I 

113TH CONGRESS 

1ST SESSION H. R. 2810 

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 

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. 

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 

6 of 2013’’. 

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

2 this 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. 

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

4 AND MEDICARE PAYMENT FOR PHYSICIANS’ 

5 SERVICES. 

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

7 (1) REPEAL OF SGR PAYMENT METHOD8 OLOGY.—Section 1848 of the Social Security Act 

9 (42 U.S.C. 1395w–4) is amended— 

10 (A) in subsection (d)— 

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

12 ‘‘or a subsequent paragraph or section 

13 1848A’’ after ‘‘paragraph (4)’’; and 

14 (ii) in paragraph (4)— 

15 (I) in the heading, by striking 

16 ‘‘YEARS BEGINNING WITH 2001’’ and 

17 inserting ‘‘2001, 2002, AND 2003’’; and 

18 (II) in subparagraph (A), by 

19 striking ‘‘a year beginning with 2001’’ 

20 and inserting ‘‘2001, 2002, and 

21 2003’’; and 

22 (B) in subsection (f)— 

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

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

3 year’’; and 

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

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

6 with 2000’’. 

7 (2) UPDATE OF RATES FOR 2014 THROUGH

8 2018.—Subsection (d) of section 1848 of the Social 

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

10 adding at the end the following new paragraph: 

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

12 update to the single conversion factor established in 

13 paragraph (1)(C) for each of 2014 through 2018 

14 shall be 0.5 percent.’’. 

15 (b) QUALITY UPDATE INCENTIVE PROGRAM (PHASE

16 II).— 

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

18 Security Act (42 U.S.C. 1395w–4), as amended by 

19 subsection (a), is further amended— 

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

21 the following new paragraph: 

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

23 ‘‘(A) IN GENERAL.—Subject to subpara24 graph (B), the update to the single conversion 

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

2 year beginning with 2019 shall be 0.5 percent. 

3 ‘‘(B) ADJUSTMENT.—In the case of an eli4 gible professional (as defined in subsection 

5 (k)(3)) who does not have a payment arrange6 ment described in section 1848A(a) in effect, 

7 the update under subparagraph (A) for a year 

8 beginning with 2019 shall be adjusted by the 

9 applicable quality adjustment determined under 

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

11 (B) in subsection (i)(1)— 

12 (i) by striking ‘‘and’’ at the end of 

13 subparagraph (D); 

14 (ii) by striking the period at the end 

15 of subparagraph (E) and inserting ‘‘, 

16 and’’; and 

17 (iii) by adding at the end the fol18 lowing new subparagraph: 

19 ‘‘(F) the implementation of subsection 

20 (q).’’. 

21 (2) ENHANCING PHYSICIAN QUALITY REPORT22 ING SYSTEM TO SUPPORT QUALITY UPDATE INCEN23 TIVE PROGRAM.—Section 1848 of the Social Secu24 rity Act (42 U.S.C. 1395w–4) is amended— 

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1 (A) in subsection (k)(1), in the first sen2 tence, by inserting ‘‘and, if applicable, clinical 

3 practice improvement activities,’’ after ‘‘quality 

4 measures’’; 

5 (B) in subsection (k)(2)— 

6 (i) in subparagraph (C)— 

7 (I) in the subparagraph heading, 

8 by striking ‘‘AND SUBSEQUENT

9 YEARS’’ and inserting ‘‘THROUGH

10 2018’’; and 

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

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

13 year’’; 

14 (ii) by redesignating subparagraph 

15 (D) as subparagraph (E); 

16 (iii) by inserting after subparagraph 

17 (C) the following new subparagraph: 

18 ‘‘(D) FOR 2019 AND SUBSEQUENT

19 YEARS.—For purposes of reporting data on 

20 quality measures and, as applicable clinical 

21 practice improvement activities, for covered pro22 fessional services furnished during the perform23 ance period (as defined in subsection (q)(2)(B)) 

24 with respect to 2019 and the performance pe25 riod with respect to each subsequent year, submstockstill on DSK4VPTVN1PROD with BILLS

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1 ject to subsection (q)(1)(D), the quality meas2 ures and clinical practice improvement activities 

3 specified under this paragraph shall be, with re4 spect to an eligible professional, the quality 

5 measures and, as applicable, clinical practice 

6 improvement activities within the final core 

7 measure set under paragraph (9)(F) applicable 

8 to the peer cohort of such provider and year in9 volved.’’; and 

10 (iv) in subparagraph (E), as redesig11 nated by subparagraph (B)(ii) of this para12 graph, by striking ‘‘AND SUBSEQUENT

13 YEARS’’; 

14 (C) in subsection (k)(3)— 

15 (i) in the paragraph heading, by strik16 ing ‘‘COVERED PROFESSIONAL SERVICES

17 AND ELIGIBLE PROFESSIONALS DEFINED’’ 

18 and inserting ‘‘DEFINITIONS’’; and 

19 (ii) by adding at the end the following 

20 new subparagraphs: 

21 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

22 ACTIVITIES.—The term ‘clinical practice im23 provement activity’ means an activity that rel24 evant eligible professional organizations and 

25 other relevant stakeholders identify as improvmstockstill on DSK4VPTVN1PROD with BILLS

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1 ing clinical practice or care delivery and that 

2 the Secretary determines, when effectively exe3 cuted, is likely to result in improved outcomes. 

4 ‘‘(D) ELIGIBLE PROFESSIONAL ORGANIZA5 TION.—The term ‘eligible professional organiza6 tion’ means a professional organization that is 

7 recognized by the American Board of Medical 

8 Specialties, American Osteopathic Association, 

9 American Board of Physician Specialties, or an 

10 equivalent certification board. 

11 ‘‘(E) PEER COHORT.—The term ‘peer co12 hort’ means a peer cohort identified on the list 

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

14 clause (ii) of such paragraph.’’; 

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

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

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

18 and (5), and the implementation of paragraph 

19 (9)’’; 

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

21 the following new paragraph: 

22 ‘‘(9) ESTABLISHMENT OF FINAL CORE MEAS23 URE SETS.— 

24 ‘‘(A) IN GENERAL.—Under the system 

25 under this subsection— 

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1 ‘‘(i) for each peer cohort identified 

2 under subparagraph (B) and in accordance 

3 with this paragraph, there shall be pub4 lished a final core measure set under sub5 paragraph (F), which shall consist of qual6 ity measures and may also consist of clin7 ical practice improvement activities, with 

8 respect to which eligible professionals shall, 

9 subject to subsection (m)(3)(C), be as10 sessed for purposes of determining, for 

11 years beginning with 2019, the quality ad12 justment under subsection (q)(3) applica13 ble to such professionals; and 

14 ‘‘(ii) each eligible professional shall 

15 self-identify, in accordance with subpara16 graph (B), within such a peer cohort for 

17 purposes of such assessments. 

18 ‘‘(B) PEER COHORTS.—The Secretary 

19 shall identify (and publish a list of) peer co20 horts by which eligible professionals shall self21 identify for purposes of this subsection and sub22 section (q) with respect to a performance period 

23 (as defined in subsection (q)(2)(B)) for a year 

24 beginning with 2019. For purposes of this sub25 section and subsection (q), the Secretary shall 

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1 develop one or more peer cohorts for multispe2 cialty groups, each of which shall be included as 

3 a peer cohort under this subparagraph. Such 

4 self-identification will be made through such a 

5 process and at such time as specified under the 

6 system under this subsection. Such list— 

7 ‘‘(i) shall include, as peer cohorts, 

8 provider specialties defined by the Amer9 ican Board of Medical Specialties or equiv10 alent certification boards and such other 

11 cohorts as established under this section in 

12 order to capture classifications of providers 

13 across eligible professional organizations 

14 and other practice areas, groupings, or cat15 egories; and 

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

17 time. 

18 ‘‘(C) QUALITY MEASURES FOR CORE MEAS19 URE SETS.— 

20 ‘‘(i) DEVELOPMENT.—Under the sys21 tem under this subsection there shall be es22 tablished a process for the development of 

23 quality measures under this subparagraph 

24 for purposes of potential inclusion of such 

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1 measures in core measure sets under this 

2 paragraph. Under such process— 

3 ‘‘(I) there shall be coordination, 

4 to the extent possible, across organi5 zations developing such measures; 

6 ‘‘(II) eligible professional organi7 zations and other relevant stake8 holders may submit best practices and 

9 clinical practice guidelines for the de10 velopment of quality measures that 

11 address quality domains (as defined 

12 under clause (ii)) for potential inclu13 sion in such core measure sets; 

14 ‘‘(III) there is encouraged to be 

15 developed, as appropriate, meaningful 

16 outcome measures (or quality of life 

17 measures in cases for which outcomes 

18 may not be a valid measurement), 

19 functional status measures, and pa20 tient experience measures; and 

21 ‘‘(IV) measures developed under 

22 this clause shall be developed, to the 

23 extent possible, in accordance with 

24 best practices and clinical practice 

25 guidelines. 

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1 ‘‘(ii) QUALITY DOMAINS.—For pur2 poses of this paragraph, the term ‘quality 

3 domains’ means at least the following do4 mains: 

5 ‘‘(I) Clinical care. 

6 ‘‘(II) Safety. 

7 ‘‘(III) Care coordination. 

8 ‘‘(IV) Patient and caregiver expe9 rience. 

10 ‘‘(V) Population health and pre11 vention. 

12 ‘‘(D) PROCESS FOR ESTABLISHING CORE

13 MEASURE SETS.— 

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

15 under this subsection, for purposes of sub16 paragraph (A), there shall be established a 

17 process to approve final core measure sets 

18 under this paragraph for peer cohorts. 

19 Each such final core measure set shall be 

20 composed of quality measures (and, as ap21 plicable, clinical practice improvement ac22 tivities) with respect to which eligible pro23 fessionals within such peer cohort shall re24 port under this subsection and be assessed 

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1 under subsection (q). Such process shall 

2 provide— 

3 ‘‘(I) for the establishment of cri4 teria, which shall be made publicly 

5 available before the request is made 

6 under clause (ii), for selecting such 

7 measures and activities for potential 

8 inclusion in such a final core measure 

9 set; and 

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

11 the extent practicable all quality do12 mains, are addressed by measures 

13 and, as applicable, clinical practice 

14 improvement activities selected to be 

15 included in a core measure set under 

16 this paragraph, which may include 

17 through the use of such a measure or 

18 clinical practice improvement activity 

19 that addresses more than one such 

20 domain or cohort. 

21 ‘‘(ii) SOLICITATION OF PUBLIC INPUT

22 ON QUALITY MEASURES AND CLINICAL

23 PRACTICE IMPROVEMENT ACTIVITIES.— 

24 Under the process established under clause 

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1 tions and other relevant stakeholders shall 

2 be requested to identify and submit quality 

3 measures and clinical practice improve4 ment activities (as defined in paragraph 

5 (3)(C)) for selection under this paragraph. 

6 For purposes of the previous sentence, 

7 measures and activities may be submitted 

8 regardless of whether such measures were 

9 previously published in a proposed rule or 

10 endorsed by an entity with a contract 

11 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) ap18 plicable to a peer cohort, quality 

19 measures to be included in a core 

20 measure set for such cohort; 

21 ‘‘(II) shall, to the extent there 

22 are insufficient quality measures ap23 plicable to a peer cohort to address 

24 one or more applicable quality do25 mains, select to be included in a core 

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1 measure set for such cohort such clin2 ical practice improvement activities 

3 described in clause (ii)(IV) as are 

4 needed and available to sufficiently 

5 address such an applicable domain 

6 with respect to such peer cohort; and 

7 ‘‘(III) may select, to the extent 

8 determined appropriate, any addi9 tional clinical practice improvement 

10 activities described in clause (ii)(IV) 

11 applicable to a peer cohort to be in12 cluded in a core measure set for such 

13 cohort. 

14 Activities selected under this paragraph 

15 shall be selected with consideration of best 

16 practices and clinical practice guidelines 

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

18 ‘‘(ii) SOURCES OF QUALITY MEASURES

19 AND CLINICAL PRACTICE IMPROVEMENT

20 ACTIVITIES.—A quality measure or clinical 

21 practice improvement activity selected for 

22 inclusion in a core measure set under the 

23 process under subparagraph (D)(i) shall 

24 be— 

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1 ‘‘(I) a measure endorsed by a 

2 consensus-based entity; 

3 ‘‘(II) a measure developed under 

4 paragraph (2)(C) or a measure other5 wise applied or developed for a similar 

6 purpose under this section; 

7 ‘‘(III) a measure developed under 

8 subparagraph (C); or 

9 ‘‘(IV) a measure or activity sub10 mitted under subparagraph (D)(ii). 

11 A measure or activity may be selected 

12 under this subparagraph, regardless of 

13 whether such measure or activity was pre14 viously published in a proposed rule. A 

15 measure so selected shall be evidence-based 

16 but (other than a measure described in 

17 subclause (I)) shall not be required to be 

18 consensus-based. 

19 ‘‘(iii) TRANSPARENCY.—Before pub20 lishing in a final regulation a core measure 

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

22 set under subparagraph (F), the Secretary 

23 shall— 

24 ‘‘(I) submit for publication in ap25 plicable specialty-appropriate peer-remstockstill on DSK4VPTVN1PROD with BILLS

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1 viewed journals such core measure set 

2 under clause (i) and the method for 

3 developing and selecting measures 

4 within such set, including clinical and 

5 other data supporting such measures, 

6 and, as applicable, the method for se7 lecting clinical practice improvement 

8 activities included within such set; 

9 and 

10 ‘‘(II) regardless of whether or not 

11 the core measure set or method is 

12 published in such a journal under sub13 clause (I), provide for notice of the 

14 proposed regulation in the Federal 

15 Register, including with respect to the 

16 applicable methods and data described 

17 in subclause (I), and a period for pub18 lic comment thereon. 

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

20 later than November 15 of the year prior to the 

21 first day of a performance period, the Secretary 

22 shall publish a final regulation in the Federal 

23 Register that includes a final core measure set 

24 (and the applicable methods and data described 

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1 in subparagraph (E)(iii)(I)) for each peer co2 hort to be applied for such performance period. 

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

4 ‘‘(i) IN GENERAL.—In carrying out 

5 this paragraph, under the system under 

6 this subsection, there shall periodically be 

7 reviewed— 

8 ‘‘(I) the quality measures and 

9 clinical practice improvement activities 

10 selected for inclusion in final core 

11 measure sets under this paragraph for 

12 each year such measures and activi13 ties are to be applied under this sub14 section or subsection (q) to ensure 

15 that such measures and activities con16 tinue to meet the conditions applicable 

17 to such measures and activities for 

18 such selection; and 

19 ‘‘(II) the final core measure sets 

20 published under subparagraph (F) for 

21 each year such sets are to be applied 

22 to peer cohorts of eligible profes23 sionals to ensure that each applicable 

24 set continues to meet the conditions 

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1 applicable to such sets before being so 

2 published. 

3 ‘‘(ii) COLLABORATION WITH STAKE4 HOLDERS.—In carrying out clause (i), rel5 evant eligible professional organizations 

6 and other relevant stakeholders may iden7 tify and submit updates to quality meas8 ures and clinical practice improvement ac9 tivities selected under this paragraph for 

10 inclusion in final core measure sets as well 

11 as any additional quality measures and 

12 clinical practice improvement activities. 

13 Not later than November 15 of the year 

14 prior to the first day of a performance pe15 riod, submissions under this clause shall be 

16 reviewed. 

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

18 MEASURES AND ACTIVITIES.—Based on 

19 the review conducted under this subpara20 graph for a period, as needed, there shall 

21 be— 

22 ‘‘(I) selected additional, and up23 dates to, quality measures and clinical 

24 practice improvement activities se25 lected under this paragraph for potenmstockstill on DSK4VPTVN1PROD with BILLS

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1 tial inclusion in final core measure 

2 sets in the same manner such quality 

3 measures and clinical practice im4 provement activities are selected 

5 under this paragraph for such poten6 tial inclusion; 

7 ‘‘(II) removed, from final core 

8 measure sets, quality measures and 

9 clinical practice improvement activities 

10 that are no longer meaningful; and 

11 ‘‘(III) updated final core measure 

12 sets published under subparagraph 

13 (F) in the same manner as such sets 

14 are approved under such subpara15 graph. 

16 For purposes of this subsection and sub17 section (q), a final core measure set, as up18 dated under this subparagraph, shall be 

19 treated in the same manner as a final core 

20 measure set published under subparagraph 

21 (F). 

22 ‘‘(iv) TRANSPARENCY.— 

23 ‘‘(I) NOTIFICATION REQUIRED

24 FOR CERTAIN UPDATES.—In the case 

25 of an update under subclause (II) or 

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1 (III) of clause (iii) that adds, materi2 ally changes, or removes a measure or 

3 activity from a measure set, such up4 date shall not apply under this sub5 section or subsection (q) unless notifi6 cation of such update is made avail7 able to applicable eligible profes8 sionals. 

9 ‘‘(II) PUBLIC AVAILABILITY OF

10 UPDATED FINAL CORE MEASURE

11 SETS.—Subparagraph (E)(iii) shall 

12 apply with respect to measure sets up13 dated under subclause (II) or (III) of 

14 clause (iii) in the same manner as 

15 such subparagraph applies to applica16 ble core measure sets under subpara17 graph (E). 

18 ‘‘(H) COORDINATION WITH EXISTING PRO19 GRAMS.—The development and selection of 

20 quality measures and clinical practice improve21 ment activities under this paragraph shall, as 

22 appropriate, be coordinated with the develop23 ment and selection of existing measures and re24 quirements, such as the development of the 

25 Physician Compare Website under subsection 

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1 (m)(5)(G) and the application of resource use 

2 management under subsection (n). To the ex3 tent feasible, such measures and activities shall 

4 align with measures used by other payers and 

5 with measures and activities in use under other 

6 programs in order to streamline the process of 

7 such development and selection under this para8 graph. The Secretary shall develop a plan to in9 tegrate reporting on quality measures under 

10 this subsection with reporting requirements 

11 under subsection (o) relating to the meaningful 

12 use of certified EHR technology. 

13 ‘‘(I) CONSULTATION WITH RELEVANT ELI14 GIBLE PROFESSIONAL ORGANIZATIONS AND

15 OTHER RELEVANT STAKEHOLDERS.—Relevant 

16 eligible professional organizations (as defined in 

17 paragraph (3)(D)) and other relevant stake18 holders, including State and national medical 

19 societies, shall be consulted in carrying out this 

20 paragraph. 

21 ‘‘(J) OPTIONAL APPLICATION.—The proc22 ess under section 1890A is not required to 

23 apply to the development or selection of meas24 ures under this paragraph.’’; and 

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

2 at the end the following new sentence: ‘‘Such 

3 process shall, beginning for 2019, treat eligible 

4 professionals in such a group practice as report5 ing on measures for purposes of application of 

6 subsections (q) and (a)(8)(A)(iii) if, in lieu of 

7 reporting measures under subsection (k)(2)(D), 

8 the group practice reports measures determined 

9 appropriate by the Secretary.’’. 

10 (3) ESTABLISHMENT OF QUALITY UPDATE IN11 CENTIVE PROGRAM.— 

12 (A) IN GENERAL.—Section 1848 of the So13 cial Security Act (42 U.S.C. 1395w–4) is 

14 amended by adding at the end the following 

15 new subsection: 

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

17 ‘‘(1) ESTABLISHMENT.— 

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

19 establish an eligible professional quality update 

20 incentive program (in this section referred to as 

21 the ‘quality update incentive program’) under 

22 which— 

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

24 accordance with paragraph (2), appro25 priate methodologies for assessing the permstockstill on DSK4VPTVN1PROD with BILLS

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1 formance of eligible professionals with re2 spect to quality measures and clinical prac3 tice improvement activities included within 

4 the final core measure sets published under 

5 subsection (k)(9)(F) applicable to the peer 

6 cohorts of such providers; 

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

8 the system under subsection (k), methods 

9 for collecting information needed for such 

10 assessments (which shall involve the min11 imum amount of administrative burden re12 quired to ensure reliable results); and 

13 ‘‘(iii) the applicable update adjust14 ments under paragraph (3) are determined 

15 by such assessments. 

16 ‘‘(B) DEFINITIONS.— 

17 ‘‘(i) ELIGIBLE PROFESSIONAL.—In 

18 this subsection, the term ‘eligible profes19 sional’ has the meaning given such term in 

20 subsection (k)(3), except that such term 

21 shall not include a professional who has a 

22 payment arrangement described in section 

23 1848A(a)(1) in effect. 

24 ‘‘(ii) PEER COHORTS; CLINICAL PRAC25 TICE IMPROVEMENT ACTIVITIES; ELIGIBLE

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1 PROFESSIONAL ORGANIZATIONS.—In this 

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

3 practice improvement activity’, and ‘eligible 

4 professional organization’ have the mean5 ings given such terms in subsection (k)(3). 

6 ‘‘(C) CONSULTATION WITH ELIGIBLE PRO7 FESSIONAL ORGANIZATIONS AND OTHER REL8 EVANT STAKEHOLDERS.—Eligible professional 

9 organizations and other relevant stakeholders, 

10 including State and national medical societies, 

11 shall be consulted in carrying out this sub12 section. 

13 ‘‘(D) APPLICATION AT GROUP PRACTICE

14 LEVEL.—The Secretary shall establish a proc15 ess, consistent with subsection (m)(3)(C), under 

16 which the provisions of this subsection are ap17 plied to eligible professionals in a group prac18 tice if the group practice reports measures de19 termined appropriate by the Secretary under 

20 such subsection. 

21 ‘‘(E) COORDINATION WITH EXISTING PRO22 GRAMS.—The application of measures and clin23 ical practice improvement activities and assess24 ment of performance under this subsection 

25 shall, as appropriate, be coordinated with the 

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1 application of measures and assessment of per2 formance under other provisions of this section. 

3 ‘‘(2) ASSESSING PERFORMANCE WITH RESPECT

4 TO FINAL CORE MEASURE SETS FOR APPLICABLE

5 PEER COHORTS.— 

6 ‘‘(A) ESTABLISHMENT OF METHODS FOR

7 ASSESSMENT.— 

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

9 update incentive program, the Secretary 

10 shall— 

11 ‘‘(I) establish one or more meth12 ods, applicable with respect to a per13 formance period, to assess (using a 

14 scoring scale of 0 to 100) the per15 formance of an eligible professional 

16 with respect to, subject to paragraph 

17 (1)(D), quality measures and clinical 

18 practice improvement activities in19 cluded within the final core measure 

20 set published under subsection 

21 (k)(9)(F) applicable for the period to 

22 the peer cohort in which the provider 

23 self-identified under subsection 

24 (k)(9)(B) for such period; and 

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1 ‘‘(II) subject to paragraph 

2 (1)(D), compute a composite score for 

3 such provider for such performance 

4 period with respect to the measures 

5 and activities included within such 

6 final core measure set. 

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

8 with respect to an eligible professional, 

9 provide that the performance of such pro10 fessional shall, subject to paragraph 

11 (1)(D), be assessed for a performance pe12 riod with respect to the quality measures 

13 and clinical practice improvement activities 

14 within the final core measure set for such 

15 period for the peer cohort of such profes16 sional and on which information is col17 lected from such professional. 

18 ‘‘(iii) WEIGHTING OF MEASURES.— 

19 Such a method may provide for the assign20 ment of different scoring weights or, as ap21 propriate, other factors— 

22 ‘‘(I) for quality measures and 

23 clinical practice improvement activi24 ties; 

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1 ‘‘(II) based on the type or cat2 egory of measure or activity; and 

3 ‘‘(III) based on the extent to 

4 which a quality measure or clinical 

5 practice improvement activity mean6 ingfully assesses quality. 

7 ‘‘(iv) RISK ADJUSTMENT.—Such a 

8 method shall provide for appropriate risk 

9 adjustments. 

10 ‘‘(v) INCORPORATION OF OTHER

11 METHODS OF MEASURING PHYSICIAN

12 QUALITY.—In establishing such methods, 

13 there shall be, as appropriate, incorporated 

14 comparable methods of measurement from 

15 physician quality incentive programs under 

16 this subsection. 

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

18 be established a period (in this subsection re19 ferred to as a ‘performance period’), with re20 spect to a year (beginning with 2019) for which 

21 the quality adjustment is applied under para22 graph (3), to assess performance on quality 

23 measures and clinical practice improvement ac24 tivities. Each such performance period shall be 

25 a period of 12 consecutive months and shall end 

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1 as close as possible to the beginning of the year 

2 for which such adjustment is applied. 

3 ‘‘(3) QUALITY ADJUSTMENT TAKING INTO AC4 COUNT QUALITY ASSESSMENTS.— 

5 ‘‘(A) QUALITY ADJUSTMENT.—For pur6 poses of subsection (d)(16), if the composite 

7 score computed under paragraph (2)(A) for an 

8 eligible professional for a year (beginning with 

9 2019) is— 

10 ‘‘(i) a score of 67 or higher, the qual11 ity adjustment under this paragraph for 

12 the eligible professional and year is 1 per13 centage point; 

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

15 67, the quality adjustment under this 

16 paragraph for the eligible professional and 

17 year is zero; or 

18 ‘‘(iii) a score below 34, the quality ad19 justment under this paragraph for the eli20 gible professional and year is ¥1 percent21 age point. 

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

23 QUALITY ADJUSTMENTS.—Each such quality 

24 adjustment shall be made each year without remstockstill on DSK4VPTVN1PROD with BILLS

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1 gard to the update adjustment for a previous 

2 year under this paragraph. 

3 ‘‘(4) TRANSITION FOR NEW ELIGIBLE PROFES4 SIONALS.—In the case of a physician, practitioner, 

5 or other supplier that during a performance period, 

6 with respect to a year for which a quality adjust7 ment is applied under paragraph (3), first becomes 

8 an eligible professional (and had not previously sub9 mitted claims under this title as a person, as an en10 tity, or as part of a physician group or under a dif11 ferent billing number or tax identifier), the quality 

12 adjustment under this subsection applicable to such 

13 physician, practitioner, or supplier— 

14 ‘‘(A) for such year, with respect to such 

15 first performance period, shall be zero; and 

16 ‘‘(B) for a year, with respect to a subse17 quent performance period, shall be the quality 

18 adjustment that would otherwise be applied 

19 under this subsection. 

20 ‘‘(5) FEEDBACK.— 

21 ‘‘(A) FEEDBACK.— 

22 ‘‘(i) ONGOING FEEDBACK.—Under the 

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

24 shall be provided, as real time as possible, 

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1 but at least quarterly, to each eligible pro2 fessional feedback— 

3 ‘‘(I) on the performance of such 

4 provider with respect to quality meas5 ures and clinical practice improvement 

6 activities within the final core meas7 ure set published under subsection 

8 (k)(9)(F) for the applicable perform9 ance period and the peer cohort of 

10 such professional; and 

11 ‘‘(II) to assess the progress of 

12 such professional under the quality 

13 update incentive program with respect 

14 to a performance period for a year. 

15 ‘‘(ii) USE OF REGISTRIES AND OTHER

16 MECHANISMS.—Feedback under this sub17 paragraph shall, to the extent an eligible 

18 professional chooses to participate in a 

19 data registry for purposes of this sub20 section (including registries under sub21 sections (k) and (m)), be provided and 

22 based on performance received through the 

23 use of such registry, and to the extent that 

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1 poses, be provided through other similar 

2 mechanisms that allow for the provision of 

3 such feedback and receipt of such perform4 ance information. 

5 ‘‘(B) DATA MECHANISM.—Under the qual6 ity update incentive program, there shall be de7 veloped an electronic interactive eligible profes8 sional mechanism through which such a profes9 sional may receive performance data, including 

10 data with respect to performance on the meas11 ures and activities developed and selected under 

12 this section. Such mechanism shall be developed 

13 in consultation with private payers and health 

14 insurance issuers (as defined in section 

15 2791(b)(2) of the Public Health Service Act) as 

16 appropriate. 

17 ‘‘(C) TRANSFER OF FUNDS.—The Sec18 retary shall provide for the transfer of 

19 $100,000,000 from the Federal Supplementary 

20 Medical Insurance Trust Fund established in 

21 section 1841 to the Center for Medicare & Med22 icaid Services Program Management Account to 

23 support such efforts to develop the infrastruc24 ture as necessary to carry out subsection (k)(9) 

25 and this subsection and for purposes of section 

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1 1889(h). Such funds shall be so transferred on 

2 the date of the enactment of this subsection 

3 and shall remain available until expended.’’. 

4 (B) INCENTIVE TO REPORT UNDER QUAL5 ITY UPDATE INCENTIVE PROGRAM.—Section 

6 1848(a)(8)(A) of the Social Security Act (42 

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

8 (i) in clause (i), by striking ‘‘With re9 spect to’’ and inserting ‘‘Subject to clause 

10 (iii), with respect to’’; and 

11 (ii) by adding at the end the following 

12 new clause: 

13 ‘‘(iii) APPLICATION TO ELIGIBLE PRO14 FESSIONALS NOT REPORTING.—With re15 spect to covered professional services (as 

16 defined in subsection (k)(3)) furnished by 

17 an eligible professional during 2019 or any 

18 subsequent year, if the eligible professional 

19 does not submit data for the performance 

20 period (as defined in subsection (q)(2)(B)) 

21 with respect to such year on, subject to 

22 subsection (q)(1)(D), the quality measures 

23 and, as applicable, clinical practice im24 provement activities within the final core 

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1 plicable to the peer cohort of such pro2 vider, the fee schedule amount for such 

3 services furnished by such professional 

4 during the year (including the fee schedule 

5 amount for purposes of determining a pay6 ment based on such amount) shall be equal 

7 to 95 percent (in lieu of the applicable per8 cent) of the fee schedule amount that 

9 would otherwise apply to such services 

10 under this subsection (determined after ap11 plication of paragraphs (3), (5), and (7), 

12 but without regard to this paragraph). The 

13 Secretary shall develop a minimum per 

14 year caseload threshold, with respect to eli15 gible professionals, and the previous sen16 tence shall not apply to eligible profes17 sionals with a caseload for a year below 

18 such threshold for such year.’’. 

19 (C) EDUCATION ON QUALITY UPDATE IN20 CENTIVE PROGRAM.—Section 1889 of the Social 

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

22 adding at the end the following new subsection: 

23 ‘‘(h) QUALITY UPDATE INCENTIVE PROGRAM.— 

24 Under this section, information shall be disseminated to 

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1 tion 1848(k)(3)) about the quality update incentive pro2 gram under section 1848(q) and quality measures under 

3 section 1848(k)(9) through multiple approaches, including 

4 a national dissemination strategy and outreach by medi5 care contractors.’’. 

6 (4) CONFORMING AMENDMENTS.— 

7 (A) TREATMENT OF SATISFACTORILY RE8 PORTING PQRS MEASURES THROUGH PARTICI9 PATION IN A QUALIFIED CLINICAL DATA REG10 ISTRY.—Section 1848(m)(3)(D) of the Social 

11 Security Act (42 U.S.C. 1395w–4(m)(3)(D)) is 

12 amended by striking ‘‘For 2014 and subsequent 

13 years’’ and inserting ‘‘For each of 2014 

14 through 2018’’. 

15 (B) COORDINATING ENHANCED PQRS RE16 PORTING WITH EHR.—Section 

17 1848(o)(2)(B)(iii) of the Social Security Act 

18 (42 U.S.C. 1395w–4(o)(2)(B)(iii)) is amended 

19 by striking ‘‘subsection (k)(2)(C)’’ and inserting 

20 ‘‘subparagraph (C) or (D) of subsection 

21 (k)(2)’’. 

22 (C) COORDINATING PQRS REPORTING PE23 RIOD WITH QUALITY UPDATE INCENTIVE PRO24 GRAM PERFORMANCE PERIOD.—Section 

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1 1848(m)(6)(C) of the Social Security Act (42 

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

3 (i) in clause (i), by striking ‘‘and (iii)’’ 

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

5 (ii) by adding at the end the following 

6 new clause: 

7 ‘‘(iv) COORDINATION WITH QUALITY

8 UPDATE INCENTIVE PROGRAM.—For 2019 

9 and each subsequent year the reporting pe10 riod shall be coordinated with the perform11 ance period under subsection (q)(2)(B).’’. 

12 (D) COORDINATING EHR REPORTING WITH

13 QUALITY UPDATE INCENTIVE PROGRAM PER14 FORMANCE PERIOD.—Section 1848(o)(5)(B) of 

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

16 4(o)(5)(B)) is amended by adding at the end 

17 the following: ‘‘Beginning for 2019, the EHR 

18 reporting period shall be coordinated with the 

19 performance period under subsection 

20 (q)(2)(B).’’. 

21 (c) ADVANCING ALTERNATIVE PAYMENT MODELS.— 

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

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

24 amended by adding at the end the following new sec25 tion: 

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

2 ‘‘(a) PAYMENT MODEL CHOICE PROGRAM.—Pay3 ment for covered professional services (as defined in sec4 tion 1848(k)) that are furnished by an eligible professional 

5 (as defined in such section) under an Alternative Payment 

6 Model specified on the list under subsection (h) (in this 

7 section referred to as an ‘eligible APM’) shall be made 

8 under this title in accordance with the payment arrange9 ment under such model. In applying the previous sentence, 

10 such a professional with such a payment arrangement in 

11 effect, shall be deemed for purposes of section 1848(a)(8) 

12 to be satisfactorily submitting data on quality measures 

13 for such covered professional services. 

14 ‘‘(b) PROCESS FOR IMPLEMENTING ELIGIBLE

15 APMS.— 

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

17 (a) and in accordance with this section, the Sec18 retary shall establish a process under which— 

19 ‘‘(A) a contract is entered into, in accord20 ance with paragraph (2); 

21 ‘‘(B) proposals for potential Alternative 

22 Payment Models are submitted in accordance 

23 with subsection (c); 

24 ‘‘(C) Alternative Payment Models so pro25 posed are recommended, in accordance with 

26 subsection (d), for evaluation, including through 

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1 the demonstration program under subsection 

2 (e), and approval under subsection (f); 

3 ‘‘(D) applicable Alternative Payment Mod4 els are evaluated under such demonstration pro5 gram; 

6 ‘‘(E) models are implemented as eligible 

7 APMs in accordance with subsection (f); and 

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

9 APMs is made publicly available, in accordance 

10 with subsection (h), for application under sub11 section (a). 

12 ‘‘(2) CONTRACT WITH APM CONTRACTING ENTI13 TY.— 

14 ‘‘(A) IN GENERAL.—For purposes of para15 graph (1)(A), the Secretary shall identify and 

16 have in effect a contract with an independent 

17 entity that has appropriate expertise to carry 

18 out the functions applicable to such entity 

19 under this section. Such entity shall be referred 

20 to in this section as the ‘APM contracting enti21 ty’. 

22 ‘‘(B) TIMING FOR FIRST CONTRACT.—As 

23 soon as practicable, but not later than one year 

24 after the date of the enactment of this section, 

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1 the Secretary shall enter into the first contract 

2 under subparagraph (A). 

3 ‘‘(C) COMPETITIVE PROCEDURES.—Com4 petitive procedures (as defined in section 4(5) 

5 of the Office of Federal Procurement Policy Act 

6 (41 U.S.C. 403(5))) shall be used to enter into 

7 a contract under subparagraph (A). 

8 ‘‘(c) SUBMISSION OF PROPOSED ALTERNATIVE PAY9 MENT MODELS.—Beginning not later than 90 days after 

10 the date the Secretary enters into a contract under sub11 section (b)(2) with the APM contracting entity, physi12 cians, eligible professional organizations, health care pro13 vider organizations, and other entities may submit to the 

14 APM contracting entity proposals for Alternative Payment 

15 Models for application under this section. Such a proposal 

16 of a model shall include suggestions for measures to be 

17 used under subsection (e)(1)(B) for purposes of evaluating 

18 such model. In reviewing submissions under this sub19 section for purposes of making recommendations under 

20 subsection (d)(1), the contracting entity shall focus on 

21 submissions for such models that are intended to improve 

22 care coordination and quality for patients through modi23 fying the manner in which physicians and other providers 

24 are paid under this title. 

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1 ‘‘(d) RECOMMENDATION BY APM CONTRACTING EN2 TITY OF PROPOSED MODELS.— 

3 ‘‘(1) RECOMMENDATION.— 

4 ‘‘(A) IN GENERAL.—Under the process 

5 under subsection (b), the APM contracting enti6 ty shall at least annually recommend to the 

7 Secretary— 

8 ‘‘(i) based on the criteria described in 

9 subparagraph (B), Alternative Payment 

10 Models submitted under subsection (c) to 

11 be evaluated through a demonstration pro12 gram under subsection (e); and 

13 ‘‘(ii) based on the criteria described in 

14 subparagraph (C), Alternative Payment 

15 Models submitted under subsection (c) for 

16 purposes of implementation under sub17 section (f), without evaluation through 

18 such a demonstration program. 

19 Such a recommendation may be made with re20 spect to a model for which a waiver would be 

21 required under paragraph (2). 

22 ‘‘(B) CRITERIA FOR RECOMMENDING MOD23 ELS FOR DEMONSTRATION.—The APM con24 tracting entity shall make a recommendation 

25 under subparagraph (A)(i), with respect to an 

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1 Alternative Payment Model, only if the entity 

2 determines that the model satisfies each of the 

3 following criteria: 

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

5 meaningful clinical and non-clinical data, 

6 with respect to a sufficient population sam7 ple, that indicates the model would be suc8 cessful at addressing each of the abilities 

9 described in clause (v). 

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

11 has already been evaluated and supported 

12 by data with respect to a population of in13 dividuals enrolled under this part, if the 

14 model were evaluated under the dem15 onstration under subsection (e) such a 

16 population would represent a sufficient 

17 number of individuals enrolled under this 

18 part to ensure meaningful evaluation. 

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

20 not been so evaluated and supported by 

21 data with respect to such a population, the 

22 population that would be furnished services 

23 under such model if the model were evalu24 ated under the demonstration under sub25 section (e) would represent a sufficient 

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1 number of individuals enrolled under this 

2 part to ensure meaningful evaluation. 

3 ‘‘(iii) Such model, including if evalu4 ated under the demonstration under sub5 section (e), would not deny or limit the 

6 coverage or provision of benefits under this 

7 title for applicable individuals. 

8 ‘‘(iv) The implementation of such 

9 model as an eligible APM under this sec10 tion is expected— 

11 ‘‘(I) to reduce spending under 

12 this title without reducing the quality 

13 of care; or 

14 ‘‘(II) improve the quality of pa15 tient care without increasing spend16 ing. 

17 ‘‘(v) The proposal for such model 

18 demonstrates— 

19 ‘‘(I) the potential to successfully 

20 manage the cost of furnishing items 

21 and services under this title so as to 

22 not result in expenditures under this 

23 title for individuals participating 

24 under such APM being greater than 

25 expenditures under this title for such 

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1 individuals if the APM were not im2 plemented; 

3 ‘‘(II) the ability to maintain or 

4 improve the overall patient care; and 

5 ‘‘(III) the ability to maintain or 

6 improve the quality of care provided 

7 to individuals enrolled under this part 

8 who participate under such mode. 

9 ‘‘(vi) The model provides for a pay10 ment arrangement— 

11 ‘‘(I) covering at least items and 

12 services furnished under this part by 

13 eligible professionals participating in 

14 the model; 

15 ‘‘(II) in the case such payment 

16 arrangement does not provide for pay17 ment under the fee schedule under 

18 section 1848 for such items and serv19 ices furnished by such eligible profes20 sionals, that provides for a payment 

21 adjustment based on meaningful EHR 

22 use comparable to such adjustment 

23 that would otherwise apply under sec24 tion 1848; and 

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1 ‘‘(III) that provides for a pay2 ment adjustment based on quality 

3 measures comparable to such adjust4 ment that would otherwise apply 

5 under section 1848. 

6 ‘‘(C) CRITERIA FOR RECOMMENDING MOD7 ELS FOR APPROVAL WITHOUT EVALUATION

8 UNDER DEMONSTRATION.—The APM con9 tracting entity may make a recommendation 

10 under subparagraph (A)(ii), with respect to an 

11 Alternative Payment Model, only if the entity 

12 determines that the model has already been 

13 evaluated for a sufficient enough period and 

14 through such evaluation the model was shown— 

15 ‘‘(i) to have satisfied the criteria de16 scribed in each of clauses (i), (ii), (iii), and 

17 (vi) of subparagraph (B); 

18 ‘‘(ii) to demonstrate each of the abili19 ties described in clause (v) of such sub20 paragraph; and 

21 ‘‘(iii)(I) to reduce spending under this 

22 title without reducing the quality of care; 

23 or 

24 ‘‘(II) improve the quality of patient 

25 care without increasing spending. 

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1 ‘‘(D) TRANSPARENCY AND DISCLO2 SURES.— 

3 ‘‘(i) DISCLOSURES.—Not later than 

4 90 days after receipt of a submission of a 

5 model under subsection (c) by an entity, 

6 the APM contracting entity shall submit to 

7 the Secretary and such entity and make 

8 publicly available a notification on whether 

9 or not, and if so how, the model meets cri10 teria for recommending such model under 

11 subparagraph (A), including whether or 

12 not such model requires a waiver under 

13 paragraph (2). In the case that the APM 

14 contracting entity determines not to rec15 ommend such model under this paragraph, 

16 such notification shall include an expla17 nation of the reasons for not making such 

18 a recommendation. Any information made 

19 publicly available pursuant to the previous 

20 sentence shall not include proprietary 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), including 

5 any such models that require a waiver 

6 under paragraph (2), and the data 

7 and analyses on such recommended 

8 models that support the criteria de9 scribed in subparagraph (B). 

10 ‘‘(II) The models recommended 

11 under subparagraph (A)(ii), including 

12 any such models that require a waiver 

13 under paragraph (2), and the data 

14 and analyses on such recommended 

15 models that support the criteria de16 scribed in subparagraph (C). 

17 For any year beginning with 2015 that the 

18 APM contracting does not recommend any 

19 models under subparagraph (A), the entity 

20 shall instead satisfy this clause by submit21 ting to the Secretary and making publicly 

22 available an explanation for not having any 

23 such recommendations. 

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

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1 ‘‘(A) IN GENERAL.—In the case that an 

2 Alternative Payment Model recommended under 

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

4 from any requirement under this title, in deter5 mining approval of such model, the Secretary 

6 may make such a waiver in order for such 

7 model to be evaluated under the demonstration 

8 program (if described in clause (i) of such para9 graph). 

10 ‘‘(B) APPROVAL.—Not later than 90 days 

11 after the date of the receipt of such submission 

12 for a model, the Secretary shall notify the APM 

13 contracting entity and the entity submitting 

14 such model under subsection (c) whether or not 

15 such a waiver for such model is provided and 

16 the reason for any denial of such a waiver. 

17 ‘‘(e) DEMONSTRATION.— 

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

19 (6), and (7), the Secretary may conduct a dem20 onstration program, with respect to an Alternative 

21 Payment Model approved under paragraph (2), 

22 under which participating entities shall be paid 

23 under this title in accordance with the payment ar24 rangement under such model and such model shall 

25 be evaluated by the independent evaluation entity 

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1 under paragraph (3). The duration of a demonstra2 tion program under this subsection, with respect to 

3 such a model, shall be 3 years (or a shorter period, 

4 taking into account the applicable recommendation 

5 under subsection (d)(1)(A)(i)). 

6 ‘‘(2) APPROVAL BY SECRETARY OF MODELS

7 FOR DEMONSTRATION.—Not later than 90 days 

8 after the date of receipt of a recommendation under 

9 subsection (d)(1)(A)(i), with respect to an Alter10 native Payment Model, the Secretary shall approve 

11 such model for a demonstration program under this 

12 subsection only if the Secretary determines the 

13 model satisfies the criteria described in subsection 

14 (d)(1)(B). The Secretary shall periodically make a 

15 available a list of such models so approved. 

16 ‘‘(3) PARTICIPATING ENTITIES.—To participate 

17 under a demonstration program under this sub18 section, with respect to an Alternative Payment 

19 Model, a physician, practitioner, or other supplier 

20 shall enter into a contract with the Administrator of 

21 the Centers for Medicare & Medicaid Services under 

22 this subsection. For purposes of this section, such a 

23 physician, practitioner, or supplier who so partici24 pates under such an Alternative Payment Model 

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1 shall be referred to as a ‘participating APM pro2 vider’. 

3 ‘‘(4) REPORTING AND EVALUATION.— 

4 ‘‘(A) INDEPENDENT EVALUATION ENTI5 TY.—Under this subsection, the Secretary shall 

6 enter into a contract with an independent entity 

7 to evaluate Alternative Payment Models under 

8 demonstration programs under this subsection 

9 based on appropriate measures specified under 

10 subparagraph (B). In this section, such entity 

11 shall be referred to as the ‘independent evalua12 tion entity’. Such contract shall be entered into 

13 in a timely manner so as to ensure evaluation 

14 of an Alternative Payment Model under a dem15 onstration program under this subsection may 

16 begin as soon as possible after the model is ap17 proved under paragraph (2). 

18 ‘‘(B) PERFORMANCE MEASURES.—For 

19 purposes of this subsection, the Secretary shall 

20 specify— 

21 ‘‘(i) measures to evaluate Alternative 

22 Payment Models under demonstration pro23 grams under this subsection, which may 

24 include measures suggested under sub25 section (c) and shall be sufficient to allow 

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1 for a comprehensive assessment of such a 

2 model; and 

3 ‘‘(ii) quality measures on which par4 ticipating entities shall report, which shall 

5 be similar to measures applicable under 

6 section 1848(k). 

7 ‘‘(C) REPORTING REQUIREMENTS.—A con8 tract entered into with a participating APM 

9 provider under paragraph (3) shall require such 

10 provider to report on appropriate measures 

11 specified under subparagraph (B). 

12 ‘‘(D) PERIODIC REVIEW.—The inde13 pendent evaluation entity shall periodically re14 view and analyze and submit such analysis to 

15 the Secretary and the participating entities in16 volved data reported under subparagraph (C) 

17 and such other data as deemed necessary to 

18 evaluate the model. 

19 ‘‘(E) FINAL EVALUATION.—Not later than 

20 6 months after the date of completion of a dem21 onstration program, the independent evaluation 

22 entity shall submit to the Secretary, the Medi23 care Payment Advisory Commission, and the 

24 Chief Actuary of the Centers for Medicare & 

25 Medicaid Services (and make publicly available) 

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1 a report on each model evaluated under such 

2 program. Such report shall include— 

3 ‘‘(i) outcomes on the clinical and 

4 claims data received through such program 

5 with respect to such model; 

6 ‘‘(ii) recommendations on— 

7 ‘‘(I) whether or not such model 

8 should be implemented as an eligible 

9 APM under this section; or 

10 ‘‘(II) whether or not the evalua11 tion of such model under the dem12 onstration program should be ex13 tended or expanded; 

14 ‘‘(iii) the justification for each such 

15 recommendation described in clause (ii); 

16 and 

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

18 to implement such model as an eligible 

19 APM, recommendations on standardized 

20 rules for purposes of such implementation. 

21 ‘‘(5) APPROVAL OF EXTENDING EVALUATION

22 UNDER DEMONSTRATION.—Not later than 90 days 

23 after the date of receipt of a submission under para24 graph (4)(E), the Secretary shall, including based on 

25 a recommendation submitted under such paragraph, 

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1 determine whether an Alternative Payment Model 

2 may be extended or expanded under the demonstra3 tion program. 

4 ‘‘(6) TERMINATION.—The Secretary shall ter5 minate a demonstration program for a model under 

6 this subsection unless the Secretary determines (and 

7 the Chief Actuary of the Centers for Medicare & 

8 Medicaid Services, with respect to program spending 

9 under this title, certifies), after testing has begun, 

10 that the model is expected to— 

11 ‘‘(A) improve the quality of care (as deter12 mined by the Administrator of the Centers for 

13 Medicare & Medicaid Services) without increas14 ing spending under this title; 

15 ‘‘(B) reduce spending under this title with16 out reducing the quality of care; or 

17 ‘‘(C) improve the quality of care and re18 duce spending. 

19 Such termination may occur at any time after such 

20 testing has begun and before completion of the test21 ing. 

22 ‘‘(7) FUNDING.— 

23 ‘‘(A) IN GENERAL.—There are appro24 priated, from amounts in the Federal Supple25 mentary Medical Insurance Trust Fund under 

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1 section 1841 not otherwise appropriated, 

2 $2,000,000,000 for the purposes described in 

3 subparagraph (B), of which no more than 2.5 

4 percent may be used for the purpose described 

5 in clause (iii) of such subparagraph. Amounts 

6 transferred under this subparagraph shall be 

7 available until expended. 

8 ‘‘(B) PURPOSES.—Amounts appropriated 

9 under subparagraph (A) shall be used for— 

10 ‘‘(i) payments for items and services 

11 furnished by participating entities under 

12 an Alternative Payment Model under a 

13 demonstration program under this sub14 section that— 

15 ‘‘(I) would not otherwise be eligi16 ble for payment under this title; or 

17 ‘‘(II) exceed the amount of pay18 ment that would otherwise be made 

19 for such items and services under this 

20 title if such items and services were 

21 not furnished under such demonstra22 tion program; 

23 ‘‘(ii) the evaluations provided for 

24 under this section of models under such a 

25 demonstration program; 

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1 ‘‘(iii) payment to the contracting enti2 ty for carrying out its duties under this 

3 section; and 

4 ‘‘(iv) for otherwise carrying out this 

5 subsection. 

6 ‘‘(C) LIMITATION.—The amounts appro7 priated under subparagraph (A) are the only 

8 amounts authorized or appropriated to carry 

9 out the purposes described in subparagraph 

10 (B). 

11 ‘‘(f) IMPLEMENTATION OF RECOMMENDED MODELS

12 AS ELIGIBLE APMS.— 

13 ‘‘(1) IN GENERAL.—Not later than the applica14 ble date under paragraph (2), the Secretary shall, 

15 implement an Alternative Payment Model rec16 ommended under subsection (d)(1)(A)(ii) or 

17 (e)(4)(E)(ii)(I) as an eligible APM only if— 

18 ‘‘(A) the Secretary determines that such 

19 model is expected to— 

20 ‘‘(i) reduce spending under this title 

21 without reducing the quality of care; or 

22 ‘‘(ii) improve the quality of patient 

23 care without increasing spending; 

24 ‘‘(B) the Chief Actuary of the Centers for 

25 Medicare & Medicaid Services certifies that 

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1 such model would reduce (or would not result 

2 in any increase in) program spending under 

3 this title; and 

4 ‘‘(C) the Secretary determines that such 

5 model would not deny or limit the coverage or 

6 provision of benefits under this title for applica7 ble individuals. 

8 Not later than 90 days after the date of issuance of 

9 a proposed rule, with respect to an Alternative Pay10 ment Model, the Medicare Payment Advisory Com11 mission shall submit comments to Congress and the 

12 Secretary evaluating the reports from the con13 tracting entity and independent evaluation entity on 

14 such model regarding the model’s impact on expend15 itures and quality of care under this title. 

16 ‘‘(2) APPLICABLE DATE.—For purposes of 

17 paragraph (1), the applicable date under this para18 graph— 

19 ‘‘(A) for an Alternative Payment Model 

20 recommended under subsection (d)(1)(A)(ii) is 

21 90 days after the date of submission of such 

22 recommendation; and 

23 ‘‘(B) for an Alternative Payment Model 

24 recommended under subsection (e)(4)(E)(ii)(I) 

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1 is 90 days after the date of submission of such 

2 recommendation 

3 ‘‘(3) JUSTIFICATION FOR DISAPPROVALS.—In 

4 the case that an Alternative Payment Model rec5 ommended under subsection (d)(1)(A)(ii) or 

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

7 APM under this subsection, the Secretary shall 

8 make publicly available the rational, in detail, for 

9 such decision. 

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

11 ‘‘(1) PERIODIC REVIEW.—In the case of an Al12 ternative Payment Model that has been imple13 mented, the Secretary and the Chief Actuary of the 

14 Centers for Medicare & Medicaid Services shall re15 view such model every 3 years to determine (and 

16 certify, in the case of the Chief Actuary and spend17 ing under this title), for the previous 3 years, wheth18 er the model 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 TER2 MINATION.—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 TERMI7 NATION.—Unless such Chief Actuary certifies 

8 under paragraph (1)(B) that the expenditures 

9 under this title under the model do not exceed 

10 the expenditures that would otherwise have 

11 been made if the model had not been imple12 mented for the period involved, the Secretary 

13 shall terminate such 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 

18 under subsection (f) and demonstrations carried out with 

19 respect to payments under section 1848 through authority 

20 in existence as of the day before the date of the enactment 

21 of this section. Under such process such list shall be peri22 odically updated and, beginning with January 1, 2015, 

23 and annually thereafter, such list shall be published in the 

24 Federal 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 

5 1848A, instead’’. 

6 SEC. 3. EXPANDING AVAILABILITY OF MEDICARE DATA. 

7 (a) EXPANDING USES OF MEDICARE DATA BY

8 QUALIFIED ENTITIES.— 

9 (1) IN GENERAL.—To the extent consistent 

10 with applicable information, privacy, security, and 

11 disclosure laws, beginning with 2014, notwith12 standing the second sentence of paragraph (4)(D) of 

13 section 1874(e) of the Social Security Act (42 

14 U.S.C. 1395kk(e)), a qualified entity may use data 

15 received by such entity under such section, and in16 formation derived from the evaluation described in 

17 such paragraph (4)(D), for additional analyses (as 

18 determined appropriate by the Secretary of Health 

19 and Human Services) that such entity may provide 

20 or sell to providers of services and suppliers (includ21 ing for the purposes of assisting providers of services 

22 and suppliers to develop and participate in quality 

23 and patient care improvement activities, including 

24 developing new models of care). 

25 (2) DEFINITIONS.—In this section: 

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

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

3 of the Social Security Act (42 U.S.C. 

4 1395kk(e)). 

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

6 services’’ have the meanings given such terms 

7 in subsections (d) and (u), respectively, of sec8 tion 1861 of the Social Security Act (42 U.S.C. 

9 1395x). 

10 (b) ACCESS TO MEDICARE DATA TO PROVIDERS OF

11 SERVICES AND SUPPLIERS TO FACILITATE DEVELOP12 MENT OF ALTERNATIVE PAYMENT MODELS AND TO

13 QUALIFIED CLINICAL DATA REGISTRIES TO FACILITATE

14 QUALITY IMPROVEMENT.—Consistent with applicable 

15 laws and regulations with respect to privacy and other rel16 evant matters, the Secretary shall provide Medicare claims 

17 data for non-public use (in a form and manner determined 

18 to be appropriate) to— 

19 (1) qualified entities, that may share with pro20 viders of services and suppliers that are registered or 

21 authorized users or subscribers, in order to facilitate 

22 the development of new models of care (including de23 velopment of Alternate Payment Models under sec24 tion 1848A of the Social Security Act, models for 

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1 small group specialty practices, and care coordina2 tion models); and 

3 (2) qualified clinical data registries under sec4 tion 1848(m)(3)(E) of the Social Security Act (42 

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

6 such data with clinical outcomes data and per7 forming analysis and research to support quality im8 provement. 

9 SEC. 4. ENCOURAGING CARE COORDINATION AND MED10 ICAL HOMES. 

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

12 1395w–4(b)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(8) ENCOURAGING CARE COORDINATION AND

15 MEDICAL HOMES.— 

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

17 the coordination of care by an applicable physi18 cian (as defined in subparagraph (B)) for indi19 viduals with complex chronic care needs who 

20 are furnished items and services by multiple 

21 physicians and other suppliers and providers of 

22 services, the Secretary shall— 

23 ‘‘(i) develop one or more HCPCS 

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1 ment services for individuals with complex 

2 chronic care needs; and 

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

4 after January 1, 2015, by an applicable 

5 physician, make payment (as the Secretary 

6 determines to be appropriate) under the 

7 fee schedule under this section using such 

8 HCPCS codes. 

9 ‘‘(B) APPLICABLE PHYSICIAN DEFINED.— 

10 For purposes of this paragraph, the term ‘ap11 plicable physician’ means a physician (as de12 fined in section 1861(r)(1)) who— 

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

14 achieving an accreditation status of level 3 

15 by the National Committee for Quality As16 surance); 

17 ‘‘(ii) is recognized as a patient-cen18 tered specialty practice by the National 

19 Committee for Quality Assurance; 

20 ‘‘(iii) has received equivalent certifi21 cation (as determined by the Secretary); or 

22 ‘‘(iv) meets such other comparable 

23 qualifications as the Secretary determines 

24 to be appropriate. 

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

2 neutrality provision under subsection 

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

4 payment under subparagraph (A)(ii). 

5 ‘‘(D) SINGLE APPLICABLE PHYSICIAN PAY6 MENT.—In carrying out this paragraph, the 

7 Secretary shall only make payment to a single 

8 applicable physician for complex chronic care 

9 management services furnished to an indi10 vidual.’’. 

11 SEC. 5. MISCELLANEOUS. 

12 (a) SOLICITATIONS, RECOMMENDATIONS, AND RE13 PORTS.— 

14 (1) SOLICITATION FOR RECOMMENDATIONS ON

15 EPISODES OF CARE DEFINITION.—The Adminis16 trator of the Centers for Medicare & Medicaid Serv17 ices shall request eligible professional organizations 

18 (as defined in section 1848(k)(3) of the Social Secu19 rity Act (42 U.S.C. 1395w–4(k)(3))) and other rel20 evant stakeholders to submit recommendations for 

21 defining non-acute related episodes of care for pur22 poses of applying such definition under subsections 

23 (k) and (q) of section 1848 of the Social Security 

24 Act (42 U.S.C. 1395w–4) and section 1848A of such 

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1 Act, as added by subsections (b) and (c) of section 

2 2. 

3 (2) SOLICITATION FOR RECOMMENDATIONS ON

4 PROVIDER FEE SCHEDULE PAYMENT BUNDLES.— 

5 (A) IN GENERAL.—The Administrator of 

6 the Centers for Medicare & Medicaid Services 

7 shall solicit from eligible professional organiza8 tions (as defined in section 1848(k)(3) of the 

9 Social Security Act (42 U.S.C. 1395w–4(k)(3))) 

10 recommendations for payment bundles for 

11 chronic conditions and expensive, high-volume 

12 services for which payment is made under title 

13 XVIII of such Act. 

14 (B) REPORT TO CONGRESS.—Not later 

15 than 24 months after the date of the enactment 

16 of this Act, the Administrator shall submit to 

17 Congress a report proposals for such payment 

18 bundles. 

19 (3) REPORTS ON MODIFIED PFS SYSTEM AND

20 PAYMENT SYSTEM ALTERNATIVES.— 

21 (A) BIANNUAL PROGRESS REPORTS.—Not 

22 later than January 15, 2016, and annually 

23 thereafter, the Secretary of Health and Human 

24 Services shall submit to Congress and post on 

25 the public Internet website of the Centers for 

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1 Medicare & Medicaid Services a biannual 

2 progress report— 

3 (i) on the implementation of para4 graph (9) of section 1848(k) of the Social 

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

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

7 update incentive program under subsection 

8 (q) of section 1848 of the Social Security 

9 Act (42 U.S.C. 1395w–4), as added by sec10 tion 2(b)(3); 

11 (ii) that includes an evaluation of 

12 such paragraph and such quality update 

13 incentive program and recommendations 

14 with respect to such program and appro15 priate update mechanisms; and 

16 (iii) on the actions taken to promote 

17 and fulfill the identification of eligible 

18 APMs under section 1848A of the Social 

19 Security Act, as added by section 2(c), for 

20 application under such section 1848A. 

21 (B) GAO AND MEDPAC REPORTS.— 

22 (i) GAO REPORT ON INITIAL STAGES

23 OF PROGRAM.—The Comptroller General 

24 of the United States shall submit to Con25 gress a report analyzing the extent to 

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1 which the system under section 1848(k)(9) 

2 of the Social Security Act (42 U.S.C. 

3 1395w–4(k)(9)) and such quality update 

4 incentive program under section 1848(q) of 

5 the Social Security Act, as added by sec6 tion 2(b), as of such date, is successfully 

7 satisfying performance objectives, including 

8 with respect to— 

9 (I) the process for developing and 

10 selecting measures and activities 

11 under subsection (k)(9) of section 

12 1848 of such Act (42 U.S.C. 1395w– 

13 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 meas19 ures and activities so selected. 

20 (ii) EVALUATION BY GAO AND

21 MEDPAC ON IMPLEMENTATION OF QUALITY

22 UPDATE INCENTIVE PROGRAM.— 

23 (I) GAO.—The Comptroller Gen24 eral of the United States shall evalu25 ate the initial phase of the quality upmstockstill on DSK4VPTVN1PROD with BILLS

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1 date incentive program under sub2 section (q) of section 1848 of the So3 cial Security Act (42 U.S.C. 1395w– 

4 4) and shall submit to Congress, not 

5 later than 2019, a report with rec6 ommendations for improving such 

7 quality update incentive program. 

8 (II) MEDPAC.—In the course of 

9 its March Report to Congress on 

10 Medicare payment policy, MedPAC 

11 shall analyze the initial phase of such 

12 quality 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. 

25 1395w–4). In analyzing such models, 

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1 the Medicare Payment Advisory Com2 mission 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 

9 payments for certain conditions 

10 and 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

20 AND ACCESS.—Beginning in 2015, the Chief 

21 Actuary of the Centers for Medicare & Medicaid 

22 Services shall track expenditure growth and 

23 beneficiary access to physicians’ services under 

24 section 1848 of the Social Security Act (42 

25 U.S.C. 1395w–4) and shall post on the public 

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1 Internet website of the Centers for Medicare & 

2 Medicaid Services annual reports on such top3 ics. 

4 (b) RELATIVE VALUES UNDER THE MEDICARE PHY5 SICIAN FEE SCHEDULE.— 

6 (1) ELIGIBLE PHYSICIANS REPORTING SYSTEM

7 TO IMPROVE ACCURACY OF RELATIVE VALUES.—Sec8 tion 1848(c) of the Social Security Act (42 U.S.C. 

9 1395w–4(c)) is amended by adding at the end the 

10 following new paragraph: 

11 ‘‘(8) PHYSICIAN REPORTING SYSTEM TO IM12 PROVE ACCURACY OF RELATIVE VALUES.— 

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

14 implement a system for the periodic reporting 

15 by physicians of data on the accuracy of relative 

16 values under this subsection, such as data relat17 ing to service volume and time. Such data shall 

18 be submitted in a form and manner specified by 

19 the Secretary and shall, as appropriate, incor20 porate data from existing sources of data, pa21 tient scheduling systems, cost accounting sys22 tems, and other similar systems. 

23 ‘‘(B) IDENTIFICATION OF REPORTING CO24 HORT.—Not later than January 1, 2015, the 

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1 cians to participate under the reporting system 

2 under this paragraph, all of whom shall collec3 tively be referred to under this paragraph as 

4 the ‘reporting group’. The reporting group shall 

5 include physicians across settings that collec6 tively represent a range of specialties and prac7 titioner types, furnish a range of physicians’ 

8 services, and serve a range of patient popu9 lations. 

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

11 system under this paragraph, the Secretary 

12 may provide for such payments under this part 

13 to physicians included in the reporting group as 

14 the Secretary determines appropriate to com15 pensate such physicians for reporting data 

16 under the system. Such payments shall be pro17 vided in such form and manner as specified by 

18 the Secretary. In carrying out this subpara19 graph, reporting by such a physician under this 

20 paragraph shall not be treated as the furnishing 

21 of physicians’ services for purposes of applying 

22 this section. 

23 ‘‘(D) FUNDING.—To carry out this para24 graph (other than with respect to payments 

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

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1 funds otherwise appropriated, the Secretary 

2 shall provide for the transfer from the Federal 

3 Supplementary Medical Insurance Trust Fund 

4 under section 1841 of $1,000,000 to the Cen5 ters for Medicare & Medicaid Services Program 

6 Management Account for each fiscal year begin7 ning with fiscal year 2014. Amounts trans8 ferred under this subparagraph for a fiscal year 

9 shall be available until expended.’’. 

10 (2) RELATIVE VALUE ADJUSTMENTS FOR

11 MISVALUED PHYSICIANS’ SERVICES.— 

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

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

14 4(c)(2)) is amended by adding at the end the 

15 following new subparagraph: 

16 ‘‘(M) ADJUSTMENTS FOR MISVALUED PHY17 SICIANS’ SERVICES.—With respect to fee sched18 ules established for 2016, 2017, and 2018, the 

19 Secretary shall— 

20 ‘‘(i) identify, based on the data re21 ported under paragraph (8) and other rel22 evant data, misvalued services for which 

23 adjustments to the relative values estab24 lished under this paragraph would result in 

25 a net reduction in expenditures under the 

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1 fee schedule under this section, with re2 spect to such year, of not more than 1 per3 cent of the projected amount of expendi4 tures under such fee schedule for such 

5 year; and 

6 ‘‘(ii) make such adjustments for each 

7 such year so as to result in such a net re8 duction for such year.’’. 

9 (B) BUDGET NEUTRALITY.—Section 

10 1848(c)(2)(B)(v) of the Social Security Act (42 

11 U.S.C. 1395w–4(c)(2)(B)(v)) is amended by 

12 adding at the end the following new subclause: 

13 ‘‘(VIII) REDUCTIONS FOR

14 MISVALUED PHYSICIANS’ SERVICES.— 

15 Reduced expenditures attributable to 

16 subparagraph (M).’’. 

17 (c) RULE OF CONSTRUCTION REGARDING HEALTH

18 CARE PROVIDER STANDARDS OF CARE.— 

19 (1) IN GENERAL.—The development, recogni20 tion, or implementation of any guideline or other 

21 standard under any Federal health care provision 

22 shall not be construed to establish the standard of 

23 care or duty of care owed by a health care provider 

24 to a patient in any medical malpractice or medical 

25 product liability action or claim. 

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1 (2) DEFINITIONS.—For purposes of this sub2 section: 

3 (A) The term ‘‘Federal health care provi4 sion’’ means any provision of the Patient Pro5 tection and Affordable Care Act (Public Law 

6 111–148), title I and subtitle B of title III of 

7 the Health Care and Education Reconciliation 

8 Act of 2010 (Public Law 111–152), and titles 

9 XVIII and XIX of the Social Security Act. 

10 (B) The term ‘‘health care provider’’ 

11 means any individual or entity— 

12 (i) licensed, registered, or certified 

13 under Federal or State laws or regulations 

14 to provide health care services; or 

15 (ii) required to be so licensed, reg16 istered, or certified but that is exempted 

17 by other statute or regulation. 

18 (C) The term ‘‘medical malpractice or 

19 medical liability action or claim’’ means a med20 ical malpractice action or claim (as defined in 

21 section 431(7) of the Health Care Quality Im22 provement Act of 1986 (42 U.S.C. 11151(7))) 

23 and includes a liability action or claim relating 

24 to a health care provider’s prescription or provi25 sion of a drug, device, or biological product (as 

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1 such terms are defined in section 201 of the 

2 Federal Food, Drug, and Cosmetic Act or sec3 tion 351 of the Public Health Service Act). 

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

5 of Columbia, Puerto Rico, and any other com6 monwealth, possession, or territory of the 

7 United States. 

8 (3) NO PREEMPTION.—No provision of the Pa9 tient Protection and Affordable Care Act (Public 

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

11 Health Care and Education Reconciliation Act of 

12 2010 (Public Law 111–152), or title XVIII or XIX 

13 of the Social Security Act shall be construed to pre14 empt any State or common law governing medical 

15 professional or medical product liability actions or 

16 claims. 

Æ 

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