)(1)’’ and inserting 

3 ‘‘paragraph (1)(A)’’; 

4 (G) in paragraph (7)— 

5 (i) by striking ‘‘subsection (f)’’ 

6 and inserting ‘‘paragraph (6)’’; 

7 and 

8 (ii) by striking ‘‘title XVIII of 

9 the Social Security Act’’ and in10 serting ‘‘this title’’; 

11 (H) in paragraph (8)— 

12 (i) by striking ‘‘subparagraphs 

13 (A) through (G) of subsection 

14 (a)(2)’’ and inserting ‘‘clauses (i) 

15 through (vii) of paragraph (1)(B)’’; 

16 (ii) by striking ‘‘title XVIII of 

17 the Social Security Act’’ and in18 serting ‘‘this title’’; and 

19 (iii) by striking ‘‘such title’’ 

20 and inserting ‘‘this title’’; and 

21 (I) in paragraph (9)— 

22 (i) in the matter preceding 

23 subparagraph (A), by striking 

24 ‘‘this section’’ and inserting ‘‘this 

25 subsection’’; 


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1 (ii) in subparagraph (A), by 

2 striking ‘‘of the Social Security 

3 Act (42 U.S.C. 1395w–4)’’; 

4 (iii) in subparagraph (B), by 

5 striking ‘‘of such Act (42 U.S.C. 

6 1395x(r))’’; 

7 (iv) in subparagraph (C), by 

8 striking ‘‘subsection (a)(1)’’ and 

9 inserting ‘‘paragraph (1)(A)’’; and 

10 (v) by striking subparagraph 

11 (D). 

12 (b) PUBLIC AVAILABILITY OF MEDICARE

13 DATA.—Section 1848(t) of the Social Security 

14 Act (42 U.S.C. 1395w–4(t)), as amended by sub15 section (a), is further amended— 

16 (1) by redesignating paragraph (9) as 

17 paragraph (10); 

18 (2) by inserting after paragraph (8) 

19 the following new paragraph: 

20 ‘‘(9) PUBLIC AVAILABILITY OF ELIGIBLE

21 PROFESSIONAL CLAIMS DATA.— 

22 ‘‘(A) IN GENERAL.—The Secretary 

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1 scribed in subparagraph (B) with re2 spect to eligible professionals. 

3 ‘‘(B) INFORMATION DESCRIBED.—The 

4 following information, with respect to 

5 an eligible professional, is described 

6 in this subparagraph: 

7 ‘‘(i) Information on the num8 ber of services furnished by the 

9 eligible professional, which may 

10 include information on the most 

11 frequent services furnished or 

12 groupings of services. 

13 ‘‘(ii) Information on submitted 

14 charges and payments for serv15 ices under this part. 

16 ‘‘(iii) A unique identifier for 

17 the eligible professional that is 

18 available to the public, such as a 

19 national provider identifier. 

20 ‘‘(C) SEARCHABILITY.—The informa21 tion made available under this para22 graph shall be searchable by at least 

23 the following: 

24 ‘‘(i) The specialty or type of 

25 the eligible professional. 


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1 ‘‘(ii) Characteristics of the 

2 services furnished, such as vol3 ume or groupings of services. 

4 ‘‘(iii) The location of the eligi5 ble professional. 

6 ‘‘(D) DISCLOSURE.—The informa7 tion made available under this para8 graph shall indicate, where appro9 priate, that publicized information 

10 may not be representative of the eli11 gible professional’s entire patient 

12 population, the variety of services 

13 furnished by the eligible professional, 

14 or the health conditions of individ15 uals treated. 

16 ‘‘(E) IMPLEMENTATION.— 

17 ‘‘(i) INITIAL IMPLEMENTATION.— 

18 Physician Compare shall include 

19 the information described in sub20 paragraph (B)— 

21 ‘‘(I) with respect to physi22 cians, by not later than July 1, 

23 2015; and 


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1 ‘‘(II) with respect to other 

2 eligible professionals, by not 

3 later than July 1, 2016. 

4 ‘‘(ii) ANNUAL UPDATING.—The 

5 information made available under 

6 this paragraph shall be updated 

7 on Physician Compare not less 

8 frequently than on an annual 

9 basis. 

10 ‘‘(F) OPPORTUNITY TO REVIEW AND

11 SUBMIT CORRECTIONS.—The Secretary 

12 shall provide for an opportunity for 

13 an eligible professional to review, and 

14 submit corrections for, the informa15 tion to be made public with respect to 

16 the eligible professional under this 

17 paragraph prior to such information 

18 being made public.’’; and 

19 (3) in paragraph (10)(C), as redesig20 nated by paragraph (1), by inserting ‘‘(or 

21 a successor website)’’ before the period at 

22 the end. 


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1 SEC. 8. EXPANDING CLAIMS DATA AVAILABILITY TO IM2 PROVE CARE. 

3 (a) EXPANSION OF USES OF CLAIMS DATA BY

4 QUALIFIED ENTITIES.—Section 1874(e) of the 

5 Social Security Act (42 U.S.C. 1395kk(e)) is 

6 amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(5) EXPANSION OF USES OF CLAIMS

9 DATA BY QUALIFIED ENTITIES.— 

10 ‘‘(A) EXPANSION.—To the extent 

11 consistent with applicable informa12 tion, privacy, security, and disclosure 

13 laws, beginning July 1, 2014, notwith14 standing paragraph (4)(B) (other than 

15 clause (iii) of such paragraph) and 

16 the second sentence of paragraph 

17 (4)(D), a qualified entity may, as de18 termined appropriate by the Sec19 retary, do any or all of the following: 

20 ‘‘(i)(I) Use the combined data 

21 described in paragraph (4)(B)(iii) 

22 to conduct analyses, other than 

23 for reports described in para24 graph (4), for entities described in 

25 subparagraph (B) for non-public 

26 uses, as determined appropriate 


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1 by the Secretary, such as for the 

2 purposes described in subclause 

3 (II). 

4 ‘‘(II) The purposes described 

5 in this subclause are assisting 

6 providers of services and sup7 pliers in developing and partici8 pating in quality and patient care 

9 improvement activities (including 

10 developing new models of care), 

11 population health management, 

12 and disease monitoring, and the 

13 purposes described in subpara14 graph (C). 

15 ‘‘(ii) Provide or sell such anal16 yses to entities described in sub17 paragraph (B). 

18 ‘‘(iii) Provide entities de19 scribed in clauses (i), (ii), (v), and 

20 (vi) of subparagraph (B) with ac21 cess to the combined data de22 scribed in paragraph (4)(B)(iii) 

23 through a qualified data enclave 

24 (as defined in subparagraph (F)) 

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1 fied entity in order for entities 

2 described in such clauses to con3 duct analyses for non-public uses, 

4 such as for the purposes de5 scribed in clause (i)(II). 

6 ‘‘(B) ENTITIES DESCRIBED.—For the 

7 purpose of subparagraph (A) clauses 

8 (i) and (ii), the entities described in 

9 this subparagraph are the following: 

10 ‘‘(i) A provider of services. 

11 ‘‘(ii) A supplier. 

12 ‘‘(iii) Subject to subparagraph 

13 (C), an employer (as defined in 

14 section 3(5) of the Employee Re15 tirement Insurance Security Act 

16 of 1974). 

17 ‘‘(iv) A health insurance issuer 

18 (as defined in section 2791 of the 

19 Public Health Service Act) that 

20 provides data under paragraph 

21 (4)(B)(iii). 

22 ‘‘(v) A medical society or hos23 pital association. 

24 ‘‘(vi) Other entities approved 

25 by the Secretary (other than an 


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1 employer (as so defined) and a 

2 health insurance issuer (as so de3 fined)). 

4 ‘‘(C) LIMITATION WITH RESPECT TO

5 EMPLOYERS.—Any analyses provided 

6 or sold under this paragraph to an 

7 employer (as so defined) may only be 

8 used by such employer for purposes 

9 of providing health insurance to em10 ployees and retirees of the employer. 

11 ‘‘(D) PROTECTION OF PATIENT IDEN12 TIFICATION.— 

13 ‘‘(i) IN GENERAL.—Except as 

14 provided in clause (ii), an analysis 

15 provided or sold under this para16 graph shall not contain informa17 tion that individually identifies a 

18 patient. 

19 ‘‘(ii) INFORMATION ON PATIENTS

20 OF THE PROVIDER OF SERVICES OR

21 SUPPLIER.—An analysis that is 

22 provided or sold under this para23 graph to a provider of services or 

24 supplier may contain data that in25 dividually identifies a patient of 


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1 such provider or supplier but 

2 only with respect to items and 

3 services furnished by such pro4 vider or supplier to such patient. 

5 ‘‘(iii) OPPORTUNITY FOR PRO6 VIDERS OF SERVICES AND SUPPLIERS

7 TO REVIEW.—Prior to a qualified 

8 entity providing or selling an 

9 analysis under this paragraph to 

10 an entity described in subpara11 graph (B), to the extent that such 

12 analysis would individually iden13 tify a provider of services or sup14 plier who is not being provided or 

15 sold such analysis, such qualified 

16 entity shall provide an oppor17 tunity for such provider or sup18 plier to review and submit correc19 tions to such analysis. 

20 ‘‘(E) NO REDISCLOSURE.—An entity 

21 described in subparagraph (B) that is 

22 provided or sold an analysis under 

23 this paragraph shall not redisclose or 

24 make public such an analysis. 


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1 ‘‘(F) REQUIREMENTS FOR A QUALI2 FIED DATA ENCLAVE.— 

3 ‘‘(i) DEFINITION.—For purposes 

4 of this paragraph, the term ‘quali5 fied data enclave’ means a data 

6 enclave that the Secretary deter7 mines meets the following: 

8 ‘‘(I) The data enclave is a 

9 web-based portal or com10 parable mechanism. 

11 ‘‘(II) Subject to the re12 quirements described in 

13 clause (ii) and such other re14 quirements as the Secretary 

15 may specify, the data enclave 

16 is capable of providing access 

17 to the combined data de18 scribed in subparagraph 

19 (A)(iii). 

20 ‘‘(ii) ENCLAVE ACCESS REQUIRE21 MENTS.—The requirements de22 scribed in this clause are the fol23 lowing: 

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1 ty that obtains access to the 

2 data from removing or ex3 tracting the data from such 

4 enclave. 

5 ‘‘(II) Subject to the suc6 ceeding sentence, the enclave 

7 shall preclude access to data 

8 that individually identifies a 

9 patient, including data on the 

10 patient’s name and date of 

11 birth and such other data as 

12 the Secretary shall specify. 

13 Such data enclave may pro14 vide providers of services and 

15 suppliers with access to such 

16 individually identifiable pa17 tient data but only with re18 spect to items and services 

19 furnished by such provider or 

20 supplier to such patient. 

21 ‘‘(III) Access to data in the 

22 enclave shall not be provided 

23 to any entity unless the quali24 fied entity and the entity have 

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1 ment, the terms of which con2 tain the requirements of this 

3 paragraph and such other 

4 terms the Secretary may 

5 specify. 

6 ‘‘(G) ANNUAL REPORTS.—Any quali7 fied entity that provides or sells anal8 yses pursuant to subparagraph (A)(ii) 

9 or provides access to a qualified data 

10 enclave pursuant to subparagraph 

11 (A)(iii) shall annually submit to the 

12 Secretary a report that includes— 

13 ‘‘(i) a summary of the analyses 

14 provided or sold, including the 

15 number of such analyses, the 

16 number of purchasers of such 

17 analyses, and the total amount of 

18 fees received for such analyses; 

19 ‘‘(ii) a description of the top20 ics and purposes of such analyses; 

21 ‘‘(iii) information on the enti22 ties who obtained access to the 

23 qualified data enclave, the uses of 

24 the data, and the total amount of 


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1 fees received for providing such 

2 access; and 

3 ‘‘(iv) other information deter4 mined appropriate by the Sec5 retary.’’. 

6 (b) EXPANSION OF DATA AVAILABLE TO

7 QUALIFIED ENTITIES.—Section 1874(e) of the 

8 Social Security Act (42 U.S.C. 1395kk(e)) is 

9 amended— 

10 (1) in the subsection heading, by 

11 striking ‘‘Medicare’’; and 

12 (2) in paragraph (3)— 

13 (A) by inserting after the first 

14 sentence the following new sentence: 

15 ‘‘Effective July 1, 2014, if the Sec16 retary determines appropriate, the 

17 data described in this paragraph may 

18 also include standardized extracts (as 

19 determined by the Secretary) of 

20 claims data under titles XIX and XXI 

21 for assistance provided under such ti22 tles for one or more specified geo23 graphic areas and time periods re24 quested by a qualified entity.’’; and 


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1 (B) in the last sentence, by insert2 ing ‘‘or under titles XIX or XXI’’ be3 fore the period at the end. 

4 (c) ACCESS TO MEDICARE DATA BY QUALI5 FIED CLINICAL DATA REGISTRIES TO FACILITATE

6 QUALITY IMPROVEMENT.—Section 1848(m)(3)(E) 

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

8 4(m)(3)(E)) is amended by adding at the end 

9 the following new clause: 

10 ‘‘(vi) ACCESS TO MEDICARE DATA

11 TO FACILITATE QUALITY IMPROVE12 MENT.— 

13 ‘‘(I) IN GENERAL.—To the 

14 extent consistent with appli15 cable information, privacy, se16 curity, and disclosure laws, 

17 and subject to other require18 ments as the Secretary may 

19 specify, beginning July 1, 

20 2014, the Secretary shall, if re21 quested by a qualified clinical 

22 data registry under this sub23 paragraph, subject to sub24 clauses (II) and (III), provide 

25 data as described in section 


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1 1874(e)(3) (in a form and man2 ner determined to be appro3 priate) to such registry for 

4 purposes of linking such data 

5 with clinical data and per6 forming analyses and re7 search to support quality im8 provement or patient safety. 

9 ‘‘(II) PROTECTION.—A quali10 fied clinical data registry may 

11 not publicly report any data 

12 made available under sub13 clause (I) (or any analyses or 

14 research described in such 

15 subclause) that individually 

16 identifies a provider of serv17 ices, supplier, or individual 

18 unless the registry obtains the 

19 consent of such provider, sup20 plier, or individual prior to 

21 such reporting. 

22 ‘‘(III) FEE.—The data de23 scribed in subclause (I) shall 

24 be made available to qualified 

25 clinical data registries at a fee 


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1 equal to the cost of making 

2 such data available. Any fee 

3 collected pursuant to the pre4 ceding sentence shall be de5 posited in the Centers for 

6 Medicare & Medicaid Services 

7 Program Management Ac8 count.’’. 

9 (d) REVISION OF PLACEMENT OF FEES.—Sec10 tion 1874(e)(4)(A) of the Social Security Act 

11 (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the 

12 second sentence— 

13 (1) by inserting ‘‘, for periods prior to 

14 July 1, 2014,’’ after ‘‘deposited’’; and 

15 (2) by inserting the following before 

16 the period at the end: ‘‘, and, beginning 

17 July 1, 2014, into the Centers for Medi18 care & Medicaid Services Program Man19 agement Account’’. 

20 SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER 

21 PROVISIONS. 

22 (a) MEDICARE PHYSICIAN AND PRACTITIONER

23 OPT-OUT TO PRIVATE CONTRACT.— 

24 (1) INDEFINITE, CONTINUING AUTOMATIC

25 EXTENSION OF OPT OUT ELECTION.— 


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1 (A) IN GENERAL.—Section 

2 1802(b)(3) of the Social Security Act 

3 (42 U.S.C. 1395a(b)(3)) is amended— 

4 (i) in subparagraph (B)(ii), by 

5 striking ‘‘during the 2-year period 

6 beginning on the date the affi7 davit is signed’’ and inserting 

8 ‘‘during the applicable 2-year pe9 riod (as defined in subparagraph 

10 (D))’’; 

11 (ii) in subparagraph (C), by 

12 striking ‘‘during the 2-year period 

13 described in subparagraph 

14 (B)(ii)’’ and inserting ‘‘during the 

15 applicable 2-year period’’; and 

16 (iii) by adding at the end the 

17 following new subparagraph: 

18 ‘‘(D) APPLICABLE 2-YEAR PERIODS

19 FOR EFFECTIVENESS OF AFFIDAVITS.—In 

20 this subsection, the term ‘applicable 

21 2-year period’ means, with respect to 

22 an affidavit of a physician or practi23 tioner under subparagraph (B), the 2- 

24 year period beginning on the date the 

25 affidavit is signed and includes each 


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1 subsequent 2-year period unless the 

2 physician or practitioner involved 

3 provides notice to the Secretary (in a 

4 form and manner specified by the 

5 Secretary), not later than 30 days be6 fore the end of the previous 2-year 

7 period, that the physician or practi8 tioner does not want to extend the 

9 application of the affidavit for such 

10 subsequent 2-year period.’’. 

11 (B) EFFECTIVE DATE.—The amend12 ments made by subparagraph (A) 

13 shall apply to affidavits entered into 

14 on or after the date that is 60 days 

15 after the date of the enactment of this 

16 Act. 

17 (2) PUBLIC AVAILABILITY OF INFORMA18 TION ON OPT-OUT PHYSICIANS AND PRACTI19 TIONERS.—Section 1802(b) of the Social 

20 Security Act (42 U.S.C. 1395a(b)) is 

21 amended— 

22 (A) in paragraph (5), by adding at 

23 the end the following new subpara24 graph: 


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1 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTI2 TIONER.—The term ‘opt-out physician 

3 or practitioner’ means a physician or 

4 practitioner who has in effect an affi5 davit under paragraph (3)(B).’’; 

6 (B) by redesignating paragraph 

7 (5) as paragraph (6); and 

8 (C) by inserting after paragraph 

9 (4) the following new paragraph: 

10 ‘‘(5) POSTING OF INFORMATION ON OPT11 OUT PHYSICIANS AND PRACTITIONERS.— 

12 ‘‘(A) IN GENERAL.—Beginning not 

13 later than February 1, 2015, the Sec14 retary shall make publicly available 

15 through an appropriate publicly ac16 cessible website of the Department of 

17 Health and Human Services informa18 tion on the number and characteris19 tics of opt-out physicians and practi20 tioners and shall update such infor21 mation on such website not less often 

22 than annually. 

23 ‘‘(B) INFORMATION TO BE IN24 CLUDED.—The information to be made 

25 available under subparagraph (A) 


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1 shall include at least the following 

2 with respect to opt-out physicians 

3 and practitioners: 

4 ‘‘(i) Their number. 

5 ‘‘(ii) Their physician or profes6 sional specialty or other designa7 tion. 

8 ‘‘(iii) Their geographic dis9 tribution. 

10 ‘‘(iv) The timing of their be11 coming opt-out physicians and 

12 practitioners, relative to when 

13 they first entered practice and 

14 with respect to applicable 2-year 

15 periods. 

16 ‘‘(v) The proportion of such 

17 physicians and practitioners who 

18 billed for emergency or urgent 

19 care services.’’. 

20 (b) MEDICARE NON-PARTICIPATING PHYSI21 CIANS DEMONSTRATION PROJECT.— 

22 (1) IN GENERAL.—The Secretary of 

23 Health and Human Services (in this sub24 section referred to as the ‘‘Secretary’’) 

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1 onstration project (in this section re2 ferred to as the ‘‘demonstration project’’) 

3 under title XVIII of the Social Security 

4 Act to provide that payments for services 

5 under such title furnished by non-partici6 pating physicians (as defined in section 

7 1861(r)(1) of the Social Security Act (42 

8 U.S.C. 1395x(r)(1))) to individuals entitled 

9 to benefits under part A or enrolled 

10 under part B of such title are paid di11 rectly to such physicians. The Secretary 

12 shall carry out the demonstration project 

13 in a geographic area that is a statistically 

14 significant area no larger than a State. 

15 (2) ADVANCE NOTICE TO PHYSICIANS.— 

16 The Secretary shall, in a timely manner 

17 and prior to the beginning of the year in 

18 which payment will be made under the 

19 demonstration project, notify physicians 

20 in the geographic area described in para21 graph (1) of the option to participate in 

22 the demonstration project. 

23 (3) TIMETABLE FOR IMPLEMENTATION.— 

24 (A) DEMONSTRATION START DATE.— 

25 The demonstration project shall 


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1 apply with respect to services fur2 nished beginning on January 1, 2015. 

3 (B) 1-YEAR DURATION.—The Sec4 retary shall implement the dem5 onstration project such that pay6 ments are made under such dem7 onstration project for a period of 1 

8 year. 

9 (4) REPORT.—Not later than 18 months 

10 after the date of the conclusion of the 

11 demonstration project, the Secretary 

12 shall submit to Congress a report ana13 lyzing the impact of the demonstration 

14 project. Such report shall include an 

15 analysis of the impact, if any, of the dem16 onstration project upon the— 

17 (A) percentage and number of 

18 physicians who choose not to partici19 pate under title XVIII of the Social 

20 Security Act and a comparison of 

21 such percentage and number to the 

22 previous year; 

23 (B) percentage of claims sub24 mitted by and payments made to phy25 sicians in the demonstration that are 


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1 unassigned and a comparison of un2 assigned claims and payments by 

3 non-participating physicians in the 

4 previous year; 

5 (C) percentage and number of the 

6 physicians in the demonstration by 

7 specialty designation; and 

8 (D) access to services for which 

9 payment is made under such title for 

10 individuals entitled to benefits under 

11 part A or enrolled under part B of 

12 such title. 

13 (5) BENEFICIARY NOTICE.— 

14 (A) NOTICE BY SECRETARY TO BENE15 FICIARIES.—The Secretary shall notify 

16 individuals entitled to benefits under 

17 part A or enrolled under part B of 

18 title XVIII of the Social Security Act 

19 in the geographic area in which the 

20 demonstration project is conducted of 

21 the implications of physician partici22 pation in the demonstration project. 

23 (B) NOTICE BY PHYSICIANS TO PA24 TIENTS.—A physician who elects to 

25 participate in the demonstration 


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1 project shall notify individuals to 

2 whom the physician furnishes serv3 ices for which payment will be pro4 vided under the demonstration 

5 project of such election. Such notifi6 cation shall be provided prior to the 

7 provision of service and include a no8 tification, with respect to each such 

9 individual, that— 

10 (i) the right of the individual 

11 to payment is being reassigned to 

12 the physician; 

13 (ii) payment for services fur14 nished by the physician to such 

15 individual will be made directly 

16 to the physician; and 

17 (iii) the individual is respon18 sible for the remaining amount, 

19 which may be higher than would 

20 be the case if the physician par21 ticipated in the Medicare pro22 gram. 

23 (c) GAINSHARING STUDY AND REPORT.—Not 

24 later than 6 months after the date of the en25 actment of this Act, the Secretary of Health 


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1 and Human Services, in consultation with the 

2 Inspector General of the Department of 

3 Health and Human Services, shall submit to 

4 Congress a report with legislative rec5 ommendations to amend existing fraud and 

6 abuse laws, through exceptions, safe harbors, 

7 or other narrowly targeted provisions, to per8 mit gainsharing or similar arrangements be9 tween physicians and hospitals that improve 

10 care while reducing waste and increasing effi11 ciency. The report shall— 

12 (1) consider whether such provisions 

13 should apply to ownership interests, com14 pensation arrangements, or other rela15 tionships; and 

16 (2) describe how the recommenda17 tions address accountability, trans18 parency, and quality, including how best 

19 to limit inducements to stint on care, dis20 charge patients prematurely, or other21 wise reduce or limit medically necessary 

22 care; and 

23 (3) consider whether a portion of any 

24 savings generated by such arrangements 

25 should accrue to the Medicare program 


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1 under title XVIII of the Social Security 

2 Act. 

3 (d) PROMOTING INTEROPERABILITY OF ELEC4 TRONIC HEALTH RECORD SYSTEMS.— 

5 (1) RECOMMENDATIONS FOR ACHIEVING

6 WIDESPREAD EHR INTEROPERABILITY.— 

7 (A) OBJECTIVE.—As a consequence 

8 of a significant Federal investment in 

9 the implementation of health infor10 mation technology through the Medi11 care EHR incentive programs, Con12 gress declares it a national objective 

13 to achieve widespread and nation14 wide exchange of health information 

15 through interoperable certified EHR 

16 technology by December 31, 2019. 

17 (B) DEFINITIONS.—In this para18 graph: 

19 (i) WIDESPREAD INTEROPER20 ABILITY.—The term ‘‘widespread 

21 interoperability’’ means nation22 wide interoperability between 

23 certified EHR technology systems 

24 employed by meaningful EHR 

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1 centive programs and other clini2 cians and health care providers. 

3 (ii) INTEROPERABILITY.—The 

4 term ‘‘interoperability’’ means the 

5 ability of two or more health in6 formation systems or components 

7 to exchange clinical and other in8 formation and to use the informa9 tion that has been exchanged 

10 using common standards as to 

11 provide access to longitudinal in12 formation for health care pro13 viders in order to facilitate co14 ordinated care and improved pa15 tient outcomes. 

16 (C) ESTABLISHMENT OF METRICS.— 

17 Not later than December 31, 2015, and 

18 in consultation with stakeholders, the 

19 Secretary shall establish metrics to 

20 be used to determine if and to the ex21 tent that the objective described in 

22 subparagraph (A) has been achieved. 

23 (D) RECOMMENDATIONS IF OBJEC24 TIVE NOT ACHIEVED.—If the Secretary 

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1 mines that the objective described in 

2 subparagraph (A) has not been 

3 achieved by December 31, 2017, then 

4 the Secretary shall submit to Con5 gress a report, by not later than De6 cember 31, 2018, that identifies bar7 riers to such objective and rec8 ommends actions that the Federal 

9 Government can take to achieve such 

10 objective. Such recommended actions 

11 may include recommendations— 

12 (i) to adjust payments for 

13 meaningful EHR users under the 

14 Medicare EHR incentive pro15 grams; and 

16 (ii) for criteria for decerti17 fying certified EHR technology 

18 products. 

19 (2) PREVENTING BLOCKING THE SHARING

20 OF INFORMATION.— 

21 (A) FOR MEANINGFUL EHR PROFES22 SIONALS.—Section 1848(o)(2)(A)(ii) of 

23 the Social Security Act (42 U.S.C. 

24 1395w–4(o)(2)(A)(ii)) is amended by 

25 inserting before the period at the end 


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1 the following: ‘‘, and the professional 

2 demonstrates (through a process 

3 specified by the Secretary, such as 

4 the use of an attestation similar to 

5 that required in the health informa6 tion technology donation safe harbor 

7 established under regulations under 

8 section 1128B(b)(3)(E)) that the pro9 fessional has not and will not take 

10 any deliberate action to limit or re11 strict the use, compatibility, or inter12 operability of the certified EHR tech13 nology’’. 

14 (B) FOR MEANINGFUL EHR HOS15 PITALS.—Section 1886(n)(3)(A)(ii) of 

16 the Social Security Act (42 U.S.C. 

17 1395ww(n)(3)(A)(ii)) is amended by in18 serting before the period at the end 

19 the following: ‘‘, and the hospital dem20 onstrates (through a process specified 

21 by the Secretary, such as the use of 

22 an attestation referred to in section 

23 1848(o)(2)(A)(ii)) that the hospital has 

24 not and will not take any deliberate 

25 action to limit or restrict the use, 


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1 compatibility, or interoperability of 

2 the certified EHR technology’’. 

3 (C) EFFECTIVE DATE.—The amend4 ments made by this subsection shall 

5 apply to meaningful EHR users as of 

6 the date that is 6 months after the 

7 date of the enactment of this Act. 

8 (3) STUDY AND REPORT ON THE FEASI9 BILITY OF ESTABLISHING A WEBSITE TO COM10 PARE CERTIFIED EHR TECHNOLOGY PROD11 UCTS.— 

12 (A) STUDY.—The Secretary shall 

13 conduct a study to examine the feasi14 bility of establishing a website (in 

15 this subsection referred to as the 

16 ‘‘website’’) that includes aggregated 

17 results of surveys of meaningful EHR 

18 users on the functionality of certified 

19 EHR technology products to enable 

20 such users to directly compare the 

21 functionality and other features of 

22 such products. Such information may 

23 be made available through contracts 

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1 ganizations that maintain such com2 parative information. 

3 (B) REPORT.—Not later than 1 

4 year after the date of the enactment 

5 of this Act, the Secretary shall submit 

6 to Congress a report on the website. 

7 The report shall include information 

8 on the benefits and resources of such 

9 a website. 

10 (4) DEFINITIONS.—In this subsection: 

11 (A) The term ‘‘certified EHR tech12 nology’’ has the meaning given such 

13 term in section 1848(o)(4) of the So14 cial Security Act (42 U.S.C. 1395w– 

15 4(o)(4)). 

16 (B) The term ‘‘meaningful EHR 

17 hospital’’ means an eligible hospital 

18 (as defined in section 1886(n)(6)(A) of 

19 the Social Security Act (42 U.S.C. 

20 1395ww(n)(6)(A)) that is a meaningful 

21 EHR user. 

22 (C) The term ‘‘meaningful EHR 

23 professional’’ means an eligible pro24 fessional (as defined in section 

25 1848(o)(5)(C) of the Social Security 


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1 Act (42 U.S.C. 1395w–4(o)(5)(C)) who 

2 is a meaningful EHR user. 

3 (D) The term ‘‘meaningful EHR 

4 user’’ has the meaning given such 

5 term under the Medicare EHR incen6 tive programs. 

7 (E) The term ‘‘Medicare EHR in8 centive programs’’ means the incen9 tive programs under section 1848(o), 

10 subsections (l) and (m) of section 

11 1853, and section 1886(n) of the Social 

12 Security Act (42 U.S.C. 1395w–4(o), 

13 1395w–23, 1395ww(n)). 

14 (F) The term ‘‘Secretary’’ means 

15 the Secretary of Health and Human 

16 Services. 

17 (e) GAO STUDY AND REPORT ON THE USE OF

18 TELEHEALTH UNDER FEDERAL PROGRAMS.— 

19 (1) STUDY.—The Comptroller General 

20 of the United States shall conduct a study 

21 on the following: 

22 (A) How the definition of tele23 health across various Federal pro24 grams and federal efforts can inform 

25 the use of telehealth in the Medicare 


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1 program under title XVIII of the So2 cial Security Act (42 U.S.C. 1395 et 

3 seq.). 

4 (B) Issues that can facilitate or in5 hibit the use of telehealth under the 

6 Medicare program under such title, 

7 including oversight and professional 

8 licensure, changing technology, pri9 vacy and security, infrastructure re10 quirements, and varying needs across 

11 urban and rural areas. 

12 (C) Potential implications of 

13 greater use of telehealth with respect 

14 to payment and delivery system 

15 transformations under the Medicare 

16 program under such title XVIII and 

17 the Medicaid program under title XIX 

18 of such Act (42 U.S.C. 1396 et seq.). 

19 (D) How the Centers for Medicare 

20 & Medicaid Services conducts over21 sight of payments made under the 

22 Medicare program under such title 

23 XVIII to providers for telehealth serv24 ices. 


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1 (2) REPORT.—Not later than 24 months 

2 after the date of the enactment of this 

3 Act, the Comptroller General shall submit 

4 to Congress a report containing the re5 sults of the study conducted under para6 graph (1), together with recommenda7 tions for such legislation and administra8 tive action as the Comptroller General 

9 determines appropriate. 

10 (f) RULE OF CONSTRUCTION REGARDING

11 HEALTH CARE PROVIDER STANDARDS OF CARE.— 

12 (1) IN GENERAL.—The development, 

13 recognition, or implementation of any 

14 guideline or other standard under any 

15 Federal health care provision shall not be 

16 construed to establish the standard of 

17 care or duty of care owed by a health 

18 care provider to a patient in any medical 

19 malpractice or medical product liability 

20 action or claim. 

21 (2) DEFINITIONS.—For purposes of this 

22 subsection: 

23 (A) The term ‘‘Federal health care 

24 provision’’ means any provision of the 

25 Patient Protection and Affordable 


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1 Care Act (Public Law 111–148), title I 

2 and subtitle B of title III of the 

3 Health Care and Education Reconcili4 ation Act of 2010 (Public Law 111– 

5 152), and titles XVIII and XIX of the 

6 Social Security Act. 

7 (B) The term ‘‘health care pro8 vider’’ means any individual or enti9 ty— 

10 (i) licensed, registered, or cer11 tified under Federal or State laws 

12 or regulations to provide health 

13 care services; or 

14 (ii) required to be so licensed, 

15 registered, or certified but that is 

16 exempted by other statute or reg17 ulation. 

18 (C) The term ‘‘medical mal19 practice or medical liability action or 

20 claim’’ means a medical malpractice 

21 action or claim (as defined in section 

22 431(7) of the Health Care Quality Im23 provement Act of 1986 (42 U.S.C. 

24 11151(7))) and includes a liability ac25 tion or claim relating to a health care 


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1 provider’s prescription or provision 

2 of a drug, device, or biological prod3 uct (as such terms are defined in sec4 tion 201 of the Federal Food, Drug, 

5 and Cosmetic Act or section 351 of 

6 the Public Health Service Act). 

7 (D) The term ‘‘State’’ includes the 

8 District of Columbia, Puerto Rico, 

9 and any other commonwealth, posses10 sion, or territory of the United States. 

11 (3) NO PREEMPTION.—No provision of 

12 the Patient Protection and Affordable 

13 Care Act (Public Law 111–148), title I or 

14 subtitle B of title III of the Health Care 

15 and Education Reconciliation Act of 2010 

16 (Public Law 111–152), or title XVIII or 

17 XIX of the Social Security Act shall be 

18 construed to preempt any State or com19 mon law governing medical professional 

20 or medical product liability actions or 

21 claims. 


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Union Calendar No. 283 

113TH CONGRESS 

2D SESSION H. R. 2810 

[Report No. 113–257, Parts I and II] 

A BILL 

To amend title XVIII of the Social Security Act to 

purposes. payment for physicians’ services, and for other reform the sustainable growth rate and Medicare 

MARCH 14, 2014 

Reported from the Committee on Ways and Means with 

to be printed Whole House on the State of the Union, and ordered an amendment, committed to the Committee of the 


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