II 

113TH CONGRESS 

2D SESSION H. R. 4015 

IN THE SENATE OF THE UNITED STATES 

MARCH 24, 2014 

Received 

AN ACT 

To amend title XVIII of the Social Security Act to repeal 

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

and for other purposes. 

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


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

3 ‘‘SGR Repeal and Medicare Provider Payment Moderniza4 tion Act of 2014’’. 

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

6 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 measure development. 

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

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

Sec. 6. Promoting evidence-based care. 

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

Sec. 8. Expanding availability of Medicare data. 

Sec. 9. Reducing administrative burden and other provisions. 

Sec. 10. Delay in implementation of penalty for failure to comply with individual health insurance mandate. 

7 SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE 

8 (SGR) AND IMPROVING MEDICARE PAYMENT 

9 FOR PHYSICIANS’ SERVICES. 

10 (a) STABILIZING FEE UPDATES.— 

11 (1) REPEAL OF SGR PAYMENT METHOD12 OLOGY.—Section 1848 of the Social Security Act 

13 (42 U.S.C. 1395w–4) is amended— 

14 (A) in subsection (d)— 

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

16 ‘‘or a subsequent paragraph’’ after ‘‘para17 graph (4)’’; and 

18 (ii) in paragraph (4)— 


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1 (I) in the heading, by inserting 

2 ‘‘AND ENDING WITH 2013’’ after 

3 ‘‘YEARS BEGINNING WITH 2001’’; and 

4 (II) in subparagraph (A), by in5 serting ‘‘and ending with 2013’’ after 

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

7 (B) in subsection (f)— 

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

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

10 year’’; and 

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

12 preceding subparagraph (A), by inserting 

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

14 with 2000’’. 

15 (2) UPDATE OF RATES FOR APRIL THROUGH

16 DECEMBER OF 2014, 2015, AND SUBSEQUENT

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

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

19 striking paragraph (15) and inserting the following 

20 new paragraphs: 

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

22 update to the single conversion factor established in 

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

24 year through 2018 shall be 0.5 percent. 


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

2 update to the single conversion factor established in 

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

4 year through 2023 shall be zero percent. 

5 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

6 YEARS.—The update to the single conversion factor 

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

8 subsequent year shall be— 

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

10 qualifying APM participant (as defined in sec11 tion 1833(z)(2)) for such year, 1.0 percent; and 

12 ‘‘(B) for other items and services, 0.5 per13 cent.’’. 

14 (3) MEDPAC REPORTS.— 

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

16 1, 2016, the Medicare Payment Advisory Com17 mission shall submit to Congress a report on 

18 the relationship between— 

19 (i) physician and other health profes20 sional utilization and expenditures (and the 

21 rate of increase of such utilization and ex22 penditures) of items and services for which 

23 payment is made under section 1848 of the 

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

25 and 


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1 (ii) total utilization and expenditures 

2 (and the rate of increase of such utilization 

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

4 of title XVIII of such Act. 

5 Such report shall include a methodology to de6 scribe such relationship and the impact of 

7 changes in such physician and other health pro8 fessional practice and service ordering patterns 

9 on total utilization and expenditures under 

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

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

12 1, 2020, the Medicare Payment Advisory Com13 mission shall submit to Congress a report on 

14 the relationship described in subparagraph (A), 

15 including the results determined from applying 

16 the methodology included in the report sub17 mitted under such subparagraph. 

18 (C) REPORT ON UPDATE TO PHYSICIANS’ 

19 SERVICES UNDER MEDICARE.—Not later than 

20 July 1, 2018, the Medicare Payment Advisory 

21 Commission shall submit to Congress a report 

22 on— 

23 (i) the payment update for profes24 sional services applied under the Medicare 

25 program under title XVIII of the Social 


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1 Security Act for the period of years 2014 

2 through 2018; 

3 (ii) the effect of such update on the 

4 efficiency, economy, and quality of care 

5 provided under such program; 

6 (iii) the effect of such update on en7 suring a sufficient number of providers to 

8 maintain access to care by Medicare bene9 ficiaries; and 

10 (iv) recommendations for any future 

11 payment updates for professional services 

12 under such program to ensure adequate 

13 access to care is maintained for Medicare 

14 beneficiaries. 

15 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

16 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN17 CENTIVE PAYMENT SYSTEM.— 

18 (1) EHR MEANINGFUL USE INCENTIVE PRO19 GRAM.— 

20 (A) SUNSETTING SEPARATE MEANINGFUL

21 USE PAYMENT ADJUSTMENTS.—Section 

22 1848(a)(7)(A) of the Social Security Act (42 

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


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

2 subsequent payment year’’ and inserting 

3 ‘‘or 2017’’; 

4 (ii) in clause (ii)— 

5 (I) in the matter preceding sub6 clause (I), by striking ‘‘Subject to 

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

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

9 at the end ‘‘and’’; 

10 (III) in subclause (II), by strik11 ing ‘‘; and’’ and inserting a period; 

12 and 

13 (IV) by striking subclause (III); 

14 and 

15 (iii) by striking clause (iii). 

16 (B) CONTINUATION OF MEANINGFUL USE

17 DETERMINATIONS FOR MIPS.—Section 

18 1848(o)(2) of the Social Security Act (42 

19 U.S.C. 1395w–4(o)(2)) is amended— 

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

21 preceding clause (i)— 

22 (I) by striking ‘‘For purposes of 

23 paragraph (1), an’’ and inserting 

24 ‘‘An’’; and 


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1 (II) by inserting ‘‘, or pursuant 

2 to subparagraph (D) for purposes of 

3 subsection (q), for a performance pe4 riod under such subsection for a year’’ 

5 after ‘‘under such subsection for a 

6 year’’; and 

7 (ii) by adding at the end the following 

8 new subparagraph: 

9 ‘‘(D) CONTINUED APPLICATION FOR PUR10 POSES OF MIPS.—With respect to 2018 and 

11 each subsequent payment year, the Secretary 

12 shall, for purposes of subsection (q) and in ac13 cordance with paragraph (1)(F) of such sub14 section, determine whether an eligible profes15 sional who is a MIPS eligible professional (as 

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

17 a meaningful EHR user under this paragraph 

18 for the performance period under subsection (q) 

19 for such year.’’. 

20 (2) QUALITY REPORTING.— 

21 (A) SUNSETTING SEPARATE QUALITY RE22 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

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

24 4(a)(8)(A)) is amended— 


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

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

3 and 

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

5 each subsequent year’’. 

6 (B) CONTINUATION OF QUALITY MEAS7 URES AND PROCESSES FOR MIPS.—Section 

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

9 1395w–4) is amended— 

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

11 end the following new paragraph: 

12 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

13 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN14 TEERING TO REPORT.—The Secretary shall, in ac15 cordance with subsection (q)(1)(F), carry out the 

16 provisions of this subsection— 

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

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

19 MIPS eligible professionals (as defined in sub20 section (q)(1)(C)) for the year involved.’’; and 

21 (ii) in subsection (m)— 

22 (I) by redesignating paragraph 

23 (7) added by section 10327(a) of Pub24 lic Law 111–148 as paragraph (8); 

25 and 


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1 (II) by adding at the end the fol2 lowing new paragraph: 

3 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

4 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN5 TEERING TO REPORT.—The Secretary shall, in ac6 cordance with subsection (q)(1)(F), carry out the 

7 processes under this subsection— 

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

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

10 MIPS eligible professionals (as defined in sub11 section (q)(1)(C)) for the year involved.’’. 

12 (3) VALUE-BASED PAYMENTS.— 

13 (A) SUNSETTING SEPARATE VALUE-BASED

14 PAYMENTS.—Clause (iii) of section 

15 1848(p)(4)(B) of the Social Security Act (42 

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

17 as follows: 

18 ‘‘(iii) APPLICATION.—The Secretary 

19 shall apply the payment modifier estab20 lished under this subsection for items and 

21 services furnished on or after January 1, 

22 2015, but before January 1, 2018, with re23 spect to specific physicians and groups of 

24 physicians the Secretary determines appro25 priate. Such payment modifier shall not be 


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1 applied for items and services furnished on 

2 or after January 1, 2018.’’. 

3 (B) CONTINUATION OF VALUE-BASED PAY4 MENT MODIFIER MEASURES FOR MIPS.—Section 

5 1848(p) of the Social Security Act (42 U.S.C. 

6 1395w–4(p)) is amended— 

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

8 end the following new subparagraph: 

9 ‘‘(C) CONTINUED APPLICATION FOR PUR10 POSES OF MIPS.—The Secretary shall, in ac11 cordance with subsection (q)(1)(F), carry out 

12 subparagraph (B) for purposes of subsection 

13 (q).’’; and 

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

15 end the following: ‘‘With respect to 2018 

16 and each subsequent year, the Secretary 

17 shall, in accordance with subsection 

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

19 purposes of subsection (q).’’. 

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

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

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

23 adding at the end the following new subsection: 

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

25 ‘‘(1) ESTABLISHMENT.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this subsection, the Sec3 retary shall establish an eligible professional 

4 Merit-based Incentive Payment System (in this 

5 subsection referred to as the ‘MIPS’) under 

6 which the Secretary shall— 

7 ‘‘(i) develop a methodology for assess8 ing the total performance of each MIPS el9 igible professional according to perform10 ance standards under paragraph (3) for a 

11 performance period (as established under 

12 paragraph (4)) for a year; 

13 ‘‘(ii) using such methodology, provide 

14 for a composite performance score in ac15 cordance with paragraph (5) for each such 

16 professional for each performance period; 

17 and 

18 ‘‘(iii) use such composite performance 

19 score of the MIPS eligible professional for 

20 a performance period for a year to deter21 mine and apply a MIPS adjustment factor 

22 (and, as applicable, an additional MIPS 

23 adjustment factor) under paragraph (6) to 

24 the professional for the year. 


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1 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

2 MIPS shall apply to payments for items and 

3 services furnished on or after January 1, 2018. 

4 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE5 FINED.— 

6 ‘‘(i) IN GENERAL.—For purposes of 

7 this subsection, subject to clauses (ii) and 

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

9 means— 

10 ‘‘(I) for the first and second 

11 years for which the MIPS applies to 

12 payments (and for the performance 

13 period for such first and second year), 

14 a physician (as defined in section 

15 1861(r)), a physician assistant, nurse 

16 practitioner, and clinical nurse spe17 cialist (as such terms are defined in 

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

19 registered nurse anesthetist (as de20 fined in section 1861(bb)(2)) and a 

21 group that includes such profes22 sionals; and 

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

24 the MIPS applies to payments (and 

25 for the performance period for such 


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1 third year) and for each succeeding 

2 year (and for the performance period 

3 for each such year), the professionals 

4 described in subclause (I) and such 

5 other eligible professionals (as defined 

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

7 by the Secretary and a group that in8 cludes such professionals. 

9 ‘‘(ii) EXCLUSIONS.—For purposes of 

10 clause (i), the term ‘MIPS eligible profes11 sional’ does not include, with respect to a 

12 year, an eligible professional (as defined in 

13 subsection (k)(3)(B)) who— 

14 ‘‘(I) is a qualifying APM partici15 pant (as defined in section 

16 1833(z)(2)); 

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

18 partial qualifying APM participant (as 

19 defined in clause (iii)) for the most re20 cent period for which data are avail21 able and who, for the performance pe22 riod with respect to such year, does 

23 not report on applicable measures and 

24 activities described in paragraph 

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1 ported by such a professional under 

2 the MIPS; or 

3 ‘‘(III) for the performance period 

4 with respect to such year, does not ex5 ceed the low-volume threshold meas6 urement selected under clause (iv). 

7 ‘‘(iii) PARTIAL QUALIFYING APM PAR8 TICIPANT.—For purposes of this subpara9 graph, the term ‘partial qualifying APM 

10 participant’ means, with respect to a year, 

11 an eligible professional for whom the Sec12 retary determines the minimum payment 

13 percentage (or percentages), as applicable, 

14 described in paragraph (2) of section 

15 1833(z) for such year have not been satis16 fied, but who would be considered a quali17 fying APM participant (as defined in such 

18 paragraph) for such year if— 

19 ‘‘(I) with respect to 2018 and 

20 2019, the reference in subparagraph 

21 (A) of such paragraph to 25 percent 

22 was instead a reference to 20 percent; 

23 ‘‘(II) with respect to 2020 and 

24 2021— 


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1 ‘‘(aa) the reference in sub2 paragraph (B)(i) of such para3 graph to 50 percent was instead 

4 a reference to 40 percent; and 

5 ‘‘(bb) the references in sub6 paragraph (B)(ii) of such para7 graph to 50 percent and 25 per8 cent of such paragraph were in9 stead references to 40 percent 

10 and 20 percent, respectively; and 

11 ‘‘(III) with respect to 2022 and 

12 subsequent years— 

13 ‘‘(aa) the reference in sub14 paragraph (C)(i) of such para15 graph to 75 percent was instead 

16 a reference to 50 percent; and 

17 ‘‘(bb) the references in sub18 paragraph (C)(ii) of such para19 graph to 75 percent and 25 per20 cent of such paragraph were in21 stead references to 50 percent 

22 and 20 percent, respectively. 

23 ‘‘(iv) SELECTION OF LOW-VOLUME

24 THRESHOLD MEASUREMENT.—The Sec25 retary shall select a low-volume threshold 


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

2 which may include one or more or a com3 bination of the following: 

4 ‘‘(I) The minimum number (as 

5 determined by the Secretary) of indi6 viduals enrolled under this part who 

7 are treated by the eligible professional 

8 for the performance period involved. 

9 ‘‘(II) The minimum number (as 

10 determined by the Secretary) of items 

11 and services furnished to individuals 

12 enrolled under this part by such pro13 fessional for such performance period. 

14 ‘‘(III) The minimum amount (as 

15 determined by the Secretary) of al16 lowed charges billed by such profes17 sional under this part for such per18 formance period. 

19 ‘‘(v) TREATMENT OF NEW MEDICARE

20 ENROLLED ELIGIBLE PROFESSIONALS.—In 

21 the case of a professional who first be22 comes a Medicare enrolled eligible profes23 sional during the performance period for a 

24 year (and had not previously submitted 

25 claims under this title such as a person, an 


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1 entity, or a part of a physician group or 

2 under a different billing number or tax 

3 identifier), such professional shall not be 

4 treated under this subsection as a MIPS 

5 eligible professional until the subsequent 

6 year and performance period for such sub7 sequent year. 

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

9 items and services furnished during a year 

10 by an individual who is not a MIPS eligible 

11 professional (including pursuant to clauses 

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

13 case shall a MIPS adjustment factor (or 

14 additional MIPS adjustment factor) under 

15 paragraph (6) apply to such individual for 

16 such year. 

17 ‘‘(vii) PARTIAL QUALIFYING APM PAR18 TICIPANT CLARIFICATIONS.— 

19 ‘‘(I) TREATMENT AS MIPS ELIGI20 BLE PROFESSIONAL.—In the case of 

21 an eligible professional who is a par22 tial qualifying APM participant, with 

23 respect to a year, and who for the 

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1 tivities described in paragraph (2)(B) 

2 that are required to be reported by 

3 such a professional under the MIPS, 

4 such eligible professional is considered 

5 to be a MIPS eligible professional 

6 with respect to such year. 

7 ‘‘(II) NOT ELIGIBLE FOR QUALI8 FYING APM PARTICIPANT PAY9 MENTS.—In no case shall an eligible 

10 professional who is a partial quali11 fying APM participant, with respect 

12 to a year, be considered a qualifying 

13 APM participant (as defined in para14 graph (2) of section 1833(z)) for such 

15 year or be eligible for the additional 

16 payment under paragraph (1) of such 

17 section for such year. 

18 ‘‘(D) APPLICATION TO GROUP PRAC19 TICES.— 

20 ‘‘(i) IN GENERAL.—Under the MIPS: 

21 ‘‘(I) QUALITY PERFORMANCE

22 CATEGORY.—The Secretary shall es23 tablish and apply a process that in24 cludes features of the provisions of 

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1 ble professionals in a group practice 

2 with respect to assessing performance 

3 of such group with respect to the per4 formance category described in clause 

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

6 ‘‘(II) OTHER PERFORMANCE CAT7 EGORIES.—The Secretary may estab8 lish and apply a process that includes 

9 features of the provisions of sub10 section (m)(3)(C) for MIPS eligible 

11 professionals in a group practice with 

12 respect to assessing the performance 

13 of such group with respect to the per14 formance categories described in 

15 clauses (ii) through (iv) of such para16 graph. 

17 ‘‘(ii) ENSURING COMPREHENSIVENESS

18 OF GROUP PRACTICE ASSESSMENT.—The 

19 process established under clause (i) shall to 

20 the extent practicable reflect the range of 

21 items and services furnished by the MIPS 

22 eligible professionals in the group practice 

23 involved. 

24 ‘‘(iii) CLARIFICATION.—MIPS eligible 

25 professionals electing to be a virtual group 


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1 under paragraph (5)(I) shall not be consid2 ered MIPS eligible professionals in a group 

3 practice for purposes of applying this sub4 paragraph. 

5 ‘‘(E) USE OF REGISTRIES.—Under the 

6 MIPS, the Secretary shall encourage the use of 

7 qualified clinical data registries pursuant to 

8 subsection (m)(3)(E) in carrying out this sub9 section. 

10 ‘‘(F) APPLICATION OF CERTAIN PROVI11 SIONS.—In applying a provision of subsection 

12 (k), (m), (o), or (p) for purposes of this sub13 section, the Secretary shall— 

14 ‘‘(i) adjust the application of such 

15 provision to ensure the provision is con16 sistent with the provisions of this sub17 section; and 

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

19 extent that the provision is duplicative with 

20 a provision of this subsection. 

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

22 ‘‘(i) RISK FACTORS.—Taking into ac23 count the relevant studies conducted and 

24 recommendations made in reports under 

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


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1 Medicare Provider Payment Modernization 

2 Act of 2014, the Secretary, on an ongoing 

3 basis, shall estimate how an individual’s 

4 health status and other risk factors affect 

5 quality and resource use outcome measures 

6 and, as feasible, shall incorporate informa7 tion from quality and resource use outcome 

8 measurement (including care episode and 

9 patient condition groups) into the MIPS. 

10 ‘‘(ii) ACCOUNTING FOR OTHER FAC11 TORS IN PAYMENT ADJUSTMENTS.—Tak12 ing into account the studies conducted and 

13 recommendations made in reports under 

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

15 Medicare Provider Payment Modernization 

16 Act of 2014 and other information as ap17 propriate, the Secretary shall account for 

18 identified factors with an effect on quality 

19 and resource use outcome measures when 

20 determining payment adjustments, com21 posite performance scores, scores for per22 formance categories, or scores for meas23 ures or activities under the MIPS. 

24 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER25 FORMANCE CATEGORIES.— 


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1 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

2 the MIPS, the Secretary shall use the following 

3 performance categories (each of which is re4 ferred to in this subsection as a performance 

5 category) in determining the composite per6 formance score under paragraph (5): 

7 ‘‘(i) Quality. 

8 ‘‘(ii) Resource use. 

9 ‘‘(iii) Clinical practice improvement 

10 activities. 

11 ‘‘(iv) Meaningful use of certified EHR 

12 technology. 

13 ‘‘(B) MEASURES AND ACTIVITIES SPECI14 FIED FOR EACH CATEGORY.—For purposes of 

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

16 (C), measures and activities specified for a per17 formance period (as established under para18 graph (4)) for a year are as follows: 

19 ‘‘(i) QUALITY.—For the performance 

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

21 the quality measures included in the final 

22 measures list published under subpara23 graph (D)(i) for such year and the list of 

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1 graph (D)(vi) used by qualified clinical 

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

3 ‘‘(ii) RESOURCE USE.—For the per4 formance category described in subpara5 graph (A)(ii), the measurement of resource 

6 use for such period under subsection 

7 (p)(3), using the methodology under sub8 section (r) as appropriate, and, as feasible 

9 and applicable, accounting for the cost of 

10 drugs under part D. 

11 ‘‘(iii) CLINICAL PRACTICE IMPROVE12 MENT ACTIVITIES.—For the performance 

13 category described in subparagraph 

14 (A)(iii), clinical practice improvement ac15 tivities (as defined in subparagraph 

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

17 by the Secretary for such period, which 

18 shall include at least the following: 

19 ‘‘(I) The subcategory of expanded 

20 practice access, which shall include ac21 tivities such as same day appoint22 ments for urgent needs and after 

23 hours access to clinician advice. 

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1 clude activities such as monitoring 

2 health conditions of individuals to pro3 vide timely health care interventions 

4 or participation in a qualified clinical 

5 data registry. 

6 ‘‘(III) The subcategory of care 

7 coordination, which shall include ac8 tivities such as timely communication 

9 of test results, timely exchange of 

10 clinical information to patients and 

11 other providers, and use of remote 

12 monitoring or telehealth. 

13 ‘‘(IV) The subcategory of bene14 ficiary engagement, which shall in15 clude activities such as the establish16 ment of care plans for individuals 

17 with complex care needs, beneficiary 

18 self-management assessment and 

19 training, and using shared decision20 making mechanisms. 

21 ‘‘(V) The subcategory of patient 

22 safety and practice assessment, such 

23 as through use of clinical or surgical 

24 checklists and practice assessments 

25 related to maintaining certification. 


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1 ‘‘(VI) The subcategory of partici2 pation in an alternative payment 

3 model (as defined in section 

4 1833(z)(3)(C)). 

5 In establishing activities under this clause, 

6 the Secretary shall give consideration to 

7 the circumstances of small practices (con8 sisting of 15 or fewer professionals) and 

9 practices located in rural areas and in 

10 health professional shortage areas (as des11 ignated under section 332(a)(1)(A) of the 

12 Public Health Service Act). 

13 ‘‘(iv) MEANINGFUL EHR USE.—For 

14 the performance category described in sub15 paragraph (A)(iv), the requirements estab16 lished for such period under subsection 

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

18 professional is a meaningful EHR user. 

19 ‘‘(C) ADDITIONAL PROVISIONS.— 

20 ‘‘(i) EMPHASIZING OUTCOME MEAS21 URES UNDER THE QUALITY PERFORMANCE

22 CATEGORY.—In applying subparagraph 

23 (B)(i), the Secretary shall, as feasible, em24 phasize the application of outcome meas25 ures. 


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1 ‘‘(ii) APPLICATION OF ADDITIONAL

2 SYSTEM MEASURES.—The Secretary may 

3 use measures used for a payment system 

4 other than for physicians, such as meas5 ures for inpatient hospitals, for purposes of 

6 the performance categories described in 

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

8 For purposes of the previous sentence, the 

9 Secretary may not use measures for hos10 pital outpatient departments, except in the 

11 case of emergency physicians. 

12 ‘‘(iii) GLOBAL AND POPULATION13 BASED MEASURES.—The Secretary may 

14 use global measures, such as global out15 come measures, and population-based 

16 measures for purposes of the performance 

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

18 ‘‘(iv) APPLICATION OF MEASURES AND

19 ACTIVITIES TO NON-PATIENT-FACING PRO20 FESSIONALS.—In carrying out this para21 graph, with respect to measures and activi22 ties specified in subparagraph (B) for per23 formance categories described in subpara24 graph (A), the Secretary— 


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1 ‘‘(I) shall give consideration to 

2 the circumstances of professional 

3 types (or subcategories of those types 

4 determined by practice characteris5 tics) who typically furnish services 

6 that do not involve face-to-face inter7 action with a patient; and 

8 ‘‘(II) may, to the extent feasible 

9 and appropriate, take into account 

10 such circumstances and apply under 

11 this subsection with respect to MIPS 

12 eligible professionals of such profes13 sional types or subcategories, alter14 native measures or activities that ful15 fill the goals of the applicable per16 formance category. 

17 In carrying out the previous sentence, the 

18 Secretary shall consult with professionals 

19 of such professional types or subcategories. 

20 ‘‘(v) CLINICAL PRACTICE IMPROVE21 MENT ACTIVITIES.— 

22 ‘‘(I) REQUEST FOR INFORMA23 TION.—In initially applying subpara24 graph (B)(iii), the Secretary shall use 

25 a request for information to solicit 


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1 recommendations from stakeholders to 

2 identify activities described in such 

3 subparagraph and specifying criteria 

4 for such activities. 

5 ‘‘(II) CONTRACT AUTHORITY FOR

6 CLINICAL PRACTICE IMPROVEMENT

7 ACTIVITIES PERFORMANCE CAT8 EGORY.—In applying subparagraph 

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

10 with entities to assist the Secretary 

11 in— 

12 ‘‘(aa) identifying activities 

13 described in subparagraph 

14 (B)(iii); 

15 ‘‘(bb) specifying criteria for 

16 such activities; and 

17 ‘‘(cc) determining whether a 

18 MIPS eligible professional meets 

19 such criteria. 

20 ‘‘(III) CLINICAL PRACTICE IM21 PROVEMENT ACTIVITIES DEFINED.— 

22 For purposes of this subsection, the 

23 term ‘clinical practice improvement 

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1 tions and other relevant stakeholders 

2 identify as improving clinical practice 

3 or care delivery and that the Sec4 retary determines, when effectively ex5 ecuted, is likely to result in improved 

6 outcomes. 

7 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

8 AVAILABLE FOR MIPS ASSESSMENT.— 

9 ‘‘(i) IN GENERAL.—Under the MIPS, 

10 the Secretary, through notice and comment 

11 rulemaking and subject to the succeeding 

12 clauses of this subparagraph, shall, with 

13 respect to the performance period for a 

14 year, establish an annual final list of qual15 ity measures from which MIPS eligible 

16 professionals may choose for purposes of 

17 assessment under this subsection for such 

18 performance period. Pursuant to the pre19 vious sentence, the Secretary shall— 

20 ‘‘(I) not later than November 1 

21 of the year prior to the first day of 

22 the first performance period under the 

23 MIPS, establish and publish in the 

24 Federal Register a final list of quality 

25 measures; and 


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1 ‘‘(II) not later than November 1 

2 of the year prior to the first day of 

3 each subsequent performance period, 

4 update the final list of quality meas5 ures from the previous year (and pub6 lish such updated final list in the Fed7 eral Register), by— 

8 ‘‘(aa) removing from such 

9 list, as appropriate, quality meas10 ures, which may include the re11 moval of measures that are no 

12 longer meaningful (such as meas13 ures that are topped out); 

14 ‘‘(bb) adding to such list, as 

15 appropriate, new quality meas16 ures; and 

17 ‘‘(cc) determining whether 

18 or not quality measures on such 

19 list that have undergone sub20 stantive changes should be in21 cluded in the updated list. 

22 ‘‘(ii) CALL FOR QUALITY MEAS23 URES.— 

24 ‘‘(I) IN GENERAL.—Eligible pro25 fessional organizations and other relVerDate Sep 11 2014 23:48 Dec 17, 2014 Jkt 049200 PO 00000 Frm 00031 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.RDS H4015

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1 evant stakeholders shall be requested 

2 to identify and submit quality meas3 ures to be considered for selection 

4 under this subparagraph in the an5 nual list of quality measures published 

6 under clause (i) and to identify and 

7 submit updates to the measures on 

8 such list. For purposes of the previous 

9 sentence, measures may be submitted 

10 regardless of whether such measures 

11 were previously published in a pro12 posed rule or endorsed by an entity 

13 with a contract under section 1890(a). 

14 ‘‘(II) ELIGIBLE PROFESSIONAL

15 ORGANIZATION DEFINED.—In this 

16 subparagraph, the term ‘eligible pro17 fessional organization’ means a pro18 fessional organization as defined by 

19 nationally recognized multispecialty 

20 boards of certification or equivalent 

21 certification boards. 

22 ‘‘(iii) REQUIREMENTS.—In selecting 

23 quality measures for inclusion in the an24 nual final list under clause (i), the Sec25 retary shall— 


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1 ‘‘(I) provide that, to the extent 

2 practicable, all quality domains (as 

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

4 addressed by such measures; and 

5 ‘‘(II) ensure that such selection 

6 is consistent with the process for se7 lection of measures under subsections 

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

9 ‘‘(iv) PEER REVIEW.—Before includ10 ing a new measure or a measure described 

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

12 measures published under clause (i) for a 

13 year, the Secretary shall submit for publi14 cation in applicable specialty-appropriate 

15 peer-reviewed journals such measure and 

16 the method for developing and selecting 

17 such measure, including clinical and other 

18 data supporting such measure. 

19 ‘‘(v) MEASURES FOR INCLUSION.— 

20 The final list of quality measures published 

21 under clause (i) shall include, as applica22 ble, measures under subsections (k), (m), 

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

24 from among— 


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1 ‘‘(I) measures endorsed by a con2 sensus-based entity; 

3 ‘‘(II) measures developed under 

4 subsection (s); and 

5 ‘‘(III) measures submitted under 

6 clause (ii)(I). 

7 Any measure selected for inclusion in such 

8 list that is not endorsed by a consensus9 based entity shall have a focus that is evi10 dence-based. 

11 ‘‘(vi) EXCEPTION FOR QUALIFIED

12 CLINICAL DATA REGISTRY MEASURES.— 

13 Measures used by a qualified clinical data 

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

15 not be subject to the requirements under 

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

17 shall publish the list of measures used by 

18 such qualified clinical data registries on 

19 the Internet website of the Centers for 

20 Medicare & Medicaid Services. 

21 ‘‘(vii) EXCEPTION FOR EXISTING

22 QUALITY MEASURES.—Any quality meas23 ure specified by the Secretary under sub24 section (k) or (m), including under sub25 section (m)(3)(E), and any measure of 


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1 quality of care established under sub2 section (p)(2) for the reporting period 

3 under the respective subsection beginning 

4 before the first performance period under 

5 the MIPS— 

6 ‘‘(I) shall not be subject to the 

7 requirements under clause (i) (except 

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

9 (II) of such clause) or to the require10 ment under clause (iv); and 

11 ‘‘(II) shall be included in the 

12 final list of quality measures pub13 lished under clause (i) unless removed 

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

15 ‘‘(viii) CONSULTATION WITH REL16 EVANT ELIGIBLE PROFESSIONAL ORGANI17 ZATIONS AND OTHER RELEVANT STAKE18 HOLDERS.—Relevant eligible professional 

19 organizations and other relevant stake20 holders, including State and national med21 ical societies, shall be consulted in carrying 

22 out this subparagraph. 

23 ‘‘(ix) OPTIONAL APPLICATION.—The 

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1 quired to apply to the selection of meas2 ures under this subparagraph. 

3 ‘‘(3) PERFORMANCE STANDARDS.— 

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

5 the Secretary shall establish performance stand6 ards with respect to measures and activities 

7 specified under paragraph (2)(B) for a perform8 ance period (as established under paragraph 

9 (4)) for a year. 

10 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

11 STANDARDS.—In establishing such performance 

12 standards with respect to measures and activi13 ties specified under paragraph (2)(B), the Sec14 retary shall consider the following: 

15 ‘‘(i) Historical performance standards. 

16 ‘‘(ii) Improvement. 

17 ‘‘(iii) The opportunity for continued 

18 improvement. 

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

20 shall establish a performance period (or periods) for 

21 a year (beginning with the year described in para22 graph (1)(B)). Such performance period (or periods) 

23 shall begin and end prior to the beginning of such 

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

25 subsection, such performance period (or periods) for 


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1 a year shall be referred to as the performance period 

2 for the year. 

3 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 

4 ‘‘(A) IN GENERAL.—Subject to the suc5 ceeding provisions of this paragraph and taking 

6 into account, as available and applicable, para7 graph (1)(G), the Secretary shall develop a 

8 methodology for assessing the total performance 

9 of each MIPS eligible professional according to 

10 performance standards under paragraph (3) 

11 with respect to applicable measures and activi12 ties specified in paragraph (2)(B) with respect 

13 to each performance category applicable to such 

14 professional for a performance period (as estab15 lished under paragraph (4)) for a year. Using 

16 such methodology, the Secretary shall provide 

17 for a composite assessment (using a scoring 

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

19 the performance period for such year. In this 

20 subsection such a composite assessment for 

21 such a professional with respect to a perform22 ance period shall be referred to as the ‘com23 posite performance score’ for such professional 

24 for such performance period. 


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1 ‘‘(B) INCENTIVE TO REPORT; ENCOUR2 AGING USE OF CERTIFIED EHR TECHNOLOGY

3 FOR REPORTING QUALITY MEASURES.— 

4 ‘‘(i) INCENTIVE TO REPORT.—Under 

5 the methodology established under sub6 paragraph (A), the Secretary shall provide 

7 that in the case of a MIPS eligible profes8 sional who fails to report on an applicable 

9 measure or activity that is required to be 

10 reported by the professional, the profes11 sional shall be treated as achieving the 

12 lowest potential score applicable to such 

13 measure or activity. 

14 ‘‘(ii) ENCOURAGING USE OF CER15 TIFIED EHR TECHNOLOGY AND QUALIFIED

16 CLINICAL DATA REGISTRIES FOR REPORT17 ING QUALITY MEASURES.—Under the 

18 methodology established under subpara19 graph (A), the Secretary shall— 

20 ‘‘(I) encourage MIPS eligible 

21 professionals to report on applicable 

22 measures with respect to the perform23 ance category described in paragraph 

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


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1 EHR technology and qualified clinical 

2 data registries; and 

3 ‘‘(II) with respect to a perform4 ance period, with respect to a year, 

5 for which a MIPS eligible professional 

6 reports such measures through the 

7 use of such EHR technology, treat 

8 such professional as satisfying the 

9 clinical quality measures reporting re10 quirement described in subsection 

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

12 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

13 ACTIVITIES PERFORMANCE SCORE.— 

14 ‘‘(i) RULE FOR ACCREDITATION.—A 

15 MIPS eligible professional who is in a 

16 practice that is certified as a patient-cen17 tered medical home or comparable spe18 cialty practice pursuant to subsection 

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

20 period shall be given the highest potential 

21 score for the performance category de22 scribed in paragraph (2)(A)(iii) for such 

23 period. 

24 ‘‘(ii) APM PARTICIPATION.—Partici25 pation by a MIPS eligible professional in 


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1 an alternative payment model (as defined 

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

3 performance period shall earn such eligible 

4 professional a minimum score of one-half 

5 of the highest potential score for the per6 formance category described in paragraph 

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

8 ‘‘(iii) SUBCATEGORIES.—A MIPS eli9 gible professional shall not be required to 

10 perform activities in each subcategory 

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

12 in an alternative payment model in order 

13 to achieve the highest potential score for 

14 the performance category described in 

15 paragraph (2)(A)(iii). 

16 ‘‘(D) ACHIEVEMENT AND IMPROVE17 MENT.— 

18 ‘‘(i) TAKING INTO ACCOUNT IMPROVE19 MENT.—Beginning with the second year to 

20 which the MIPS applies, in addition to the 

21 achievement of a MIPS eligible profes22 sional, if data sufficient to measure im23 provement is available, the methodology 

24 developed under subparagraph (A)— 


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1 ‘‘(I) in the case of the perform2 ance score for the performance cat3 egory described in clauses (i) and (ii) 

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

5 account the improvement of the pro6 fessional; and 

7 ‘‘(II) in the case of performance 

8 scores for other performance cat9 egories, may take into account the im10 provement of the professional. 

11 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

12 ACHIEVEMENT.—Beginning with the 

13 fourth year to which the MIPS applies, 

14 under the methodology developed under 

15 subparagraph (A), the Secretary may as16 sign a higher scoring weight under sub17 paragraph (F) with respect to the achieve18 ment of a MIPS eligible professional than 

19 with respect to any improvement of such 

20 professional applied under clause (i) with 

21 respect to a measure, activity, or category 

22 described in paragraph (2). 

23 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

24 CATEGORIES.— 


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1 ‘‘(i) IN GENERAL.—Under the meth2 odology developed under subparagraph (A), 

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

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

5 score shall be determined as follows: 

6 ‘‘(I) QUALITY.— 

7 ‘‘(aa) IN GENERAL.—Sub8 ject to item (bb), thirty percent 

9 of such score shall be based on 

10 performance with respect to the 

11 category described in clause (i) of 

12 paragraph (2)(A). In applying 

13 the previous sentence, the Sec14 retary shall, as feasible, encour15 age the application of outcome 

16 measures within such category. 

17 ‘‘(bb) FIRST 2 YEARS.—For 

18 the first and second years for 

19 which the MIPS applies to pay20 ments, the percentage applicable 

21 under item (aa) shall be in22 creased in a manner such that 

23 the total percentage points of the 

24 increase under this item for the 

25 respective year equals the total 


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1 number of percentage points by 

2 which the percentage applied 

3 under subclause (II)(bb) for the 

4 respective year is less than 30 

5 percent. 

6 ‘‘(II) RESOURCE USE.— 

7 ‘‘(aa) IN GENERAL.—Sub8 ject to item (bb), thirty percent 

9 of such score shall be based on 

10 performance with respect to the 

11 category described in clause (ii) 

12 of paragraph (2)(A). 

13 ‘‘(bb) FIRST 2 YEARS.—For 

14 the first year for which the MIPS 

15 applies to payments, not more 

16 than 10 percent of such score 

17 shall be based on performance 

18 with respect to the category de19 scribed in clause (ii) of para20 graph (2)(A). For the second 

21 year for which the MIPS applies 

22 to payments, not more than 15 

23 percent of such score shall be 

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1 spect to the category described in 

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

3 ‘‘(III) CLINICAL PRACTICE IM4 PROVEMENT ACTIVITIES.—Fifteen 

5 percent of such score shall be based 

6 on performance with respect to the 

7 category described in clause (iii) of 

8 paragraph (2)(A). 

9 ‘‘(IV) MEANINGFUL USE OF CER10 TIFIED EHR TECHNOLOGY.—Twenty11 five percent of such score shall be 

12 based on performance with respect to 

13 the category described in clause (iv) of 

14 paragraph (2)(A). 

15 ‘‘(ii) AUTHORITY TO ADJUST PER16 CENTAGES IN CASE OF HIGH EHR MEAN17 INGFUL USE ADOPTION.—In any year in 

18 which the Secretary estimates that the pro19 portion of eligible professionals (as defined 

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

21 EHR users (as determined under sub22 section (o)(2)) is 75 percent or greater, the 

23 Secretary may reduce the percent applica24 ble under clause (i)(IV), but not below 15 

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1 duction for a year, subject to subclauses 

2 (I)(bb) and (II)(bb) of clause (i), the per3 centages applicable under one or more of 

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

5 for such year shall be increased in a man6 ner such that the total percentage points 

7 of the increase under this clause for such 

8 year equals the total number of percentage 

9 points reduced under the preceding sen10 tence for such year. 

11 ‘‘(F) CERTAIN FLEXIBILITY FOR

12 WEIGHTING PERFORMANCE CATEGORIES, MEAS13 URES, AND ACTIVITIES.—Under the method14 ology under subparagraph (A), if there are not 

15 sufficient measures and clinical practice im16 provement activities applicable and available to 

17 each type of eligible professional involved, the 

18 Secretary shall assign different scoring weights 

19 (including a weight of 0)— 

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

21 weights specified in subparagraph (E), for 

22 each performance category based on the 

23 extent to which the category is applicable 

24 to the type of eligible professional involved; 

25 and 


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1 ‘‘(ii) for each measure and activity 

2 specified under paragraph (2)(B) with re3 spect to each such category based on the 

4 extent to which the measure or activity is 

5 applicable and available to the type of eli6 gible professional involved. 

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

8 performance category described in paragraph 

9 (2)(A)(ii) shall include results from the method10 ology described in subsection (r)(5), as appro11 priate. 

12 ‘‘(H) INCLUSION OF QUALITY MEASURE

13 DATA FROM OTHER PAYERS.—In applying sub14 sections (k), (m), and (p) with respect to meas15 ures described in paragraph (2)(B)(i), analysis 

16 of the performance category described in para17 graph (2)(A)(i) may include data submitted by 

18 MIPS eligible professionals with respect to 

19 items and services furnished to individuals who 

20 are not individuals entitled to benefits under 

21 part A or enrolled under part B. 

22 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

23 FOR CERTAIN ASSESSMENT PURPOSES.— 

24 ‘‘(i) IN GENERAL.—In the case of 

25 MIPS eligible professionals electing to be a 


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1 virtual group under clause (ii) with respect 

2 to a performance period for a year, for 

3 purposes of applying the methodology 

4 under subparagraph (A)— 

5 ‘‘(I) the assessment of perform6 ance provided under such methodology 

7 with respect to the performance cat8 egories described in clauses (i) and 

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

10 applied to each such professional in 

11 such group for such performance pe12 riod shall be with respect to the com13 bined performance of all such profes14 sionals in such group for such period; 

15 and 

16 ‘‘(II) the composite score pro17 vided under this paragraph for such 

18 performance period with respect to 

19 each such performance category for 

20 each such MIPS eligible professional 

21 in such virtual group shall be based 

22 on the assessment of the combined 

23 performance under subclause (I) for 

24 the performance category and per25 formance period. 


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1 ‘‘(ii) ELECTION OF PRACTICES TO BE

2 A VIRTUAL GROUP.—The Secretary shall, 

3 in accordance with clause (iii), establish 

4 and have in place a process to allow an in5 dividual MIPS eligible professional or a 

6 group practice consisting of not more than 

7 10 MIPS eligible professionals to elect, 

8 with respect to a performance period for a 

9 year, for such individual MIPS eligible pro10 fessional or all such MIPS eligible profes11 sionals in such group practice, respectively, 

12 to be a virtual group under this subpara13 graph with at least one other such indi14 vidual MIPS eligible professional or group 

15 practice making such an election. Such a 

16 virtual group may be based on geographic 

17 areas or on provider specialties defined by 

18 nationally recognized multispecialty boards 

19 of certification or equivalent certification 

20 boards and such other eligible professional 

21 groupings in order to capture classifica22 tions of providers across eligible profes23 sional organizations and other practice 

24 areas or categories. 


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1 ‘‘(iii) REQUIREMENTS.—The process 

2 under clause (ii)— 

3 ‘‘(I) shall provide that an election 

4 under such clause, with respect to a 

5 performance period, shall be made be6 fore or during the beginning of such 

7 performance period and may not be 

8 changed during such performance pe9 riod; 

10 ‘‘(II) shall provide that a practice 

11 described in such clause, and each 

12 MIPS eligible professional in such 

13 practice, may elect to be in no more 

14 than one virtual group for a perform15 ance period; and 

16 ‘‘(III) may provide that a virtual 

17 group may be combined at the tax 

18 identification number level. 

19 ‘‘(6) MIPS PAYMENTS.— 

20 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak21 ing into account paragraph (1)(G), the Sec22 retary shall specify a MIPS adjustment factor 

23 for each MIPS eligible professional for a year. 

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1 ble professional for a year shall be in the form 

2 of a percent and shall be determined— 

3 ‘‘(i) by comparing the composite per4 formance score of the eligible professional 

5 for such year to the performance threshold 

6 established under subparagraph (D)(i) for 

7 such year; 

8 ‘‘(ii) in a manner such that the ad9 justment factors specified under this sub10 paragraph for a year result in differential 

11 payments under this paragraph reflecting 

12 that— 

13 ‘‘(I) MIPS eligible professionals 

14 with composite performance scores for 

15 such year at or above such perform16 ance threshold for such year receive 

17 zero or positive incentive payment ad18 justment factors for such year in ac19 cordance with clause (iii), with such 

20 professionals having higher composite 

21 performance scores receiving higher 

22 adjustment factors; and 

23 ‘‘(II) MIPS eligible professionals 

24 with composite performance scores for 

25 such year below such performance 


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1 threshold for such year receive nega2 tive payment adjustment factors for 

3 such year in accordance with clause 

4 (iv), with such professionals having 

5 lower composite performance scores 

6 receiving lower adjustment factors; 

7 ‘‘(iii) in a manner such that MIPS eli8 gible professionals with composite scores 

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

10 subject to clauses (i) and (ii) of subpara11 graph (F), receive a zero or positive ad12 justment factor on a linear sliding scale 

13 such that an adjustment factor of 0 per14 cent is assigned for a score at the perform15 ance threshold and an adjustment factor of 

16 the applicable percent specified in subpara17 graph (B) is assigned for a score of 100; 

18 and 

19 ‘‘(iv) in a manner such that— 

20 ‘‘(I) subject to subclause (II), 

21 MIPS eligible professionals with com22 posite performance scores described in 

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

24 negative payment adjustment factor 

25 on a linear sliding scale such that an 


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1 adjustment factor of 0 percent is as2 signed for a score at the performance 

3 threshold and an adjustment factor of 

4 the negative of the applicable percent 

5 specified in subparagraph (B) is as6 signed for a score of 0; and 

7 ‘‘(II) MIPS eligible professionals 

8 with composite performance scores 

9 that are equal to or greater than 0, 

but not greater than 1 10 ⁄4 of the per11 formance threshold specified under 

12 subparagraph (D)(i) for such year, re13 ceive a negative payment adjustment 

14 factor that is equal to the negative of 

15 the applicable percent specified in 

16 subparagraph (B) for such year. 

17 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

18 For purposes of this paragraph, the term ‘ap19 plicable percent’ means— 

20 ‘‘(i) for 2018, 4 percent; 

21 ‘‘(ii) for 2019, 5 percent; 

22 ‘‘(iii) for 2020, 7 percent; and 

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

24 9 percent. 


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1 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC2 TORS FOR EXCEPTIONAL PERFORMANCE.— 

3 ‘‘(i) IN GENERAL.—In the case of a 

4 MIPS eligible professional with a com5 posite performance score for a year at or 

6 above the additional performance threshold 

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

8 in addition to the MIPS adjustment factor 

9 under subparagraph (A) for the eligible 

10 professional for such year, subject to the 

11 availability of funds under clause (ii), the 

12 Secretary shall specify an additional posi13 tive MIPS adjustment factor for such pro14 fessional and year. Such additional MIPS 

15 adjustment factors shall be determined by 

16 the Secretary in a manner such that pro17 fessionals having higher composite per18 formance scores above the additional per19 formance threshold receive higher addi20 tional MIPS adjustment factors. 

21 ‘‘(ii) ADDITIONAL FUNDING POOL.— 

22 For 2018 and each subsequent year 

23 through 2023, there is appropriated from 

24 the Federal Supplementary Medical Insur25 ance Trust Fund $500,000,000 for MIPS 


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1 payments under this paragraph resulting 

2 from the application of the additional 

3 MIPS adjustment factors under clause (i). 

4 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

5 THRESHOLDS.— 

6 ‘‘(i) PERFORMANCE THRESHOLD.— 

7 For each year of the MIPS, the Secretary 

8 shall compute a performance threshold 

9 with respect to which the composite per10 formance score of MIPS eligible profes11 sionals shall be compared for purposes of 

12 determining adjustment factors under sub13 paragraph (A) that are positive, negative, 

14 and zero. Such performance threshold for 

15 a year shall be the mean or median (as se16 lected by the Secretary) of the composite 

17 performance scores for all MIPS eligible 

18 professionals with respect to a prior period 

19 specified by the Secretary. The Secretary 

20 may reassess the selection under the pre21 vious sentence every 3 years. 

22 ‘‘(ii) ADDITIONAL PERFORMANCE

23 THRESHOLD FOR EXCEPTIONAL PERFORM24 ANCE.—In addition to the performance 

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


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1 the MIPS, the Secretary shall compute an 

2 additional performance threshold for pur3 poses of determining the additional MIPS 

4 adjustment factors under subparagraph 

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

6 shall apply either of the following methods 

7 for computing such additional performance 

8 threshold for such a year: 

9 ‘‘(I) The threshold shall be the 

10 score that is equal to the 25th per11 centile of the range of possible com12 posite performance scores above the 

13 performance threshold with respect to 

14 the prior period described in clause 

15 (i). 

16 ‘‘(II) The threshold shall be the 

17 score that is equal to the 25th per18 centile of the actual composite per19 formance scores for MIPS eligible 

20 professionals with composite perform21 ance scores at or above the perform22 ance threshold with respect to the 

23 prior period described in clause (i). 

24 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

25 YEARS.—With respect to each of the first 


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1 two years to which the MIPS applies, the 

2 Secretary shall, prior to the performance 

3 period for such years, establish a perform4 ance threshold for purposes of determining 

5 MIPS adjustment factors under subpara6 graph (A) and a threshold for purposes of 

7 determining additional MIPS adjustment 

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

9 such performance threshold shall— 

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

11 such performance periods; and 

12 ‘‘(II) take into account— 

13 ‘‘(aa) data available with re14 spect to performance on meas15 ures and activities that may be 

16 used under the performance cat17 egories under subparagraph 

18 (2)(B); and 

19 ‘‘(bb) other factors deter20 mined appropriate by the Sec21 retary. 

22 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

23 FACTORS.—In the case of items and services 

24 furnished by a MIPS eligible professional dur25 ing a year (beginning with 2018), the amount 


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1 otherwise paid under this part with respect to 

2 such items and services and MIPS eligible pro3 fessional for such year, shall be multiplied by— 

4 ‘‘(i) 1, plus 

5 ‘‘(ii) the sum of— 

6 ‘‘(I) the MIPS adjustment factor 

7 determined under subparagraph (A) 

8 divided by 100, and 

9 ‘‘(II) as applicable, the additional 

10 MIPS adjustment factor determined 

11 under subparagraph (C)(i) divided by 

12 100. 

13 ‘‘(F) AGGREGATE APPLICATION OF MIPS

14 ADJUSTMENT FACTORS.— 

15 ‘‘(i) APPLICATION OF SCALING FAC16 TOR.— 

17 ‘‘(I) IN GENERAL.—With respect 

18 to positive MIPS adjustment factors 

19 under subparagraph (A)(ii)(I) for eli20 gible professionals whose composite 

21 performance score is above the per22 formance threshold under subpara23 graph (D)(i) for such year, subject to 

24 subclause (II), the Secretary shall in25 crease or decrease such adjustment 


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1 factors by a scaling factor in order to 

2 ensure that the budget neutrality re3 quirement of clause (ii) is met. 

4 ‘‘(II) SCALING FACTOR LIMIT.— 

5 In no case may be the scaling factor 

6 applied under this clause exceed 3.0. 

7 ‘‘(ii) BUDGET NEUTRALITY REQUIRE8 MENT.— 

9 ‘‘(I) IN GENERAL.—Subject to 

10 clause (iii), the Secretary shall ensure 

11 that the estimated amount described 

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

13 the estimated amount described in 

14 subclause (III) for such year. 

15 ‘‘(II) AGGREGATE INCREASES.— 

16 The amount described in this sub17 clause is the estimated increase in the 

18 aggregate allowed charges resulting 

19 from the application of positive MIPS 

20 adjustment factors under subpara21 graph (A) (after application of the 

22 scaling factor described in clause (i)) 

23 to MIPS eligible professionals whose 

24 composite performance score for a 

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1 old under subparagraph (D)(i) for 

2 such year. 

3 ‘‘(III) AGGREGATE DE4 CREASES.—The amount described in 

5 this subclause is the estimated de6 crease in the aggregate allowed 

7 charges resulting from the application 

8 of negative MIPS adjustment factors 

9 under subparagraph (A) to MIPS eli10 gible professionals whose composite 

11 performance score for a year is below 

12 the performance threshold under sub13 paragraph (D)(i) for such year. 

14 ‘‘(iii) EXCEPTIONS.— 

15 ‘‘(I) In the case that all MIPS el16 igible professionals receive composite 

17 performance scores for a year that are 

18 below the performance threshold 

19 under subparagraph (D)(i) for such 

20 year, the negative MIPS adjustment 

21 factors under subparagraph (A) shall 

22 apply with respect to such MIPS eligi23 ble professionals and the budget neu24 trality requirement of clause (ii) shall 

25 not apply for such year. 


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1 ‘‘(II) In the case that, with re2 spect to a year, the application of 

3 clause (i) results in a scaling factor 

4 equal to the maximum scaling factor 

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

6 factor shall apply and the budget neu7 trality requirement of clause (ii) shall 

8 not apply for such year. 

9 ‘‘(iv) ADDITIONAL INCENTIVE PAY10 MENT ADJUSTMENTS.—In specifying the 

11 MIPS additional adjustment factors under 

12 subparagraph (C)(i) for each applicable 

13 MIPS eligible professional for a year, the 

14 Secretary shall ensure that the estimated 

15 increase in payments under this part re16 sulting from the application of such addi17 tional adjustment factors for MIPS eligible 

18 professionals in a year shall be equal (as 

19 estimated by the Secretary) to the addi20 tional funding pool amount for such year 

21 under subparagraph (C)(ii). 

22 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST23 MENTS.—Under the MIPS, the Secretary shall, not 

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

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1 sionals the MIPS adjustment factor (and, as appli2 cable, the additional MIPS adjustment factor) under 

3 paragraph (6) applicable to the eligible professional 

4 for items and services furnished by the professional 

5 for such year. The Secretary may include such infor6 mation in the confidential feedback under paragraph 

7 (12). 

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

9 MIPS adjustment factors and additional MIPS ad10 justment factors under paragraph (6) shall apply 

11 only with respect to the year involved, and the Sec12 retary shall not take into account such adjustment 

13 factors in making payments to a MIPS eligible pro14 fessional under this part in a subsequent year. 

15 ‘‘(9) PUBLIC REPORTING.— 

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

17 in an easily understandable format, make avail18 able on the Physician Compare Internet website 

19 of the Centers for Medicare & Medicaid Serv20 ices the following: 

21 ‘‘(i) Information regarding the per22 formance of MIPS eligible professionals 

23 under the MIPS, which— 

24 ‘‘(I) shall include the composite 

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1 fessional and the performance of each 

2 such MIPS eligible professional with 

3 respect to each performance category; 

4 and 

5 ‘‘(II) may include the perform6 ance of each such MIPS eligible pro7 fessional with respect to each measure 

8 or activity specified in paragraph 

9 (2)(B). 

10 ‘‘(ii) The names of eligible profes11 sionals in eligible alternative payment mod12 els (as defined in section 1833(z)(3)(D)) 

13 and, to the extent feasible, the names of 

14 such eligible alternative payment models 

15 and performance of such models. 

16 ‘‘(B) DISCLOSURE.—The information 

17 made available under this paragraph shall indi18 cate, where appropriate, that publicized infor19 mation may not be representative of the eligible 

20 professional’s entire patient population, the va21 riety of services furnished by the eligible profes22 sional, or the health conditions of individuals 

23 treated. 

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1 vide for an opportunity for a professional de2 scribed in subparagraph (A) to review, and sub3 mit corrections for, the information to be made 

4 public with respect to the professional under 

5 such subparagraph prior to such information 

6 being made public. 

7 ‘‘(D) AGGREGATE INFORMATION.—The 

8 Secretary shall periodically post on the Physi9 cian Compare Internet website aggregate infor10 mation on the MIPS, including the range of 

11 composite scores for all MIPS eligible profes12 sionals and the range of the performance of all 

13 MIPS eligible professionals with respect to each 

14 performance category. 

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

16 consult with stakeholders in carrying out the MIPS, 

17 including for the identification of measures and ac18 tivities under paragraph (2)(B) and the methodolo19 gies developed under paragraphs (5)(A) and (6) and 

20 regarding the use of qualified clinical data registries. 

21 Such consultation shall include the use of a request 

22 for information or other mechanisms determined ap23 propriate. 


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1 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC2 TICES AND PRACTICES IN HEALTH PROFESSIONAL

3 SHORTAGE AREAS.— 

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

5 enter into contracts or agreements with appro6 priate entities (such as quality improvement or7 ganizations, regional extension centers (as de8 scribed in section 3012(c) of the Public Health 

9 Service Act), or regional health collaboratives) 

10 to offer guidance and assistance to MIPS eligi11 ble professionals in practices of 15 or fewer pro12 fessionals (with priority given to such practices 

13 located in rural areas, health professional short14 age areas (as designated under in section 

15 332(a)(1)(A) of such Act), and medically under16 served areas, and practices with low composite 

17 scores) with respect to— 

18 ‘‘(i) the performance categories de19 scribed in clauses (i) through (iv) of para20 graph (2)(A); or 

21 ‘‘(ii) how to transition to the imple22 mentation of and participation in an alter23 native payment model as described in sec24 tion 1833(z)(3)(C). 

25 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 


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1 ‘‘(i) IN GENERAL.—For purposes of 

2 implementing subparagraph (A), the Sec3 retary shall provide for the transfer from 

4 the Federal Supplementary Medical Insur5 ance Trust Fund established under section 

6 1841 to the Centers for Medicare & Med7 icaid Services Program Management Ac8 count of $40,000,000 for each of fiscal 

9 years 2015 through 2019. Amounts trans10 ferred under this subparagraph for a fiscal 

11 year shall be available until expended. 

12 ‘‘(ii) TECHNICAL ASSISTANCE.—Of 

13 the amounts transferred pursuant to clause 

14 (i) for each of fiscal years 2015 through 

15 2019, not less than $10,000,000 shall be 

16 made available for each such year for tech17 nical assistance to small practices in health 

18 professional shortage areas (as so des19 ignated) and medically underserved areas. 

20 ‘‘(12) FEEDBACK AND INFORMATION TO IM21 PROVE PERFORMANCE.— 

22 ‘‘(A) PERFORMANCE FEEDBACK.— 

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

24 2016, the Secretary— 


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1 ‘‘(I) shall make available timely 

2 (such as quarterly) confidential feed3 back to MIPS eligible professionals on 

4 the performance of such professionals 

5 with respect to the performance cat6 egories under clauses (i) and (ii) of 

7 paragraph (2)(A); and 

8 ‘‘(II) may make available con9 fidential feedback to each such profes10 sional on the performance of such 

11 professional with respect to the per12 formance categories under clauses (iii) 

13 and (iv) of such paragraph. 

14 ‘‘(ii) MECHANISMS.—The Secretary 

15 may use one or more mechanisms to make 

16 feedback available under clause (i), which 

17 may include use of a web-based portal or 

18 other mechanisms determined appropriate 

19 by the Secretary. With respect to the per20 formance category described in paragraph 

21 (2)(A)(i), feedback under this subpara22 graph shall, to the extent an eligible pro23 fessional chooses to participate in a data 

24 registry for purposes of this subsection (in25 cluding registries under subsections (k) 


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1 and (m)), be provided based on perform2 ance on quality measures reported through 

3 the use of such registries. With respect to 

4 any other performance category described 

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

6 encourage provision of feedback through 

7 qualified clinical data registries as de8 scribed in subsection (m)(3)(E)). 

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

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

11 with respect to a MIPS eligible profes12 sional, from periods prior to the current 

13 performance period and may use rolling 

14 periods in order to make illustrative cal15 culations about the performance of such 

16 professional. 

17 ‘‘(iv) DISCLOSURE EXEMPTION.— 

18 Feedback made available under this sub19 paragraph shall be exempt from disclosure 

20 under section 552 of title 5, United States 

21 Code. 

22 ‘‘(v) RECEIPT OF INFORMATION.— 

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1 mation from professionals, such as infor2 mation with respect to this subsection. 

3 ‘‘(B) ADDITIONAL INFORMATION.— 

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

5 2017, the Secretary shall make available to 

6 each MIPS eligible professional informa7 tion, with respect to individuals who are 

8 patients of such MIPS eligible professional, 

9 about items and services for which pay10 ment is made under this title that are fur11 nished to such individuals by other sup12 pliers and providers of services, which may 

13 include information described in clause (ii). 

14 Such information may be made available 

15 under the previous sentence to such MIPS 

16 eligible professionals by mechanisms deter17 mined appropriate by the Secretary, which 

18 may include use of a web-based portal. 

19 Such information may be made available in 

20 accordance with the same or similar terms 

21 as data are made available to accountable 

22 care organizations participating in the 

23 shared savings program under section 

24 1899, including a beneficiary opt-out. 


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1 ‘‘(ii) TYPE OF INFORMATION.—For 

2 purposes of clause (i), the information de3 scribed in this clause, is the following: 

4 ‘‘(I) With respect to selected 

5 items and services (as determined ap6 propriate by the Secretary) for which 

7 payment is made under this title and 

8 that are furnished to individuals, who 

9 are patients of a MIPS eligible profes10 sional, by another supplier or provider 

11 of services during the most recent pe12 riod for which data are available (such 

13 as the most recent three-month pe14 riod), such as the name of such pro15 viders furnishing such items and serv16 ices to such patients during such pe17 riod, the types of such items and serv18 ices so furnished, and the dates such 

19 items and services were so furnished. 

20 ‘‘(II) Historical data, such as 

21 averages and other measures of the 

22 distribution if appropriate, of the 

23 total, and components of, allowed 

24 charges (and other figures as deter25 mined appropriate by the Secretary). 


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1 ‘‘(13) REVIEW.— 

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

3 shall establish a process under which a MIPS 

4 eligible professional may seek an informal re5 view of the calculation of the MIPS adjustment 

6 factor applicable to such eligible professional 

7 under this subsection for a year. The results of 

8 a review conducted pursuant to the previous 

9 sentence shall not be taken into account for 

10 purposes of paragraph (6) with respect to a 

11 year (other than with respect to the calculation 

12 of such eligible professional’s MIPS adjustment 

13 factor for such year or additional MIPS adjust14 ment factor for such year) after the factors de15 termined in subparagraph (A) and subpara16 graph (C) of such paragraph have been deter17 mined for such year. 

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

19 in subparagraph (A), there shall be no adminis20 trative or judicial review under section 1869, 

21 section 1878, or otherwise of the following: 

22 ‘‘(i) The methodology used to deter23 mine the amount of the MIPS adjustment 

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

25 amount of the additional MIPS adjustment 


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

2 determination of such amounts. 

3 ‘‘(ii) The establishment of the per4 formance standards under paragraph (3) 

5 and the performance period under para6 graph (4). 

7 ‘‘(iii) The identification of measures 

8 and activities specified under paragraph 

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

10 posted on the Physician Compare Internet 

11 website of the Centers for Medicare & 

12 Medicaid Services under paragraph (9). 

13 ‘‘(iv) The methodology developed 

14 under paragraph (5) that is used to cal15 culate performance scores and the calcula16 tion of such scores, including the weighting 

17 of measures and activities under such 

18 methodology.’’. 

19 (2) GAO REPORTS.— 

20 (A) EVALUATION OF ELIGIBLE PROFES21 SIONAL MIPS.—Not later than October 1, 2019, 

22 and October 1, 2022, the Comptroller General 

23 of the United States shall submit to Congress 

24 a report evaluating the eligible professional 

25 Merit-based Incentive Payment System under 


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1 subsection (q) of section 1848 of the Social Se2 curity Act (42 U.S.C. 1395w–4), as added by 

3 paragraph (1). Such report shall— 

4 (i) examine the distribution of the 

5 composite performance scores and MIPS 

6 adjustment factors (and additional MIPS 

7 adjustment factors) for MIPS eligible pro8 fessionals (as defined in subsection 

9 (q)(1)(c) of such section) under such pro10 gram, and patterns relating to such scores 

11 and adjustment factors, including based on 

12 type of provider, practice size, geographic 

13 location, and patient mix; 

14 (ii) provide recommendations for im15 proving such program; 

16 (iii) evaluate the impact of technical 

17 assistance funding under section 

18 1848(q)(11) of the Social Security Act, as 

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

20 professionals to improve within such pro21 gram or successfully transition to an alter22 native payment model (as defined in sec23 tion 1833(z)(3) of the Social Security Act, 

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

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1 cated in rural areas, health professional 

2 shortage areas (as designated in section 

3 332(a)(1)(a) of the Public Health Service 

4 Act), and medically underserved areas; and 

5 (iv) provide recommendations for opti6 mizing the use of such technical assistance 

7 funds. 

8 (B) STUDY TO EXAMINE ALIGNMENT OF

9 QUALITY MEASURES USED IN PUBLIC AND PRI10 VATE PROGRAMS.— 

11 (i) IN GENERAL.—Not later than 18 

12 months after the date of the enactment of 

13 this Act, the Comptroller General of the 

14 United States shall submit to Congress a 

15 report that— 

16 (I) compares the similarities and 

17 differences in the use of quality meas18 ures under the original Medicare fee19 for-service program under parts A and 

20 B of title XVIII of the Social Security 

21 Act, the Medicare Advantage program 

22 under part C of such title, selected 

23 State Medicaid programs under title 

24 XIX of such Act, and private payer 

25 arrangements; and 


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1 (II) makes recommendations on 

2 how to reduce the administrative bur3 den involved in applying such quality 

4 measures. 

5 (ii) REQUIREMENTS.—The report 

6 under clause (i) shall— 

7 (I) consider those measures ap8 plicable to individuals entitled to, or 

9 enrolled for, benefits under such part 

10 A, or enrolled under such part B and 

11 individuals under the age of 65; and 

12 (II) focus on those measures that 

13 comprise the most significant compo14 nent of the quality performance cat15 egory of the eligible professional 

16 MIPS incentive program under sub17 section (q) of section 1848 of the So18 cial Security Act (42 U.S.C. 1395w– 

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

20 (C) STUDY ON ROLE OF INDEPENDENT

21 RISK MANAGERS.—Not later than January 1, 

22 2016, the Comptroller General of the United 

23 States shall submit to Congress a report exam24 ining whether entities that pool financial risk 

25 for physician practices, such as independent 


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1 risk managers, can play a role in supporting 

2 physician practices, particularly small physician 

3 practices, in assuming financial risk for the 

4 treatment of patients. Such report shall exam5 ine barriers that small physician practices cur6 rently face in assuming financial risk for treat7 ing patients, the types of risk management enti8 ties that could assist physician practices in par9 ticipating in two-sided risk payment models, 

10 and how such entities could assist with risk 

11 management and with quality improvement ac12 tivities. Such report shall also include an anal13 ysis of any existing legal barriers to such ar14 rangements. 

15 (D) STUDY TO EXAMINE RURAL AND

16 HEALTH PROFESSIONAL SHORTAGE AREA AL17 TERNATIVE PAYMENT MODELS.—Not later than 

18 October 1, 2020, and October 1, 2022, the 

19 Comptroller General of the United States shall 

20 submit to Congress a report that examines the 

21 transition of professionals in rural areas, health 

22 professional shortage areas (as designated in 

23 section 332(a)(1)(A) of the Public Health Serv24 ice Act), or medically underserved areas to an 

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1 tion 1833(z)(3) of the Social Security Act, as 

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

3 make recommendations for removing adminis4 trative barriers to practices, including small 

5 practices consisting of 15 or fewer profes6 sionals, in rural areas, health professional 

7 shortage areas, and medically underserved areas 

8 to participation in such models. 

9 (3) FUNDING FOR IMPLEMENTATION.—For 

10 purposes of implementing the provisions of and the 

11 amendments made by this section, the Secretary of 

12 Health and Human Services shall provide for the 

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

14 Medical Insurance Trust Fund established under 

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

16 1395t) to the Centers for Medicare & Medicaid Pro17 gram Management Account for each of the fiscal 

18 years 2014 through 2018. Amounts transferred 

19 under this paragraph shall be available until ex20 pended. 

21 (d) IMPROVING QUALITY REPORTING FOR COM22 POSITE SCORES.— 

23 (1) CHANGES FOR GROUP REPORTING OP24 TION.— 


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1 (A) IN GENERAL.—Section 

2 1848(m)(3)(C)(ii)) of the Social Security Act 

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

4 by inserting ‘‘and, for 2015 and subsequent 

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

6 (B) CLARIFICATION OF QUALIFIED CLIN7 ICAL DATA REGISTRY REPORTING TO GROUP

8 PRACTICES.—Section 1848(m)(3)(D) of the So9 cial Security Act (42 U.S.C. 1395w– 

10 4(m)(3)(D)) is amended by inserting ‘‘and, for 

11 2015 and subsequent years, subparagraph (A) 

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

13 (2) CHANGES FOR MULTIPLE REPORTING PERI14 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC15 TORY REPORTING.—Section 1848(m)(5)(F) of the 

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

17 is amended— 

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

19 and inserting ‘‘through reporting periods occur20 ring in 2014’’; and 

21 (B) by inserting ‘‘and, for reporting peri22 ods occurring in 2015 and subsequent years, 

23 the Secretary may establish’’ following ‘‘shall 

24 establish’’. 


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1 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

2 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

3 1848(n) of the Social Security Act (42 U.S.C. 

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

5 following new paragraph: 

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

7 under the Program shall not be provided after De8 cember 31, 2016. See subsection (q)(12) for reports 

9 under the eligible professionals Merit-based Incentive 

10 Payment System.’’. 

11 (4) COORDINATION WITH SATISFYING MEANING12 FUL EHR USE CLINICAL QUALITY MEASURE REPORT13 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

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

15 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub16 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara17 graph (B)(ii)’’. 

18 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

19 (1) INCREASING TRANSPARENCY OF PHYSICIAN

20 FOCUSED PAYMENT MODELS.—Section 1868 of the 

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

22 by adding at the end the following new subsection: 

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

24 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 


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1 ‘‘(A) ESTABLISHMENT.—There is estab2 lished an ad hoc committee to be known as the 

3 ‘Payment Model Technical Advisory Committee’ 

4 (referred to in this subsection as the ‘Com5 mittee’). 

6 ‘‘(B) MEMBERSHIP.— 

7 ‘‘(i) NUMBER AND APPOINTMENT.— 

8 The Committee shall be composed of 11 

9 members appointed by the Comptroller 

10 General of the United States. 

11 ‘‘(ii) QUALIFICATIONS.—The member12 ship of the Committee shall include indi13 viduals with national recognition for their 

14 expertise in payment models and related 

15 delivery of care. No more than 5 members 

16 of the Committee shall be providers of 

17 services or suppliers, or representatives of 

18 providers of services or suppliers. 

19 ‘‘(iii) PROHIBITION ON FEDERAL EM20 PLOYMENT.—A member of the Committee 

21 shall not be an employee of the Federal 

22 Government. 

23 ‘‘(iv) ETHICS DISCLOSURE.—The 

24 Comptroller General shall establish a sys25 tem for public disclosure by members of 


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1 the Committee of financial and other po2 tential conflicts of interest relating to such 

3 members. Members of the Committee shall 

4 be treated as employees of Congress for 

5 purposes of applying title I of the Ethics 

6 in Government Act of 1978 (Public Law 

7 95–521). 

8 ‘‘(v) DATE OF INITIAL APPOINT9 MENTS.—The initial appointments of mem10 bers of the Committee shall be made by 

11 not later than 180 days after the date of 

12 enactment of this subsection. 

13 ‘‘(C) TERM; VACANCIES.— 

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

15 the Committee shall be for 3 years except 

16 that the Comptroller General shall des17 ignate staggered terms for the members 

18 first appointed. 

19 ‘‘(ii) VACANCIES.—Any member ap20 pointed to fill a vacancy occurring before 

21 the expiration of the term for which the 

22 member’s predecessor was appointed shall 

23 be appointed only for the remainder of that 

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1 cessor has taken office. A vacancy in the 

2 Committee shall be filled in the manner in 

3 which the original appointment was made. 

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

5 as needed, to provide comments and rec6 ommendations to the Secretary, as described in 

7 paragraph (2)(C), on physician-focused pay8 ment models. 

9 ‘‘(E) COMPENSATION OF MEMBERS.— 

10 ‘‘(i) IN GENERAL.—Except as pro11 vided in clause (ii), a member of the Com12 mittee shall serve without compensation. 

13 ‘‘(ii) TRAVEL EXPENSES.—A member 

14 of the Committee shall be allowed travel 

15 expenses, including per diem in lieu of sub16 sistence, at rates authorized for an em17 ployee of an agency under subchapter I of 

18 chapter 57 of title 5, United States Code, 

19 while away from the home or regular place 

20 of business of the member in the perform21 ance of the duties of the Committee. 

22 ‘‘(F) OPERATIONAL AND TECHNICAL SUP23 PORT.— 

24 ‘‘(i) IN GENERAL.—The Assistant 

25 Secretary for Planning and Evaluation 


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1 shall provide technical and operational sup2 port for the Committee, which may be by 

3 use of a contractor. The Office of the Ac4 tuary of the Centers for Medicare & Med5 icaid Services shall provide to the Com6 mittee actuarial assistance as needed. 

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

8 provide for the transfer, from the Federal 

9 Supplementary Medical Insurance Trust 

10 Fund under section 1841, such amounts as 

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

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

13 and each subsequent fiscal year. Any 

14 amounts transferred under the preceding 

15 sentence for a fiscal year shall remain 

16 available until expended. 

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

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

19 App.) shall not apply to the Committee. 

20 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

21 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

22 MODELS.— 

23 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN24 FOCUSED PAYMENT MODELS.— 


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1 ‘‘(i) RULEMAKING.—Not later than 

2 November 1, 2015, the Secretary shall, 

3 through notice and comment rulemaking, 

4 following a request for information, estab5 lish criteria for physician-focused payment 

6 models, including models for specialist phy7 sicians, that could be used by the Com8 mittee for making comments and rec9 ommendations pursuant to paragraph 

10 (1)(D). 

11 ‘‘(ii) MEDPAC SUBMISSION OF COM12 MENTS.—During the comment period for 

13 the proposed rule described in clause (i), 

14 the Medicare Payment Advisory Commis15 sion may submit comments to the Sec16 retary on the proposed criteria under such 

17 clause. 

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

19 update the criteria established under this 

20 subparagraph through rulemaking. 

21 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY22 SICIAN FOCUSED PAYMENT MODELS.—On an 

23 ongoing basis, individuals and stakeholder enti24 ties may submit to the Committee proposals for 

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1 dividuals and entities believe meet the criteria 

2 described in subparagraph (A). 

3 ‘‘(C) TAC REVIEW OF MODELS SUB4 MITTED.—The Committee shall, on a periodic 

5 basis, review models submitted under subpara6 graph (B), prepare comments and recommenda7 tions regarding whether such models meet the 

8 criteria described in subparagraph (A), and 

9 submit such comments and recommendations to 

10 the Secretary. 

11 ‘‘(D) SECRETARY REVIEW AND RE12 SPONSE.—The Secretary shall review the com13 ments and recommendations submitted by the 

14 Committee under subparagraph (C) and post a 

15 detailed response to such comments and rec16 ommendations on the Internet Website of the 

17 Centers for Medicare & Medicaid Services. 

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

19 this subsection shall be construed to impact the de20 velopment or testing of models under this title or ti21 tles XI, XIX, or XXI.’’. 

22 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

23 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

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


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1 1395l) is amended by adding at the end the fol2 lowing new subsection: 

3 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

4 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

5 ‘‘(1) PAYMENT INCENTIVE.— 

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

7 professional services furnished by an eligible 

8 professional during a year that is in the period 

9 beginning with 2018 and ending with 2023 and 

10 for which the professional is a qualifying APM 

11 participant, in addition to the amount of pay12 ment that would otherwise be made for such 

13 covered professional services under this part for 

14 such year, there also shall be paid to such pro15 fessional an amount equal to 5 percent of the 

16 payment amount for the covered professional 

17 services under this part for the preceding year. 

18 For purposes of the previous sentence, the pay19 ment amount for the preceding year may be an 

20 estimation for the full preceding year based on 

21 a period of such preceding year that is less than 

22 the full year. The Secretary shall establish poli23 cies to implement this subparagraph in cases 

24 where payment for covered professional services 

25 furnished by a qualifying APM participant in 


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1 an alternative payment model is made to an en2 tity participating in the alternative payment 

3 model rather than directly to the qualifying 

4 APM participant. 

5 ‘‘(B) FORM OF PAYMENT.—Payments 

6 under this subsection shall be made in a lump 

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

8 ‘‘(C) TREATMENT OF PAYMENT INCEN9 TIVE.—Payments under this subsection shall 

10 not be taken into account for purposes of deter11 mining actual expenditures under an alternative 

12 payment model and for purposes of determining 

13 or rebasing any benchmarks used under the al14 ternative payment model. 

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

16 additional payment for an item or service under 

17 this subsection or subsection (m) shall be deter18 mined without regard to any additional pay19 ment for the item or service under subsection 

20 (m) and this subsection, respectively. The 

21 amount of the additional payment for an item 

22 or service under this subsection or subsection 

23 (x) shall be determined without regard to any 

24 additional payment for the item or service 

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1 spectively. The amount of the additional pay2 ment for an item or service under this sub3 section or subsection (y) shall be determined 

4 without regard to any additional payment for 

5 the item or service under subsection (y) and 

6 this subsection, respectively. 

7 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur8 poses of this subsection, the term ‘qualifying APM 

9 participant’ means the following: 

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

11 2018 and 2019, an eligible professional for 

12 whom the Secretary determines that at least 25 

13 percent of payments under this part for covered 

14 professional services furnished by such profes15 sional during the most recent period for which 

16 data are available (which may be less than a 

17 year) were attributable to such services fur18 nished under this part through an entity that 

19 participates in an eligible alternative payment 

20 model with respect to such services. 

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

22 2020 and 2021, an eligible professional de23 scribed in either of the following clauses: 

24 ‘‘(i) MEDICARE REVENUE THRESHOLD

25 OPTION.—An eligible professional for 


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1 whom the Secretary determines that at 

2 least 50 percent of payments under this 

3 part for covered professional services fur4 nished by such professional during the 

5 most recent period for which data are 

6 available (which may be less than a year) 

7 were attributable to such services furnished 

8 under this part through an entity that par9 ticipates in an eligible alternative payment 

10 model with respect to such services. 

11 ‘‘(ii) COMBINATION ALL-PAYER AND

12 MEDICARE REVENUE THRESHOLD OP13 TION.—An eligible professional— 

14 ‘‘(I) for whom the Secretary de15 termines, with respect to items and 

16 services furnished by such professional 

17 during the most recent period for 

18 which data are available (which may 

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

20 percent of the sum of— 

21 ‘‘(aa) payments described in 

22 clause (i); and 

23 ‘‘(bb) all other payments, re24 gardless of payer (other than 

25 payments made by the Secretary 


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1 of Defense or the Secretary of 

2 Veterans Affairs under chapter 

3 55 of title 10, United States 

4 Code, or title 38, United States 

5 Code, or any other provision of 

6 law, and other than payments 

7 made under title XIX in a State 

8 in which no medical home or al9 ternative payment model is avail10 able under the State program 

11 under that title), 

12 meet the requirement described in 

13 clause (iii)(I) with respect to pay14 ments described in item (aa) and meet 

15 the requirement described in clause 

16 (iii)(II) with respect to payments de17 scribed in item (bb); 

18 ‘‘(II) for whom the Secretary de19 termines at least 25 percent of pay20 ments under this part for covered pro21 fessional services furnished by such 

22 professional during the most recent 

23 period for which data are available 

24 (which may be less than a year) were 

25 attributable to such services furnished 


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1 under this part through an entity that 

2 participates in an eligible alternative 

3 payment model with respect to such 

4 services; and 

5 ‘‘(III) who provides to the Sec6 retary such information as is nec7 essary for the Secretary to make a de8 termination under subclause (I), with 

9 respect to such professional. 

10 ‘‘(iii) REQUIREMENT.—For purposes 

11 of clause (ii)(I)— 

12 ‘‘(I) the requirement described in 

13 this subclause, with respect to pay14 ments described in item (aa) of such 

15 clause, is that such payments are 

16 made under an eligible alternative 

17 payment model; and 

18 ‘‘(II) the requirement described 

19 in this subclause, with respect to pay20 ments described in item (bb) of such 

21 clause, is that such payments are 

22 made under an arrangement in 

23 which— 

24 ‘‘(aa) quality measures com25 parable to measures under the 


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1 performance category described 

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

3 ‘‘(bb) certified EHR tech4 nology is used; and 

5 ‘‘(cc) the eligible profes6 sional (AA) bears more than 

7 nominal financial risk if actual 

8 aggregate expenditures exceeds 

9 expected aggregate expenditures; 

10 or (BB) is a medical home (with 

11 respect to beneficiaries under 

12 title XIX) that meets criteria 

13 comparable to medical homes ex14 panded under section 1115A(c). 

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

16 2022 and each subsequent year, an eligible pro17 fessional described in either of the following 

18 clauses: 

19 ‘‘(i) MEDICARE REVENUE THRESHOLD

20 OPTION.—An eligible professional for 

21 whom the Secretary determines that at 

22 least 75 percent of payments under this 

23 part for covered professional services fur24 nished by such professional during the 

25 most recent period for which data are 


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1 available (which may be less than a year) 

2 were attributable to such services furnished 

3 under this part through an entity that par4 ticipates in an eligible alternative payment 

5 model with respect to such services. 

6 ‘‘(ii) COMBINATION ALL-PAYER AND

7 MEDICARE REVENUE THRESHOLD OP8 TION.—An eligible professional— 

9 ‘‘(I) for whom the Secretary de10 termines, with respect to items and 

11 services furnished by such professional 

12 during the most recent period for 

13 which data are available (which may 

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

15 percent of the sum of— 

16 ‘‘(aa) payments described in 

17 clause (i); and 

18 ‘‘(bb) all other payments, re19 gardless of payer (other than 

20 payments made by the Secretary 

21 of Defense or the Secretary of 

22 Veterans Affairs under chapter 

23 55 of title 10, United States 

24 Code, or title 38, United States 

25 Code, or any other provision of 


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1 law, and other than payments 

2 made under title XIX in a State 

3 in which no medical home or al4 ternative payment model is avail5 able under the State program 

6 under that title), 

7 meet the requirement described in 

8 clause (iii)(I) with respect to pay9 ments described in item (aa) and meet 

10 the requirement described in clause 

11 (iii)(II) with respect to payments de12 scribed in item (bb); 

13 ‘‘(II) for whom the Secretary de14 termines at least 25 percent of pay15 ments under this part for covered pro16 fessional services furnished by such 

17 professional during the most recent 

18 period for which data are available 

19 (which may be less than a year) were 

20 attributable to such services furnished 

21 under this part through an entity that 

22 participates in an eligible alternative 

23 payment model with respect to such 

24 services; and 


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1 ‘‘(III) who provides to the Sec2 retary such information as is nec3 essary for the Secretary to make a de4 termination under subclause (I), with 

5 respect to such professional. 

6 ‘‘(iii) REQUIREMENT.—For purposes 

7 of clause (ii)(I)— 

8 ‘‘(I) the requirement described in 

9 this subclause, with respect to pay10 ments described in item (aa) of such 

11 clause, is that such payments are 

12 made under an eligible alternative 

13 payment model; and 

14 ‘‘(II) the requirement described 

15 in this subclause, with respect to pay16 ments described in item (bb) of such 

17 clause, is that such payments are 

18 made under an arrangement in 

19 which— 

20 ‘‘(aa) quality measures com21 parable to measures under the 

22 performance category described 

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

24 ‘‘(bb) certified EHR tech25 nology is used; and 


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1 ‘‘(cc) the eligible profes2 sional (AA) bears more than 

3 nominal financial risk if actual 

4 aggregate expenditures exceeds 

5 expected aggregate expenditures; 

6 or (BB) is a medical home (with 

7 respect to beneficiaries under 

8 title XIX) that meets criteria 

9 comparable to medical homes ex10 panded under section 1115A(c). 

11 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub12 section: 

13 ‘‘(A) COVERED PROFESSIONAL SERV14 ICES.—The term ‘covered professional services’ 

15 has the meaning given that term in section 

16 1848(k)(3)(A). 

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

18 ‘eligible professional’ has the meaning given 

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

20 ‘‘(C) ALTERNATIVE PAYMENT MODEL

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

22 means any of the following: 

23 ‘‘(i) A model under section 1115A 

24 (other than a health care innovation 

25 award). 


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1 ‘‘(ii) The shared savings program 

2 under section 1899. 

3 ‘‘(iii) A demonstration under section 

4 1866C. 

5 ‘‘(iv) A demonstration required by 

6 Federal law. 

7 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

8 MODEL (APM).— 

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

10 alternative payment model’ means, with re11 spect to a year, an alternative payment 

12 model— 

13 ‘‘(I) that requires use of certified 

14 EHR technology (as defined in sub15 section (o)(4)); 

16 ‘‘(II) that provides for payment 

17 for covered professional services based 

18 on quality measures comparable to 

19 measures under the performance cat20 egory described in section 

21 1848(q)(2)(B)(i); and 

22 ‘‘(III) that satisfies the require23 ment described in clause (ii). 

24 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

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1 ment described in this clause, with respect 

2 to a year and an alternative payment 

3 model, is that the alternative payment 

4 model— 

5 ‘‘(I) is one in which one or more 

6 entities bear financial risk for mone7 tary losses under such model that are 

8 in excess of a nominal amount; or 

9 ‘‘(II) is a medical home expanded 

10 under section 1115A(c). 

11 ‘‘(4) LIMITATION.—There shall be no adminis12 trative or judicial review under section 1869, 1878, 

13 or otherwise, of the following: 

14 ‘‘(A) The determination that an eligible 

15 professional is a qualifying APM participant 

16 under paragraph (2) and the determination 

17 that an alternative payment model is an eligible 

18 alternative payment model under paragraph 

19 (3)(D). 

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

21 the 5 percent payment incentive under para22 graph (1)(A), including any estimation as part 

23 of such determination.’’. 


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1 (3) COORDINATION CONFORMING AMEND2 MENTS.—Section 1833 of the Social Security Act 

3 (42 U.S.C. 1395l) is further amended— 

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

5 end the following new sentence: ‘‘The amount 

6 of the additional payment for a service under 

7 this subsection and subsection (z) shall be de8 termined without regard to any additional pay9 ment for the service under subsection (z) and 

10 this subsection, respectively.’’; and 

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

12 end the following new sentence: ‘‘The amount 

13 of the additional payment for a service under 

14 this subsection and subsection (z) shall be de15 termined without regard to any additional pay16 ment for the service under subsection (z) and 

17 this subsection, respectively.’’. 

18 (4) ENCOURAGING DEVELOPMENT AND TEST19 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

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

21 amended— 

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

23 end the following new clauses: 

24 ‘‘(xxi) Focusing primarily on physi25 cians’ services (as defined in section 


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1 1848(j)(3)) furnished by physicians who 

2 are not primary care practitioners. 

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

4 fewer professionals. 

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

6 for small physician practices which may in7 volve two-sided risk and prospective patient 

8 assignment, and which examine risk-ad9 justed decreases in mortality rates, hos10 pital readmissions rates, and other relevant 

11 and appropriate clinical measures. 

12 ‘‘(xxiv) Focusing primarily on title 

13 XIX, working in conjunction with the Cen14 ter for Medicaid and CHIP Services.’’; and 

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

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

17 and inserting ‘‘other public sector payers, pri18 vate sector payers, or Statewide payment mod19 els’’. 

20 (5) CONSTRUCTION REGARDING TELEHEALTH

21 SERVICES.—Nothing in the provisions of, or amend22 ments made by, this Act shall be construed as pre23 cluding an alternative payment model or a qualifying 

24 APM participant (as those terms are defined in sec25 tion 1833(z) of the Social Security Act, as added by 


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1 paragraph (1)) from furnishing a telehealth service 

2 for which payment is not made under section 

3 1834(m) of the Social Security Act (42 U.S.C. 

4 1395m(m)). 

5 (6) INTEGRATING MEDICARE ADVANTAGE AL6 TERNATIVE PAYMENT MODELS.—Not later than July 

7 1, 2015, the Secretary of Health and Human Serv8 ices shall submit to Congress a study that examines 

9 the feasibility of integrating alternative payment 

10 models in the Medicare Advantage payment system. 

11 The study shall include the feasibility of including a 

12 value-based modifier and whether such modifier 

13 should be budget neutral. 

14 (7) STUDY AND REPORT ON FRAUD RELATED

15 TO ALTERNATIVE PAYMENT MODELS UNDER THE

16 MEDICARE PROGRAM.— 

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

18 Human Services, in consultation with the In19 spector General of the Department of Health 

20 and Human Services, shall conduct a study 

21 that— 

22 (i) examines the applicability of the 

23 Federal fraud prevention laws to items and 

24 services furnished under title XVIII of the 

25 Social Security Act for which payment is 


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1 made under an alternative payment model 

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

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

4 (ii) identifies aspects of such alter5 native payment models that are vulnerable 

6 to fraudulent activity; and 

7 (iii) examines the implications of waiv8 ers to such laws granted in support of such 

9 alternative payment models, including 

10 under any potential expansion of such 

11 models. 

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

13 the date of the enactment of this Act, the Sec14 retary shall submit to Congress a report con15 taining the results of the study conducted under 

16 subparagraph (A). Such report shall include 

17 recommendations for actions to be taken to re18 duce the vulnerability of such alternative pay19 ment models to fraudulent activity. Such report 

20 also shall include, as appropriate, recommenda21 tions of the Inspector General for changes in 

22 Federal fraud prevention laws to reduce such 

23 vulnerability. 

24 (f) IMPROVING PAYMENT ACCURACY.— 


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1 (1) STUDIES AND REPORTS OF EFFECT OF CER2 TAIN INFORMATION ON QUALITY AND RESOURCE

3 USE.— 

4 (A) STUDY USING EXISTING MEDICARE

5 DATA.— 

6 (i) STUDY.—The Secretary of Health 

7 and Human Services (in this subsection re8 ferred to as the ‘‘Secretary’’) shall conduct 

9 a study that examines the effect of individ10 uals’ socioeconomic status on quality and 

11 resource use outcome measures for individ12 uals under the Medicare program (such as 

13 to recognize that less healthy individuals 

14 may require more intensive interventions). 

15 The study shall use information collected 

16 on such individuals in carrying out such 

17 program, such as urban and rural location, 

18 eligibility for Medicaid (recognizing and ac19 counting for varying Medicaid eligibility 

20 across States), and eligibility for benefits 

21 under the supplemental security income 

22 (SSI) program. The Secretary shall carry 

23 out this paragraph acting through the As24 sistant Secretary for Planning and Evalua25 tion. 


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

2 after the date of the enactment of this Act, 

3 the Secretary shall submit to Congress a 

4 report on the study conducted under clause 

5 (i). 

6 (B) STUDY USING OTHER DATA.— 

7 (i) STUDY.—The Secretary shall con8 duct a study that examines the impact of 

9 risk factors, such as those described in sec10 tion 1848(p)(3) of the Social Security Act 

11 (42 U.S.C. 1395w–4(p)(3)), race, health 

12 literacy, limited English proficiency (LEP), 

13 and patient activation, on quality and re14 source use outcome measures under the 

15 Medicare program (such as to recognize 

16 that less healthy individuals may require 

17 more intensive interventions). In con18 ducting such study the Secretary may use 

19 existing Federal data and collect such ad20 ditional data as may be necessary to com21 plete the study. 

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

23 after the date of the enactment of this Act, 

24 the Secretary shall submit to Congress a 


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1 report on the study conducted under clause 

2 (i). 

3 (C) EXAMINATION OF DATA IN CON4 DUCTING STUDIES.—In conducting the studies 

5 under subparagraphs (A) and (B), the Sec6 retary shall examine what non-Medicare data 

7 sets, such as data from the American Commu8 nity Survey (ACS), can be useful in conducting 

9 the types of studies under such paragraphs and 

10 how such data sets that are identified as useful 

11 can be coordinated with Medicare administra12 tive data in order to improve the overall data 

13 set available to do such studies and for the ad14 ministration of the Medicare program. 

15 (D) RECOMMENDATIONS TO ACCOUNT FOR

16 INFORMATION IN PAYMENT ADJUSTMENT

17 MECHANISMS.—If the studies conducted under 

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

19 between the factors examined in the studies and 

20 quality and resource use outcome measures, 

21 then the Secretary shall also provide rec22 ommendations for how the Centers for Medicare 

23 & Medicaid Services should— 

24 (i) obtain access to the necessary data 

25 (if such data is not already being collected) 


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1 on such factors, including recommenda2 tions on how to address barriers to the 

3 Centers in accessing such data; and 

4 (ii) account for such factors in deter5 mining payment adjustments based on 

6 quality and resource use outcome measures 

7 under the eligible professional Merit-based 

8 Incentive Payment System under section 

9 1848(q) of the Social Security Act (42 

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

11 determines appropriate, other similar pro12 visions of title XVIII of such Act. 

13 (E) FUNDING.—There are hereby appro14 priated from the Federal Supplementary Med15 ical Insurance Trust Fund under section 1841 

16 of the Social Security Act to the Secretary to 

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

18 available until expended. 

19 (2) CMS ACTIVITIES.— 

20 (A) HIERARCHAL CONDITION CATEGORY

21 (HCC) IMPROVEMENT.—Taking into account the 

22 relevant studies conducted and recommenda23 tions made in reports under paragraph (1), the 

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

25 Secretary determines appropriate, estimate how 


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1 an individual’s health status and other risk fac2 tors affect quality and resource use outcome 

3 measures and, as feasible, shall incorporate in4 formation from quality and resource use out5 come measurement (including care episode and 

6 patient condition groups) into provisions of title 

7 XVIII of the Social Security Act that are simi8 lar to the eligible professional Merit-based In9 centive Payment System under section 1848(q) 

10 of such Act. 

11 (B) ACCOUNTING FOR OTHER FACTORS IN

12 PAYMENT ADJUSTMENT MECHANISMS.— 

13 (i) IN GENERAL.—Taking into ac14 count the studies conducted and rec15 ommendations made in reports under para16 graph (1) and other information as appro17 priate, the Secretary shall, as the Sec18 retary determines appropriate, account for 

19 identified factors with an effect on quality 

20 and resource use outcome measures when 

21 determining payment adjustment mecha22 nisms under provisions of title XVIII of 

23 the Social Security Act that are similar to 

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1 tive Payment System under section 

2 1848(q) of such Act. 

3 (ii) ACCESSING DATA.—The Secretary 

4 shall collect or otherwise obtain access to 

5 the data necessary to carry out this para6 graph through existing and new data 

7 sources. 

8 (iii) PERIODIC ANALYSES.—The Sec9 retary shall carry out periodic analyses, at 

10 least every 3 years, based on the factors 

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

12 changes in possible relationships. 

13 (C) FUNDING.—There are hereby appro14 priated from the Federal Supplementary Med15 ical Insurance Trust Fund under section 1841 

16 of the Social Security Act to the Secretary to 

17 carry out this paragraph and the application of 

18 this paragraph to the Merit-based Incentive 

19 Payment System under section 1848(q) of such 

20 Act $10,000,000, to remain available until ex21 pended. 

22 (3) STRATEGIC PLAN FOR ACCESSING RACE

23 AND ETHNICITY DATA.—Not later than 18 months 

24 after the date of the enactment of this Act, the Sec25 retary shall develop and report to Congress on a 


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1 strategic plan for collecting or otherwise accessing 

2 data on race and ethnicity for purposes of carrying 

3 out the eligible professional Merit-based Incentive 

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

5 Security Act and, as the Secretary determines ap6 propriate, other similar provisions of title XVIII of 

7 such Act. 

8 (g) COLLABORATING WITH THE PHYSICIAN, PRACTI9 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

10 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 

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

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

13 at the end the following new subsection: 

14 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC15 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

16 IMPROVE RESOURCE USE MEASUREMENT.— 

17 ‘‘(1) IN GENERAL.—In order to involve the phy18 sician, practitioner, and other stakeholder commu19 nities in enhancing the infrastructure for resource 

20 use measurement, including for purposes of the 

21 value-based performance incentive program under 

22 subsection (q) and alternative payment models under 

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

24 steps described in the succeeding provisions of this 

25 subsection. 


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1 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA2 TIENT CONDITION GROUPS AND CLASSIFICATION

3 CODES.— 

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

5 similar patients into care episode groups and 

6 patient condition groups, the Secretary shall 

7 undertake the steps described in the succeeding 

8 provisions of this paragraph. 

9 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

10 EFFORTS TO DESIGN AN EPISODE GROUPER.— 

11 Not later than 120 days after the date of the 

12 enactment of this subsection, the Secretary 

13 shall post on the Internet website of the Cen14 ters for Medicare & Medicaid Services a list of 

15 the episode groups developed pursuant to sub16 section (n)(9)(A) and related descriptive infor17 mation. 

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

20 days after the day the Secretary posts the list 

21 pursuant to subparagraph (B), suggestions 

22 from physician specialty societies, applicable 

23 practitioner organizations, and other stake24 holders for episode groups in addition to those 

25 posted pursuant to such subparagraph, and 


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1 specific clinical criteria and patient characteris2 tics to classify patients into— 

3 ‘‘(i) care episode groups; and 

4 ‘‘(ii) patient condition groups. 

5 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS6 SIFICATION CODES.— 

7 ‘‘(i) IN GENERAL.—Taking into ac8 count the information described in sub9 paragraph (B) and the information re10 ceived under subparagraph (C), the Sec11 retary shall— 

12 ‘‘(I) establish care episode groups 

13 and patient condition groups, which 

14 account for a target of an estimated 

2 15 ⁄3 of expenditures under parts A and 

16 B; and 

17 ‘‘(II) assign codes to such 

18 groups. 

19 ‘‘(ii) CARE EPISODE GROUPS.—In es20 tablishing the care episode groups under 

21 clause (i), the Secretary shall take into ac22 count— 

23 ‘‘(I) the patient’s clinical prob24 lems at the time items and services 

25 are furnished during an episode of 


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1 care, such as the clinical conditions or 

2 diagnoses, whether or not inpatient 

3 hospitalization is anticipated or oc4 curs, and the principal procedures or 

5 services planned or furnished; and 

6 ‘‘(II) other factors determined 

7 appropriate by the Secretary. 

8 ‘‘(iii) PATIENT CONDITION GROUPS.— 

9 In establishing the patient condition 

10 groups under clause (i), the Secretary shall 

11 take into account— 

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

13 at the time of each medical visit, such 

14 as the patient’s combination of chron15 ic conditions, current health status, 

16 and recent significant history (such as 

17 hospitalization and major surgery dur18 ing a previous period, such as 3 

19 months); and 

20 ‘‘(II) other factors determined 

21 appropriate by the Secretary, such as 

22 eligibility status under this title (in23 cluding eligibility under section 

24 226(a), 226(b), or 226A, and dual eli25 gibility under this title and title XIX). 


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1 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

2 CONDITION GROUPS AND CLASSIFICATION

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

4 of the comment period described in subpara5 graph (C), the Secretary shall post on the 

6 Internet website of the Centers for Medicare & 

7 Medicaid Services a draft list of the care epi8 sode and patient condition codes established 

9 under subparagraph (D) (and the criteria and 

10 characteristics assigned to such code). 

11 ‘‘(F) SOLICITATION OF INPUT.—The Sec12 retary shall seek, through the date that is 60 

13 days after the Secretary posts the list pursuant 

14 to subparagraph (E), comments from physician 

15 specialty societies, applicable practitioner orga16 nizations, and other stakeholders, including rep17 resentatives of individuals entitled to benefits 

18 under part A or enrolled under this part, re19 garding the care episode and patient condition 

20 groups (and codes) posted under subparagraph 

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

22 shall use one or more mechanisms (other than 

23 notice and comment rulemaking) that may in24 clude use of open door forums, town hall meet25 ings, or other appropriate mechanisms. 


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1 ‘‘(G) OPERATIONAL LIST OF CARE EPI2 SODE AND PATIENT CONDITION GROUPS AND

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

4 of the comment period described in subpara5 graph (F), taking into account the comments 

6 received under such subparagraph, the Sec7 retary shall post on the Internet website of the 

8 Centers for Medicare & Medicaid Services an 

9 operational list of care episode and patient con10 dition codes (and the criteria and characteris11 tics assigned to such code). 

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

13 than November 1 of each year (beginning with 

14 2017), the Secretary shall, through rulemaking, 

15 make revisions to the operational lists of care 

16 episode and patient condition codes as the Sec17 retary determines may be appropriate. Such re18 visions may be based on experience, new infor19 mation developed pursuant to subsection 

20 (n)(9)(A), and input from the physician spe21 cialty societies, applicable practitioner organiza22 tions, and other stakeholders, including rep23 resentatives of individuals entitled to benefits 

24 under part A or enrolled under this part. 


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1 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI2 CIANS OR PRACTITIONERS.— 

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

4 the attribution of patients and episodes (in 

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

6 applicable practitioners furnishing items and 

7 services, the Secretary shall undertake the steps 

8 described in the succeeding provisions of this 

9 paragraph. 

10 ‘‘(B) DEVELOPMENT OF PATIENT RELA11 TIONSHIP CATEGORIES AND CODES.—The Sec12 retary shall develop patient relationship cat13 egories and codes that define and distinguish 

14 the relationship and responsibility of a physi15 cian or applicable practitioner with a patient at 

16 the time of furnishing an item or service. Such 

17 patient relationship categories shall include dif18 ferent relationships of the physician or applica19 ble practitioner to the patient (and the codes 

20 may reflect combinations of such categories), 

21 such as a physician or applicable practitioner 

22 who— 

23 ‘‘(i) considers themself to have the 

24 primary responsibility for the general and 


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1 ongoing care for the patient over extended 

2 periods of time; 

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

4 physician or practitioner and who furnishes 

5 items and services and coordinates care 

6 furnished by other physicians or practi7 tioners for the patient during an acute epi8 sode; 

9 ‘‘(iii) furnishes items and services to 

10 the patient on a continuing basis during an 

11 acute episode of care, but in a supportive 

12 rather than a lead role; 

13 ‘‘(iv) furnishes items and services to 

14 the patient on an occasional basis, usually 

15 at the request of another physician or 

16 practitioner; or 

17 ‘‘(v) furnishes items and services only 

18 as ordered by another physician or practi19 tioner. 

20 ‘‘(C) DRAFT LIST OF PATIENT RELATION21 SHIP CATEGORIES AND CODES.—Not later than 

22 270 days after the date of the enactment of this 

23 subsection, the Secretary shall post on the 

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1 lationship categories and codes developed under 

2 subparagraph (B). 

3 ‘‘(D) STAKEHOLDER INPUT.—The Sec4 retary shall seek, through the date that is 60 

5 days after the Secretary posts the list pursuant 

6 to subparagraph (C), comments from physician 

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

10 under part A or enrolled under this part, re11 garding the patient relationship categories and 

12 codes posted under subparagraph (C). In seek13 ing such comments, the Secretary shall use one 

14 or more mechanisms (other than notice and 

15 comment rulemaking) that may include open 

16 door forums, town hall meetings, or other ap17 propriate mechanisms. 

18 ‘‘(E) OPERATIONAL LIST OF PATIENT RE19 LATIONSHIP CATEGORIES AND CODES.—Not 

20 later than 180 days after the end of the com21 ment period described in subparagraph (D), 

22 taking into account the comments received 

23 under such subparagraph, the Secretary shall 

24 post on the Internet website of the Centers for 


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1 Medicare & Medicaid Services an operational 

2 list of patient relationship categories and codes. 

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

4 than November 1 of each year (beginning with 

5 2017), the Secretary shall, through rulemaking, 

6 make revisions to the operational list of patient 

7 relationship categories and codes as the Sec8 retary determines appropriate. Such revisions 

9 may be based on experience, new information 

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

11 input from the physician specialty societies, ap12 plicable practitioner organizations, and other 

13 stakeholders, including representatives of indi14 viduals entitled to benefits under part A or en15 rolled under this part. 

16 ‘‘(4) REPORTING OF INFORMATION FOR RE17 SOURCE USE MEASUREMENT.—Claims submitted for 

18 items and services furnished by a physician or appli19 cable practitioner on or after January 1, 2017, shall, 

20 as determined appropriate by the Secretary, in21 clude— 

22 ‘‘(A) applicable codes established under 

23 paragraphs (2) and (3); and 

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

25 ordering physician or applicable practitioner (if 


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1 different from the billing physician or applicable 

2 practitioner). 

3 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL4 YSIS.— 

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

6 the resources used to treat patients (with re7 spect to care episode and patient condition 

8 groups), the Secretary shall— 

9 ‘‘(i) use the patient relationship codes 

10 reported on claims pursuant to paragraph 

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

12 part) to one or more physicians and appli13 cable practitioners; 

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

15 condition codes reported on claims pursu16 ant to paragraph (4) as a basis to compare 

17 similar patients and care episodes and pa18 tient condition groups; and 

19 ‘‘(iii) conduct an analysis of resource 

20 use (with respect to care episodes and pa21 tient condition groups of such patients), as 

22 the Secretary determines appropriate. 

23 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI24 CIANS AND PRACTITIONERS.—In conducting the 

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


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1 respect to patients attributed to physicians and 

2 applicable practitioners, the Secretary shall, as 

3 feasible— 

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

5 such patients by patient condition codes 

6 during a common period, such as 12 

7 months; and 

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

9 such patients by care episode codes— 

10 ‘‘(I) in the case of episodes with11 out a hospitalization, during periods 

12 of time (such as the number of days) 

13 determined appropriate by the Sec14 retary; and 

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

16 a hospitalization, during periods of 

17 time (such as the number of days) be18 fore, during, and after the hospitaliza19 tion. 

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

21 In measuring such resource use, the Sec22 retary— 

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

24 charges for all services under part A and 

25 this part (and, if the Secretary determines 


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1 appropriate, part D) for the analysis of pa2 tient resource use, by care episode codes 

3 and by patient condition codes; and 

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

5 use other measures of allowed charges 

6 (such as subtotals for categories of items 

7 and services) and measures of utilization of 

8 items and services (such as frequency of 

9 specific items and services and the ratio of 

10 specific items and services among attrib11 uted patients or episodes). 

12 ‘‘(D) STAKEHOLDER INPUT.—The Sec13 retary shall seek comments from the physician 

14 specialty societies, applicable practitioner orga15 nizations, and other stakeholders, including rep16 resentatives of individuals entitled to benefits 

17 under part A or enrolled under this part, re18 garding the resource use methodology estab19 lished pursuant to this paragraph. In seeking 

20 comments the Secretary shall use one or more 

21 mechanisms (other than notice and comment 

22 rulemaking) that may include open door fo23 rums, town hall meetings, or other appropriate 

24 mechanisms. 


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

2 the Secretary contracts with an entity to carry out 

3 any part of the provisions of this subsection, the 

4 Secretary may not contract with an entity or an en5 tity with a subcontract if the entity or subcon6 tracting entity currently makes recommendations to 

7 the Secretary on relative values for services under 

8 the fee schedule for physicians’ services under this 

9 section. 

10 ‘‘(7) LIMITATION.—There shall be no adminis11 trative or judicial review under section 1869, section 

12 1878, or otherwise of— 

13 ‘‘(A) care episode and patient condition 

14 groups and codes established under paragraph 

15 (2); 

16 ‘‘(B) patient relationship categories and 

17 codes established under paragraph (3); and 

18 ‘‘(C) measurement of, and analyses of re19 source use with respect to, care episode and pa20 tient condition codes and patient relationship 

21 codes pursuant to paragraph (5). 

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

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

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


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

2 has the meaning given such term in section 

3 1861(r)(1). 

4 ‘‘(B) APPLICABLE PRACTITIONER.—The 

5 term ‘applicable practitioner’ means— 

6 ‘‘(i) a physician assistant, nurse prac7 titioner, and clinical nurse specialist (as 

8 such terms are defined in section 

9 1861(aa)(5)), and a certified registered 

10 nurse anesthetist (as defined in section 

11 1861(bb)(2)); and 

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

13 other eligible professionals (as defined in 

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

15 Secretary. 

16 ‘‘(10) CLARIFICATION.—The provisions of sec17 tions 1890(b)(7) and 1890A shall not apply to this 

18 subsection.’’. 

19 SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVEL20 OPMENT. 

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

22 1395w–4), as amended by subsections (c) and (g) of sec23 tion 2, is further amended by inserting at the end the fol24 lowing new subsection: 


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1 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE2 VELOPMENT.— 

3 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP4 MENT PRIORITIES AND TIMELINES.— 

5 ‘‘(A) DRAFT MEASURE DEVELOPMENT

6 PLAN.—Not later than January 1, 2015, the 

7 Secretary shall develop, and post on the Inter8 net website of the Centers for Medicare & Med9 icaid Services, a draft plan for the development 

10 of quality measures for application under the 

11 applicable provisions (as defined in paragraph 

12 (5)). Under such plan the Secretary shall— 

13 ‘‘(i) address how measures used by 

14 private payers and integrated delivery sys15 tems could be incorporated under title 

16 XVIII; 

17 ‘‘(ii) describe how coordination, to the 

18 extent possible, will occur across organiza19 tions developing such measures; and 

20 ‘‘(iii) take into account how clinical 

21 best practices and clinical practice guide22 lines should be used in the development of 

23 quality measures. 


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1 ‘‘(B) QUALITY DOMAINS.—For purposes of 

2 this subsection, the term ‘quality domains’ 

3 means at least the following domains: 

4 ‘‘(i) Clinical care. 

5 ‘‘(ii) Safety. 

6 ‘‘(iii) Care coordination. 

7 ‘‘(iv) Patient and caregiver experience. 

8 ‘‘(v) Population health and preven9 tion. 

10 ‘‘(C) CONSIDERATION.—In developing the 

11 draft plan under this paragraph, the Secretary 

12 shall consider— 

13 ‘‘(i) gap analyses conducted by the en14 tity with a contract under section 1890(a) 

15 or other contractors or entities; 

16 ‘‘(ii) whether measures are applicable 

17 across health care settings; 

18 ‘‘(iii) clinical practice improvement ac19 tivities submitted under subsection 

20 (q)(2)(C)(iv) for identifying possible areas 

21 for future measure development and identi22 fying existing gaps with respect to such 

23 measures; and 

24 ‘‘(iv) the quality domains applied 

25 under this subsection. 


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1 ‘‘(D) PRIORITIES.—In developing the draft 

2 plan under this paragraph, the Secretary shall 

3 give priority to the following types of measures: 

4 ‘‘(i) Outcome measures, including pa5 tient reported outcome and functional sta6 tus measures. 

7 ‘‘(ii) Patient experience measures. 

8 ‘‘(iii) Care coordination measures. 

9 ‘‘(iv) Measures of appropriate use of 

10 services, including measures of over use. 

11 ‘‘(E) STAKEHOLDER INPUT.—The Sec12 retary shall accept through March 1, 2015, 

13 comments on the draft plan posted under para14 graph (1)(A) from the public, including health 

15 care providers, payers, consumers, and other 

16 stakeholders. 

17 ‘‘(F) FINAL MEASURE DEVELOPMENT

18 PLAN.—Not later than May 1, 2015, taking 

19 into account the comments received under this 

20 subparagraph, the Secretary shall finalize the 

21 plan and post on the Internet website of the 

22 Centers for Medicare & Medicaid Services an 

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1 sions. Such plan shall be updated as appro2 priate. 

3 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

4 FOR QUALITY MEASURE DEVELOPMENT.— 

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

6 enter into contracts or other arrangements with 

7 entities for the purpose of developing, improv8 ing, updating, or expanding in accordance with 

9 the plan under paragraph (1) quality measures 

10 for application under the applicable provisions. 

11 Such entities shall include organizations with 

12 quality measure development expertise. 

13 ‘‘(B) PRIORITIZATION.— 

14 ‘‘(i) IN GENERAL.—In entering into 

15 contracts or other arrangements under 

16 subparagraph (A), the Secretary shall give 

17 priority to the development of the types of 

18 measures described in paragraph (1)(D). 

19 ‘‘(ii) CONSIDERATION.—In selecting 

20 measures for development under this sub21 section, the Secretary shall consider— 

22 ‘‘(I) whether such measures 

23 would be electronically specified; and 


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1 ‘‘(II) clinical practice guidelines 

2 to the extent that such guidelines 

3 exist. 

4 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

5 ‘‘(A) IN GENERAL.—Not later than May 1, 

6 2016, and annually thereafter, the Secretary 

7 shall post on the Internet website of the Cen8 ters for Medicare & Medicaid Services a report 

9 on the progress made in developing quality 

10 measures for application under the applicable 

11 provisions. 

12 ‘‘(B) REQUIREMENTS.—Each report sub13 mitted pursuant to subparagraph (A) shall in14 clude the following: 

15 ‘‘(i) A description of the Secretary’s 

16 efforts to implement this paragraph. 

17 ‘‘(ii) With respect to the measures de18 veloped during the previous year— 

19 ‘‘(I) a description of the total 

20 number of quality measures developed 

21 and the types of such measures, such 

22 as an outcome or patient experience 

23 measure; 

24 ‘‘(II) the name of each measure 

25 developed; 


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1 ‘‘(III) the name of the developer 

2 and steward of each measure; 

3 ‘‘(IV) with respect to each type 

4 of measure, an estimate of the total 

5 amount expended under this title to 

6 develop all measures of such type; and 

7 ‘‘(V) whether the measure would 

8 be electronically specified. 

9 ‘‘(iii) With respect to measures in de10 velopment at the time of the report— 

11 ‘‘(I) the information described in 

12 clause (ii), if available; and 

13 ‘‘(II) a timeline for completion of 

14 the development of such measures. 

15 ‘‘(iv) A description of any updates to 

16 the plan under paragraph (1) (including 

17 newly identified gaps and the status of pre18 viously identified gaps) and the inventory 

19 of measures applicable under the applicable 

20 provisions. 

21 ‘‘(v) Other information the Secretary 

22 determines to be appropriate. 

23 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

24 paragraph (1), the Secretary shall seek stakeholder 

25 input with respect to— 


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1 ‘‘(A) the identification of gaps where no 

2 quality measures exist, particularly with respect 

3 to the types of measures described in paragraph 

4 (1)(D); 

5 ‘‘(B) prioritizing quality measure develop6 ment to address such gaps; and 

7 ‘‘(C) other areas related to quality measure 

8 development determined appropriate by the Sec9 retary. 

10 ‘‘(5) DEFINITION OF APPLICABLE PROVI11 SIONS.—In this subsection, the term ‘applicable pro12 visions’ means the following provisions: 

13 ‘‘(A) Subsection (q)(2)(B)(i). 

14 ‘‘(B) Section 1833(z)(2)(C). 

15 ‘‘(6) FUNDING.—For purposes of carrying out 

16 this subsection, the Secretary shall provide for the 

17 transfer, from the Federal Supplementary Medical 

18 Insurance Trust Fund under section 1841, of 

19 $15,000,000 to the Centers for Medicare & Medicaid 

20 Services Program Management Account for each of 

21 fiscal years 2014 through 2018. Amounts trans22 ferred under this paragraph shall remain available 

23 through the end of fiscal year 2021.’’. 


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1 SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVID2 UALS WITH CHRONIC CARE NEEDS. 

3 (a) IN GENERAL.—Section 1848(b) of the Social Se4 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

5 at the end the following new paragraph: 

6 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

7 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

8 ‘‘(A) IN GENERAL.—In order to encourage 

9 the management of care by an applicable pro10 vider (as defined in subparagraph (B)) for indi11 viduals with chronic care needs the Secretary 

12 shall— 

13 ‘‘(i) establish one or more HCPCS 

14 codes for chronic care management serv15 ices for such individuals; and 

16 ‘‘(ii) subject to subparagraph (D), 

17 make payment (as the Secretary deter18 mines to be appropriate) under this section 

19 for such management services furnished on 

20 or after January 1, 2015, by an applicable 

21 provider. 

22 ‘‘(B) APPLICABLE PROVIDER DEFINED.— 

23 For purposes of this paragraph, the term ‘ap24 plicable provider’ means a physician (as defined 

25 in section 1861(r)(1)), physician assistant or 

26 nurse practitioner (as defined in section 


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1 1861(aa)(5)(A)), or clinical nurse specialist (as 

2 defined in section 1861(aa)(5)(B)) who fur3 nishes services as part of a patient-centered 

4 medical home or a comparable specialty practice 

5 that— 

6 ‘‘(i) is recognized as such a medical 

7 home or comparable specialty practice by 

8 an organization that is recognized by the 

9 Secretary for purposes of such recognition 

10 as such a medical home or practice; or 

11 ‘‘(ii) meets such other comparable 

12 qualifications as the Secretary determines 

13 to be appropriate. 

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

15 neutrality provision under subsection 

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

17 payment under subparagraph (A)(ii). 

18 ‘‘(D) POLICIES RELATING TO PAYMENT.— 

19 In carrying out this paragraph, with respect to 

20 chronic care management services, the Sec21 retary shall— 

22 ‘‘(i) make payment to only one appli23 cable provider for such services furnished 

24 to an individual during a period; 


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1 ‘‘(ii) not make payment under sub2 paragraph (A) if such payment would be 

3 duplicative of payment that is otherwise 

4 made under this title for such services 

5 (such as in the case of hospice care or 

6 home health services); and 

7 ‘‘(iii) not require that an annual 

8 wellness visit (as defined in section 

9 1861(hhh)) or an initial preventive phys10 ical examination (as defined in section 

11 1861(ww)) be furnished as a condition of 

12 payment for such management services.’’. 

13 (b) EDUCATION AND OUTREACH.— 

14 (1) CAMPAIGN.— 

15 (A) IN GENERAL.—The Secretary of 

16 Health and Human Services (in this subsection 

17 referred to as the ‘‘Secretary’’) shall conduct an 

18 education and outreach campaign to inform 

19 professionals who furnish items and services 

20 under part B of title XVIII of the Social Secu21 rity Act and individuals enrolled under such 

22 part of the benefits of chronic care management 

23 services described in section 1848(b)(8) of the 

24 Social Security Act, as added by subsection (a), 


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1 and encourage such individuals with chronic 

2 care needs to receive such services. 

3 (B) REQUIREMENTS.—Such campaign 

4 shall— 

5 (i) be directed by the Office of Rural 

6 Health Policy of the Department of Health 

7 and Human Services and the Office of Mi8 nority Health of the Centers for Medicare 

9 & Medicaid Services; and 

10 (ii) focus on encouraging participation 

11 by underserved rural populations and ra12 cial and ethnic minority populations. 

13 (2) REPORT.— 

14 (A) IN GENERAL.—Not later than Decem15 ber 31, 2017, the Secretary shall submit to 

16 Congress a report on the use of chronic care 

17 management services described in such section 

18 1848(b)(8) by individuals living in rural areas 

19 and by racial and ethnic minority populations. 

20 Such report shall— 

21 (i) identify barriers to receiving chron22 ic care management services; and 

23 (ii) make recommendations for in24 creasing the appropriate use of chronic 

25 care management services. 


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1 SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES 

2 UNDER THE PHYSICIAN FEE SCHEDULE. 

3 (a) AUTHORITY TO COLLECT AND USE INFORMA4 TION ON PHYSICIANS’ SERVICES IN THE DETERMINATION

5 OF RELATIVE VALUES.— 

6 (1) IN GENERAL.—Section 1848(c)(2) of the 

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

8 amended by adding at the end the following new 

9 subparagraph: 

10 ‘‘(M) AUTHORITY TO COLLECT AND USE

11 INFORMATION ON PHYSICIANS’ SERVICES IN

12 THE DETERMINATION OF RELATIVE VALUES.— 

13 ‘‘(i) COLLECTION OF INFORMATION.— 

14 Notwithstanding any other provision of 

15 law, the Secretary may collect or obtain in16 formation on the resources directly or indi17 rectly related to furnishing services for 

18 which payment is made under the fee 

19 schedule established under subsection (b). 

20 Such information may be collected or ob21 tained from any eligible professional or any 

22 other source. 

23 ‘‘(ii) USE OF INFORMATION.—Not24 withstanding any other provision of law, 

25 subject to clause (v), the Secretary may 

26 (as the Secretary determines appropriate) 


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1 use information collected or obtained pur2 suant to clause (i) in the determination of 

3 relative values for services under this sec4 tion. 

5 ‘‘(iii) TYPES OF INFORMATION.—The 

6 types of information described in clauses 

7 (i) and (ii) may, at the Secretary’s discre8 tion, include any or all of the following: 

9 ‘‘(I) Time involved in furnishing 

10 services. 

11 ‘‘(II) Amounts and types of prac12 tice expense inputs involved with fur13 nishing services. 

14 ‘‘(III) Prices (net of any dis15 counts) for practice expense inputs, 

16 which may include paid invoice prices 

17 or other documentation or records. 

18 ‘‘(IV) Overhead and accounting 

19 information for practices of physicians 

20 and other suppliers. 

21 ‘‘(V) Any other element that 

22 would improve the valuation of serv23 ices under this section. 

24 ‘‘(iv) INFORMATION COLLECTION

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1 lected or obtained pursuant to this sub2 paragraph from any or all of the following: 

3 ‘‘(I) Surveys of physicians, other 

4 suppliers, providers of services, manu5 facturers, and vendors. 

6 ‘‘(II) Surgical logs, billing sys7 tems, or other practice or facility 

8 records. 

9 ‘‘(III) Electronic health records. 

10 ‘‘(IV) Any other mechanism de11 termined appropriate by the Sec12 retary. 

13 ‘‘(v) TRANSPARENCY OF USE OF IN14 FORMATION.— 

15 ‘‘(I) IN GENERAL.—Subject to 

16 subclauses (II) and (III), if the Sec17 retary uses information collected or 

18 obtained under this subparagraph in 

19 the determination of relative values 

20 under this subsection, the Secretary 

21 shall disclose the information source 

22 and discuss the use of such informa23 tion in such determination of relative 

24 values through notice and comment 

25 rulemaking. 


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1 ‘‘(II) THRESHOLDS FOR USE.— 

2 The Secretary may establish thresh3 olds in order to use such information, 

4 including the exclusion of information 

5 collected or obtained from eligible pro6 fessionals who use very high resources 

7 (as determined by the Secretary) in 

8 furnishing a service. 

9 ‘‘(III) DISCLOSURE OF INFORMA10 TION.—The Secretary shall make ag11 gregate information available under 

12 this subparagraph but shall not dis13 close information in a form or manner 

14 that identifies an eligible professional 

15 or a group practice, or information 

16 collected or obtained pursuant to a 

17 nondisclosure agreement. 

18 ‘‘(vi) INCENTIVE TO PARTICIPATE.— 

19 The Secretary may provide for such pay20 ments under this part to an eligible profes21 sional that submits such solicited informa22 tion under this subparagraph as the Sec23 retary determines appropriate in order to 

24 compensate such eligible professional for 

25 such submission. Such payments shall be 


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1 provided in a form and manner specified 

2 by the Secretary. 

3 ‘‘(vii) ADMINISTRATION.—Chapter 35 

4 of title 44, United States Code, shall not 

5 apply to information collected or obtained 

6 under this subparagraph. 

7 ‘‘(viii) DEFINITION OF ELIGIBLE PRO8 FESSIONAL.—In this subparagraph, the 

9 term ‘eligible professional’ has the meaning 

10 given such term in subsection (k)(3)(B). 

11 ‘‘(ix) FUNDING.—For purposes of car12 rying out this subparagraph, in addition to 

13 funds otherwise appropriated, the Sec14 retary shall provide for the transfer, from 

15 the Federal Supplementary Medical Insur16 ance Trust Fund under section 1841, of 

17 $2,000,000 to the Centers for Medicare & 

18 Medicaid Services Program Management 

19 Account for each fiscal year beginning with 

20 fiscal year 2014. Amounts transferred 

21 under the preceding sentence for a fiscal 

22 year shall be available until expended.’’. 

23 (2) LIMITATION ON REVIEW.—Section 

24 1848(i)(1) of the Social Security Act (42 U.S.C. 

25 1395w–4(i)(1)) is amended— 


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1 (A) in subparagraph (D), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (E), by striking the 

4 period at the end and inserting ‘‘, and’’; and 

5 (C) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(F) the collection and use of information 

8 in the determination of relative values under 

9 subsection (c)(2)(M).’’. 

10 (b) AUTHORITY FOR ALTERNATIVE APPROACHES TO

11 ESTABLISHING PRACTICE EXPENSE RELATIVE VAL12 UES.—Section 1848(c)(2) of the Social Security Act (42 

13 U.S.C. 1395w–4(c)(2)), as amended by subsection (a), is 

14 amended by adding at the end the following new subpara15 graph: 

16 ‘‘(N) AUTHORITY FOR ALTERNATIVE AP17 PROACHES TO ESTABLISHING PRACTICE EX18 PENSE RELATIVE VALUES.—The Secretary may 

19 establish or adjust practice expense relative val20 ues under this subsection using cost, charge, or 

21 other data from suppliers or providers of serv22 ices, including information collected or obtained 

23 under subparagraph (M).’’. 

24 (c) REVISED AND EXPANDED IDENTIFICATION OF

25 POTENTIALLY MISVALUED CODES.—Section 


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1 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 

2 1395w–4(c)(2)(K)(ii)) is amended to read as follows: 

3 ‘‘(ii) IDENTIFICATION OF POTEN4 TIALLY MISVALUED CODES.—For purposes 

5 of identifying potentially misvalued codes 

6 pursuant to clause (i)(I), the Secretary 

7 shall examine codes (and families of codes 

8 as appropriate) based on any or all of the 

9 following criteria: 

10 ‘‘(I) Codes that have experienced 

11 the fastest growth. 

12 ‘‘(II) Codes that have experi13 enced substantial changes in practice 

14 expenses. 

15 ‘‘(III) Codes that describe new 

16 technologies or services within an ap17 propriate time period (such as 3 

18 years) after the relative values are ini19 tially established for such codes. 

20 ‘‘(IV) Codes which are multiple 

21 codes that are frequently billed in con22 junction with furnishing a single serv23 ice. 

24 ‘‘(V) Codes with low relative val25 ues, particularly those that are often 


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1 billed multiple times for a single treat2 ment. 

3 ‘‘(VI) Codes that have not been 

4 subject to review since implementation 

5 of the fee schedule. 

6 ‘‘(VII) Codes that account for 

7 the majority of spending under the 

8 physician fee schedule. 

9 ‘‘(VIII) Codes for services that 

10 have experienced a substantial change 

11 in the hospital length of stay or proce12 dure time. 

13 ‘‘(IX) Codes for which there may 

14 be a change in the typical site of serv15 ice since the code was last valued. 

16 ‘‘(X) Codes for which there is a 

17 significant difference in payment for 

18 the same service between different 

19 sites of service. 

20 ‘‘(XI) Codes for which there may 

21 be anomalies in relative values within 

22 a family of codes. 

23 ‘‘(XII) Codes for services where 

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1 ice is furnished at the same time as 

2 other services. 

3 ‘‘(XIII) Codes with high intra4 service work per unit of time. 

5 ‘‘(XIV) Codes with high practice 

6 expense relative value units. 

7 ‘‘(XV) Codes with high cost sup8 plies. 

9 ‘‘(XVI) Codes as determined ap10 propriate by the Secretary.’’. 

11 (d) TARGET FOR RELATIVE VALUE ADJUSTMENTS

12 FOR MISVALUED SERVICES.— 

13 (1) IN GENERAL.—Section 1848(c)(2) of the 

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

15 amended by subsections (a) and (b), is amended by 

16 adding at the end the following new subparagraph: 

17 ‘‘(O) TARGET FOR RELATIVE VALUE AD18 JUSTMENTS FOR MISVALUED SERVICES.—With 

19 respect to fee schedules established for each of 

20 2015 through 2018, the following shall apply: 

21 ‘‘(i) DETERMINATION OF NET REDUC22 TION IN EXPENDITURES.—For each year, 

23 the Secretary shall determine the esti24 mated net reduction in expenditures under 

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1 spect to the year as a result of adjust2 ments to the relative values established 

3 under this paragraph for misvalued codes. 

4 ‘‘(ii) BUDGET NEUTRAL REDISTRIBU5 TION OF FUNDS IF TARGET MET AND

6 COUNTING OVERAGES TOWARDS THE TAR7 GET FOR THE SUCCEEDING YEAR.—If the 

8 estimated net reduction in expenditures de9 termined under clause (i) for the year is 

10 equal to or greater than the target for the 

11 year— 

12 ‘‘(I) reduced expenditures attrib13 utable to such adjustments shall be 

14 redistributed for the year in a budget 

15 neutral manner in accordance with 

16 subparagraph (B)(ii)(II); and 

17 ‘‘(II) the amount by which such 

18 reduced expenditures exceeds the tar19 get for the year shall be treated as a 

20 reduction in expenditures described in 

21 clause (i) for the succeeding year, for 

22 purposes of determining whether the 

23 target has or has not been met under 

24 this subparagraph with respect to that 

25 year. 


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1 ‘‘(iii) EXEMPTION FROM BUDGET

2 NEUTRALITY IF TARGET NOT MET.—If the 

3 estimated net reduction in expenditures de4 termined under clause (i) for the year is 

5 less than the target for the year, reduced 

6 expenditures in an amount equal to the 

7 target recapture amount shall not be taken 

8 into account in applying subparagraph 

9 (B)(ii)(II) with respect to fee schedules be10 ginning with 2015. 

11 ‘‘(iv) TARGET RECAPTURE AMOUNT.— 

12 For purposes of clause (iii), the target re13 capture amount is, with respect to a year, 

14 an amount equal to the difference be15 tween— 

16 ‘‘(I) the target for the year; and 

17 ‘‘(II) the estimated net reduction 

18 in expenditures determined under 

19 clause (i) for the year. 

20 ‘‘(v) TARGET.—For purposes of this 

21 subparagraph, with respect to a year, the 

22 target is calculated as 0.5 percent of the 

23 estimated amount of expenditures under 

24 the fee schedule under this section for the 

25 year.’’. 


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1 (2) CONFORMING AMENDMENT.—Section 

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

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

4 at the end the following new subclause: 

5 ‘‘(VIII) REDUCTIONS FOR

6 MISVALUED SERVICES IF TARGET NOT

7 MET.—Effective for fee schedules be8 ginning with 2015, reduced expendi9 tures attributable to the application of 

10 the target recapture amount described 

11 in subparagraph (O)(iii).’’. 

12 (e) PHASE-IN OF SIGNIFICANT RELATIVE VALUE

13 UNIT (RVU) REDUCTIONS.— 

14 (1) IN GENERAL.—Section 1848(c) of the So15 cial Security Act (42 U.S.C. 1395w–4(c)) is amend16 ed by adding at the end the following new para17 graph: 

18 ‘‘(7) PHASE-IN OF SIGNIFICANT RELATIVE

19 VALUE UNIT (RVU) REDUCTIONS.—Effective for fee 

20 schedules established beginning with 2015, if the 

21 total relative value units for a service for a year 

22 would otherwise be decreased by an estimated 

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1 tice expense, and malpractice relative value units 

2 shall be phased-in over a 2-year period.’’. 

3 (2) CONFORMING AMENDMENTS.—Section 

4 1848(c)(2) of the Social Security Act (42 U.S.C. 

5 1395w–4(c)(2)) is amended— 

6 (A) in subparagraph (B)(ii)(I), by striking 

7 ‘‘subclause (II)’’ and inserting ‘‘subclause (II) 

8 and paragraph (7)’’; and 

9 (B) in subparagraph (K)(iii)(VI)— 

10 (i) by striking ‘‘provisions of subpara11 graph (B)(ii)(II)’’ and inserting ‘‘provi12 sions of subparagraph (B)(ii)(II) and para13 graph (7)’’; and 

14 (ii) by striking ‘‘under subparagraph 

15 (B)(ii)(II)’’ and inserting ‘‘under subpara16 graph (B)(ii)(I)’’. 

17 (f) AUTHORITY TO SMOOTH RELATIVE VALUES

18 WITHIN GROUPS OF SERVICES.—Section 1848(c)(2)(C) of 

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

20 amended— 

21 (1) in each of clauses (i) and (iii), by striking 

22 ‘‘the service’’ and inserting ‘‘the service or group of 

23 services’’ each place it appears; and 

24 (2) in the first sentence of clause (ii), by insert25 ing ‘‘or group of services’’ before the period. 


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1 (g) GAO STUDY AND REPORT ON RELATIVE VALUE

2 SCALE UPDATE COMMITTEE.— 

3 (1) STUDY.—The Comptroller General of the 

4 United States (in this subsection referred to as the 

5 ‘‘Comptroller General’’) shall conduct a study of the 

6 processes used by the Relative Value Scale Update 

7 Committee (RUC) to provide recommendations to 

8 the Secretary of Health and Human Services regard9 ing relative values for specific services under the 

10 Medicare physician fee schedule under section 1848 

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

12 (2) REPORT.—Not later than 1 year after the 

13 date of the enactment of this Act, the Comptroller 

14 General shall submit to Congress a report containing 

15 the results of the study conducted under paragraph 

16 (1). 

17 (h) ADJUSTMENT TO MEDICARE PAYMENT LOCAL18 ITIES.— 

19 (1) IN GENERAL.—Section 1848(e) of the So20 cial Security Act (42 U.S.C. 1395w–4(e)) is amend21 ed by adding at the end the following new para22 graph: 

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

24 CALIFORNIA.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this paragraph and not3 withstanding the previous provisions of this 

4 subsection, for services furnished on or after 

5 January 1, 2017, the fee schedule areas used 

6 for payment under this section applicable to 

7 California shall be the following: 

8 ‘‘(i) Each Metropolitan Statistical 

9 Area (each in this paragraph referred to as 

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

11 the Office of Management and Budget as 

12 of December 31 of the previous year, shall 

13 be a fee schedule area. 

14 ‘‘(ii) All areas not included in an MSA 

15 shall be treated as a single rest-of-State 

16 fee schedule area. 

17 ‘‘(B) TRANSITION FOR MSAS PREVIOUSLY

18 IN REST-OF-STATE PAYMENT LOCALITY OR IN

19 LOCALITY 3.— 

20 ‘‘(i) IN GENERAL.—For services fur21 nished in California during a year begin22 ning with 2017 and ending with 2021 in 

23 an MSA in a transition area (as defined in 

24 subparagraph (D)), subject to subpara25 graph (C), the geographic index values to 


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1 be applied under this subsection for such 

2 year shall be equal to the sum of the fol3 lowing: 

4 ‘‘(I) CURRENT LAW COMPO5 NENT.—The old weighting factor (de6 scribed in clause (ii)) for such year 

7 multiplied by the geographic index 

8 values under this subsection for the 

9 fee schedule area that included such 

10 MSA that would have applied in such 

11 area (as estimated by the Secretary) 

12 if this paragraph did not apply. 

13 ‘‘(II) MSA-BASED COMPO14 NENT.—The MSA-based weighting 

15 factor (described in clause (iii)) for 

16 such year multiplied by the geographic 

17 index values computed for the fee 

18 schedule area under subparagraph (A) 

19 for the year (determined without re20 gard to this subparagraph). 

21 ‘‘(ii) OLD WEIGHTING FACTOR.—The 

22 old weighting factor described in this 

23 clause— 

‘‘(I) for 2017, is 5 24 ⁄6; and 


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

2 the old weighting factor described in 

3 this clause for the previous year 

minus 1 4 ⁄6. 

5 ‘‘(iii) MSA-BASED WEIGHTING FAC6 TOR.—The MSA-based weighting factor 

7 described in this clause for a year is 1 

8 minus the old weighting factor under 

9 clause (ii) for that year. 

10 ‘‘(C) HOLD HARMLESS.—For services fur11 nished in a transition area in California during 

12 a year beginning with 2017, the geographic 

13 index values to be applied under this subsection 

14 for such year shall not be less than the cor15 responding geographic index values that would 

16 have applied in such transition area (as esti17 mated by the Secretary) if this paragraph did 

18 not apply. 

19 ‘‘(D) TRANSITION AREA DEFINED.—In 

20 this paragraph, the term ‘transition area’ 

21 means each of the following fee schedule areas 

22 for 2013: 

23 ‘‘(i) The rest-of-State payment local24 ity. 

25 ‘‘(ii) Payment locality 3. 


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1 ‘‘(E) REFERENCES TO FEE SCHEDULE

2 AREAS.—Effective for services furnished on or 

3 after January 1, 2017, for California, any ref4 erence in this section to a fee schedule area 

5 shall be deemed a reference to a fee schedule 

6 area established in accordance with this para7 graph.’’. 

8 (2) CONFORMING AMENDMENT TO DEFINITION

9 OF FEE SCHEDULE AREA.—Section 1848(j)(2) of the 

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

11 amended by striking ‘‘The term’’ and inserting ‘‘Ex12 cept as provided in subsection (e)(6)(D), the term’’. 

13 (i) DISCLOSURE OF DATA USED TO ESTABLISH

14 MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY.— 

15 The Secretary of Health and Human Services shall make 

16 publicly available the information used to establish the 

17 multiple procedure payment reduction policy to the profes18 sional component of imaging services in the final rule pub19 lished in the Federal Register, v. 77, n. 222, November 

20 16, 2012, pages 68891–69380 under the physician fee 

21 schedule under section 1848 of the Social Security Act (42 

22 U.S.C. 1395w–4). 


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1 SEC. 6. PROMOTING EVIDENCE-BASED CARE. 

2 (a) IN GENERAL.—Section 1834 of the Social Secu3 rity Act (42 U.S.C. 1395m) is amended by adding at the 

4 end the following new subsection: 

5 ‘‘(p) RECOGNIZING APPROPRIATE USE CRITERIA FOR

6 CERTAIN IMAGING SERVICES.— 

7 ‘‘(1) PROGRAM ESTABLISHED.— 

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

9 establish a program to promote the use of ap10 propriate use criteria (as defined in subpara11 graph (B)) for applicable imaging services (as 

12 defined in subparagraph (C)) furnished in an 

13 applicable setting (as defined in subparagraph 

14 (D)) by ordering professionals and furnishing 

15 professionals (as defined in subparagraphs (E) 

16 and (F), respectively). 

17 ‘‘(B) APPROPRIATE USE CRITERIA DE18 FINED.—In this subsection, the term ‘appro19 priate use criteria’ means criteria, only devel20 oped or endorsed by national professional med21 ical specialty societies or other provider-led enti22 ties, to assist ordering professionals and fur23 nishing professionals in making the most appro24 priate treatment decision for a specific clinical 

25 condition. To the extent feasible, such criteria 

26 shall be evidence-based. 


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1 ‘‘(C) APPLICABLE IMAGING SERVICE DE2 FINED.—In this subsection, the term ‘applicable 

3 imaging service’ means an advanced diagnostic 

4 imaging service (as defined in subsection 

5 (e)(1)(B)) for which the Secretary determines— 

6 ‘‘(i) one or more applicable appro7 priate use criteria specified under para8 graph (2) apply; 

9 ‘‘(ii) there are one or more qualified 

10 clinical decision support mechanisms listed 

11 under paragraph (3)(C); and 

12 ‘‘(iii) one or more of such mechanisms 

13 is available free of charge. 

14 ‘‘(D) APPLICABLE SETTING DEFINED.—In 

15 this subsection, the term ‘applicable setting’ 

16 means a physician’s office, a hospital outpatient 

17 department (including an emergency depart18 ment), an ambulatory surgical center, and any 

19 other provider-led outpatient setting determined 

20 appropriate by the Secretary. 

21 ‘‘(E) ORDERING PROFESSIONAL DE22 FINED.—In this subsection, the term ‘ordering 

23 professional’ means a physician (as defined in 

24 section 1861(r)) or a practitioner described in 


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1 section 1842(b)(18)(C) who orders an applica2 ble imaging service for an individual. 

3 ‘‘(F) FURNISHING PROFESSIONAL DE4 FINED.—In this subsection, the term ‘fur5 nishing professional’ means a physician (as de6 fined in section 1861(r)) or a practitioner de7 scribed in section 1842(b)(18)(C) who furnishes 

8 an applicable imaging service for an individual. 

9 ‘‘(2) ESTABLISHMENT OF APPLICABLE APPRO10 PRIATE USE CRITERIA.— 

11 ‘‘(A) IN GENERAL.—Not later than No12 vember 15, 2015, the Secretary shall through 

13 rulemaking, and in consultation with physi14 cians, practitioners, and other stakeholders, 

15 specify applicable appropriate use criteria for 

16 applicable imaging services only from among 

17 appropriate use criteria developed or endorsed 

18 by national professional medical specialty soci19 eties or other provider-led entities. 

20 ‘‘(B) CONSIDERATIONS.—In specifying ap21 plicable appropriate use criteria under subpara22 graph (A), the Secretary shall take into account 

23 whether the criteria— 

24 ‘‘(i) have stakeholder consensus; 


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1 ‘‘(ii) are scientifically valid and evi2 dence based; and 

3 ‘‘(iii) are based on studies that are 

4 published and reviewable by stakeholders. 

5 ‘‘(C) REVISIONS.—The Secretary shall re6 view, on an annual basis, the specified applica7 ble appropriate use criteria to determine if 

8 there is a need to update or revise (as appro9 priate) such specification of applicable appro10 priate use criteria and make such updates or 

11 revisions through rulemaking. 

12 ‘‘(D) TREATMENT OF MULTIPLE APPLICA13 BLE APPROPRIATE USE CRITERIA.—In the case 

14 where the Secretary determines that more than 

15 one appropriate use criteria applies with respect 

16 to an applicable imaging service, the Secretary 

17 shall permit one or more applicable appropriate 

18 use criteria under this paragraph for the serv19 ice. 

20 ‘‘(3) MECHANISMS FOR CONSULTATION WITH

21 APPLICABLE APPROPRIATE USE CRITERIA.— 

22 ‘‘(A) IDENTIFICATION OF MECHANISMS TO

23 CONSULT WITH APPLICABLE APPROPRIATE USE

24 CRITERIA.— 


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1 ‘‘(i) IN GENERAL.—The Secretary 

2 shall specify qualified clinical decision sup3 port mechanisms that could be used by or4 dering professionals to consult with appli5 cable appropriate use criteria for applicable 

6 imaging services. 

7 ‘‘(ii) CONSULTATION.—The Secretary 

8 shall consult with physicians, practitioners, 

9 health care technology experts, and other 

10 stakeholders in specifying mechanisms 

11 under this paragraph. 

12 ‘‘(iii) INCLUSION OF CERTAIN MECHA13 NISMS.—Mechanisms specified under this 

14 paragraph may include any or all of the 

15 following that meet the requirements de16 scribed in subparagraph (B)(ii): 

17 ‘‘(I) Use of clinical decision sup18 port modules in certified EHR tech19 nology (as defined in section 

20 1848(o)(4)). 

21 ‘‘(II) Use of private sector clin22 ical decision support mechanisms that 

23 are independent from certified EHR 

24 technology, which may include use of 

25 clinical decision support mechanisms 


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1 available from medical specialty orga2 nizations. 

3 ‘‘(III) Use of a clinical decision 

4 support mechanism established by the 

5 Secretary. 

6 ‘‘(B) QUALIFIED CLINICAL DECISION SUP7 PORT MECHANISMS.— 

8 ‘‘(i) IN GENERAL.—For purposes of 

9 this subsection, a qualified clinical decision 

10 support mechanism is a mechanism that 

11 the Secretary determines meets the re12 quirements described in clause (ii). 

13 ‘‘(ii) REQUIREMENTS.—The require14 ments described in this clause are the fol15 lowing: 

16 ‘‘(I) The mechanism makes avail17 able to the ordering professional appli18 cable appropriate use criteria specified 

19 under paragraph (2) and the sup20 porting documentation for the applica21 ble imaging service ordered. 

22 ‘‘(II) In the case where there are 

23 more than one applicable appropriate 

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1 ice, the mechanism indicates the cri2 teria that it uses for the service. 

3 ‘‘(III) The mechanism determines 

4 the extent to which an applicable im5 aging service ordered is consistent 

6 with the applicable appropriate use 

7 criteria so specified. 

8 ‘‘(IV) The mechanism generates 

9 and provides to the ordering profes10 sional a certification or documentation 

11 that documents that the qualified clin12 ical decision support mechanism was 

13 consulted by the ordering professional. 

14 ‘‘(V) The mechanism is updated 

15 on a timely basis to reflect revisions 

16 to the specification of applicable ap17 propriate use criteria under such 

18 paragraph. 

19 ‘‘(VI) The mechanism meets pri20 vacy and security standards under ap21 plicable provisions of law. 

22 ‘‘(VII) The mechanism performs 

23 such other functions as specified by 

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1 quirement to provide aggregate feed2 back to the ordering professional. 

3 ‘‘(C) LIST OF MECHANISMS FOR CON4 SULTATION WITH APPLICABLE APPROPRIATE

5 USE CRITERIA.— 

6 ‘‘(i) INITIAL LIST.—Not later than 

7 April 1, 2016, the Secretary shall publish 

8 a list of mechanisms specified under this 

9 paragraph. 

10 ‘‘(ii) PERIODIC UPDATING OF LIST.— 

11 The Secretary shall identify on an annual 

12 basis the list of qualified clinical decision 

13 support mechanisms specified under this 

14 paragraph. 

15 ‘‘(4) CONSULTATION WITH APPLICABLE APPRO16 PRIATE USE CRITERIA.— 

17 ‘‘(A) CONSULTATION BY ORDERING PRO18 FESSIONAL.—Beginning with January 1, 2017, 

19 subject to subparagraph (C), with respect to an 

20 applicable imaging service ordered by an order21 ing professional that would be furnished in an 

22 applicable setting and paid for under an appli23 cable payment system (as defined in subpara24 graph (D)), an ordering professional shall— 


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1 ‘‘(i) consult with a qualified decision 

2 support mechanism listed under paragraph 

3 (3)(C); and 

4 ‘‘(ii) provide to the furnishing profes5 sional the information described in clauses 

6 (i) through (iii) of subparagraph (B). 

7 ‘‘(B) REPORTING BY FURNISHING PROFES8 SIONAL.—Beginning with January 1, 2017, 

9 subject to subparagraph (C), with respect to an 

10 applicable imaging service furnished in an ap11 plicable setting and paid for under an applica12 ble payment system (as defined in subpara13 graph (D)), payment for such service may only 

14 be made if the claim for the service includes the 

15 following: 

16 ‘‘(i) Information about which qualified 

17 clinical decision support mechanism was 

18 consulted by the ordering professional for 

19 the service. 

20 ‘‘(ii) Information regarding— 

21 ‘‘(I) whether the service ordered 

22 would adhere to the applicable appro23 priate use criteria specified under 

24 paragraph (2); 


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1 ‘‘(II) whether the service ordered 

2 would not adhere to such criteria; or 

3 ‘‘(III) whether such criteria was 

4 not applicable to the service ordered. 

5 ‘‘(iii) The national provider identifier 

6 of the ordering professional (if different 

7 from the furnishing professional). 

8 ‘‘(C) EXCEPTIONS.—The provisions of sub9 paragraphs (A) and (B) and paragraph (6)(A) 

10 shall not apply to the following: 

11 ‘‘(i) EMERGENCY SERVICES.—An ap12 plicable imaging service ordered for an in13 dividual with an emergency medical condi14 tion (as defined in section 1867(e)(1)). 

15 ‘‘(ii) INPATIENT SERVICES.—An appli16 cable imaging service ordered for an inpa17 tient and for which payment is made under 

18 part A. 

19 ‘‘(iii) ALTERNATIVE PAYMENT MOD20 ELS.—An applicable imaging service or21 dered by an ordering professional with re22 spect to an individual attributed to an al23 ternative payment model (as defined in 

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


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1 ‘‘(iv) SIGNIFICANT HARDSHIP.—An 

2 applicable imaging service ordered by an 

3 ordering professional who the Secretary 

4 may, on a case-by-case basis, exempt from 

5 the application of such provisions if the 

6 Secretary determines, subject to annual re7 newal, that consultation with applicable ap8 propriate use criteria would result in a sig9 nificant hardship, such as in the case of a 

10 professional who practices in a rural area 

11 without sufficient Internet access. 

12 ‘‘(D) APPLICABLE PAYMENT SYSTEM DE13 FINED.—In this subsection, the term ‘applicable 

14 payment system’ means the following: 

15 ‘‘(i) The physician fee schedule estab16 lished under section 1848(b). 

17 ‘‘(ii) The prospective payment system 

18 for hospital outpatient department services 

19 under section 1833(t). 

20 ‘‘(iii) The ambulatory surgical center 

21 payment systems under section 1833(i). 

22 ‘‘(5) IDENTIFICATION OF OUTLIER ORDERING

23 PROFESSIONALS.— 

24 ‘‘(A) IN GENERAL.—With respect to appli25 cable imaging services furnished beginning with 


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1 2017, the Secretary shall determine, on an an2 nual basis, no more than five percent of the 

3 total number of ordering professionals who are 

4 outlier ordering professionals. 

5 ‘‘(B) OUTLIER ORDERING PROFES6 SIONALS.—The determination of an outlier or7 dering professional shall— 

8 ‘‘(i) be based on low adherence to ap9 plicable appropriate use criteria specified 

10 under paragraph (2), which may be based 

11 on comparison to other ordering profes12 sionals; and 

13 ‘‘(ii) include data for ordering profes14 sionals for whom prior authorization under 

15 paragraph (6)(A) applies. 

16 ‘‘(C) USE OF TWO YEARS OF DATA.—The 

17 Secretary shall use two years of data to identify 

18 outlier ordering professionals under this para19 graph. 

20 ‘‘(D) PROCESS.—The Secretary shall es21 tablish a process for determining when an 

22 outlier ordering professional is no longer an 

23 outlier ordering professional. 

24 ‘‘(E) CONSULTATION WITH STAKE25 HOLDERS.—The Secretary shall consult with 


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1 physicians, practitioners and other stakeholders 

2 in developing methods to identify outlier order3 ing professionals under this paragraph. 

4 ‘‘(6) PRIOR AUTHORIZATION FOR ORDERING

5 PROFESSIONALS WHO ARE OUTLIERS.— 

6 ‘‘(A) IN GENERAL.—Beginning January 1, 

7 2020, subject to paragraph (4)(C), with respect 

8 to services furnished during a year, the Sec9 retary shall, for a period determined appro10 priate by the Secretary, apply prior authoriza11 tion for applicable imaging services that are or12 dered by an outlier ordering professional identi13 fied under paragraph (5). 

14 ‘‘(B) APPROPRIATE USE CRITERIA IN

15 PRIOR AUTHORIZATION.—In applying prior au16 thorization under subparagraph (A), the Sec17 retary shall utilize only the applicable appro18 priate use criteria specified under this sub19 section. 

20 ‘‘(C) FUNDING.—For purposes of carrying 

21 out this paragraph, the Secretary shall provide 

22 for the transfer, from the Federal Supple23 mentary Medical Insurance Trust Fund under 

24 section 1841, of $5,000,000 to the Centers for 

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1 agement Account for each of fiscal years 2019 

2 through 2021. Amounts transferred under the 

3 preceding sentence shall remain available until 

4 expended. 

5 ‘‘(7) CONSTRUCTION.—Nothing in this sub6 section shall be construed as granting the Secretary 

7 the authority to develop or initiate the development 

8 of clinical practice guidelines or appropriate use cri9 teria.’’. 

10 (b) CONFORMING AMENDMENT.—Section 

11 1833(t)(16) of the Social Security Act (42 U.S.C. 

12 1395l(t)(16)) is amended by adding at the end the fol13 lowing new subparagraph: 

14 ‘‘(E) APPLICATION OF APPROPRIATE USE

15 CRITERIA FOR CERTAIN IMAGING SERVICES.— 

16 For provisions relating to the application of ap17 propriate use criteria for certain imaging serv18 ices, see section 1834(p).’’. 

19 (c) REPORT ON EXPERIENCE OF IMAGING APPRO20 PRIATE USE CRITERIA PROGRAM.—Not later than 18 

21 months after the date of the enactment of this Act, the 

22 Comptroller General of the United States shall submit to 

23 Congress a report that includes a description of the extent 

24 to which appropriate use criteria could be used for other 

25 services under part B of title XVIII of the Social Security 


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1 Act (42 U.S.C. 1395j et seq.), such as radiation therapy 

2 and clinical diagnostic laboratory services. 

3 SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH 

4 ACCESS TO INFORMATION ON PHYSICIANS’ 

5 SERVICES. 

6 (a) IN GENERAL.—The Secretary shall make publicly 

7 available on Physician Compare the information described 

8 in subsection (b) with respect to eligible professionals. 

9 (b) INFORMATION DESCRIBED.—The following infor10 mation, with respect to an eligible professional, is de11 scribed in this subsection: 

12 (1) Information on the number of services fur13 nished by the eligible professional under part B of 

14 title XVIII of the Social Security Act (42 U.S.C. 

15 1395j et seq.), which may include information on the 

16 most frequent services furnished or groupings of 

17 services. 

18 (2) Information on submitted charges and pay19 ments for services under such part. 

20 (3) A unique identifier for the eligible profes21 sional that is available to the public, such as a na22 tional provider identifier. 

23 (c) SEARCHABILITY.—The information made avail24 able under this section shall be searchable by at least the 

25 following: 


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1 (1) The specialty or type of the eligible profes2 sional. 

3 (2) Characteristics of the services furnished, 

4 such as volume or groupings of services. 

5 (3) The location of the eligible professional. 

6 (d) DISCLOSURE.—The information made available 

7 under this section shall indicate, where appropriate, that 

8 publicized information may not be representative of the 

9 eligible professional’s entire patient population, the variety 

10 of services furnished by the eligible professional, or the 

11 health conditions of individuals treated. 

12 (e) IMPLEMENTATION.— 

13 (1) INITIAL IMPLEMENTATION.—Physician 

14 Compare shall include the information described in 

15 subsection (b)— 

16 (A) with respect to physicians, by not later 

17 than July 1, 2015; and 

18 (B) with respect to other eligible profes19 sionals, by not later than July 1, 2016. 

20 (2) ANNUAL UPDATING.—The information 

21 made available under this section shall be updated 

22 on Physician Compare not less frequently than on 

23 an annual basis. 

24 (f) OPPORTUNITY TO REVIEW AND SUBMIT CORREC25 TIONS.—The Secretary shall provide for an opportunity 


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1 for an eligible professional to review, and submit correc2 tions for, the information to be made public with respect 

3 to the eligible professional under this section prior to such 

4 information being made public. 

5 (g) DEFINITIONS.—In this section: 

6 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC7 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi8 cian’’, and ‘‘Secretary’’ have the meaning given such 

9 terms in section 10331(i) of Public Law 111–148. 

10 (2) PHYSICIAN COMPARE.—The term ‘‘Physi11 cian Compare’’ means the Physician Compare Inter12 net website of the Centers for Medicare & Medicaid 

13 Services (or a successor website). 

14 SEC. 8. EXPANDING AVAILABILITY OF MEDICARE DATA. 

15 (a) EXPANDING USES OF MEDICARE DATA BY

16 QUALIFIED ENTITIES.— 

17 (1) ADDITIONAL ANALYSES.— 

18 (A) IN GENERAL.—Subject to subpara19 graph (B), to the extent consistent with appli20 cable information, privacy, security, and disclo21 sure laws (including paragraph (3)), notwith22 standing paragraph (4)(B) of section 1874(e) of 

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

24 and the second sentence of paragraph (4)(D) of 

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1 fied entity may use the combined data described 

2 in paragraph (4)(B)(iii) of such section received 

3 by such entity under such section, and informa4 tion derived from the evaluation described in 

5 such paragraph (4)(D), to conduct additional 

6 non-public analyses (as determined appropriate 

7 by the Secretary) and provide or sell such anal8 yses to authorized users for non-public use (in9 cluding for the purposes of assisting providers 

10 of services and suppliers to develop and partici11 pate in quality and patient care improvement 

12 activities, including developing new models of 

13 care). 

14 (B) LIMITATIONS WITH RESPECT TO ANAL15 YSES.— 

16 (i) EMPLOYERS.—Any analyses pro17 vided or sold under subparagraph (A) to 

18 an employer described in paragraph 

19 (9)(A)(iii) may only be used by such em20 ployer for purposes of providing health in21 surance to employees and retirees of the 

22 employer. 

23 (ii) HEALTH INSURANCE ISSUERS.—A 

24 qualified entity may not provide or sell an 

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1 scribed in paragraph (9)(A)(iv) unless the 

2 issuer is providing the qualified entity with 

3 data under section 1874(e)(4)(B)(iii) of 

4 the Social Security Act (42 U.S.C. 

5 1395kk(e)(4)(B)(iii)). 

6 (2) ACCESS TO CERTAIN DATA.— 

7 (A) ACCESS.—To the extent consistent 

8 with applicable information, privacy, security, 

9 and disclosure laws (including paragraph (3)), 

10 notwithstanding paragraph (4)(B) of section 

11 1874(e) of the Social Security Act (42 U.S.C. 

12 1395kk(e)) and the second sentence of para13 graph (4)(D) of such section, beginning July 1, 

14 2015, a qualified entity may— 

15 (i) provide or sell the combined data 

16 described in paragraph (4)(B)(iii) of such 

17 section to authorized users described in 

18 clauses (i), (ii), and (v) of paragraph 

19 (9)(A) for non-public use, including for the 

20 purposes described in subparagraph (B); 

21 or 

22 (ii) subject to subparagraph (C), pro23 vide Medicare claims data to authorized 

24 users described in clauses (i), (ii), and (v), 

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1 cluding for the purposes described in sub2 paragraph (B). 

3 (B) PURPOSES DESCRIBED.—The purposes 

4 described in this subparagraph are assisting 

5 providers of services and suppliers in developing 

6 and participating in quality and patient care 

7 improvement activities, including developing 

8 new models of care. 

9 (C) MEDICARE CLAIMS DATA MUST BE

10 PROVIDED AT NO COST.—A qualified entity may 

11 not charge a fee for providing the data under 

12 subparagraph (A)(ii). 

13 (3) PROTECTION OF INFORMATION.— 

14 (A) IN GENERAL.—Except as provided in 

15 subparagraph (B), an analysis or data that is 

16 provided or sold under paragraph (1) or (2) 

17 shall not contain information that individually 

18 identifies a patient. 

19 (B) INFORMATION ON PATIENTS OF THE

20 PROVIDER OF SERVICES OR SUPPLIER.—To the 

21 extent consistent with applicable information, 

22 privacy, security, and disclosure laws, an anal23 ysis or data that is provided or sold to a pro24 vider of services or supplier under paragraph 

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1 ually identifies a patient of such provider or 

2 supplier, including with respect to items and 

3 services furnished to the patient by other pro4 viders of services or suppliers. 

5 (C) PROHIBITION ON USING ANALYSES OR

6 DATA FOR MARKETING PURPOSES.—An author7 ized user shall not use an analysis or data pro8 vided or sold under paragraph (1) or (2) for 

9 marketing purposes. 

10 (4) DATA USE AGREEMENT.—A qualified entity 

11 and an authorized user described in clauses (i), (ii), 

12 and (v) of paragraph (9)(A) shall enter into an 

13 agreement regarding the use of any data that the 

14 qualified entity is providing or selling to the author15 ized user under paragraph (2). Such agreement shall 

16 describe the requirements for privacy and security of 

17 the data and, as determined appropriate by the Sec18 retary, any prohibitions on using such data to link 

19 to other individually identifiable sources of informa20 tion. If the authorized user is not a covered entity 

21 under the rules promulgated pursuant to the Health 

22 Insurance Portability and Accountability Act of 

23 1996, the agreement shall identify the relevant regu24 lations, as determined by the Secretary, that the 


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1 user shall comply with as if it were acting in the ca2 pacity of such a covered entity. 

3 (5) NO REDISCLOSURE OF ANALYSES OR

4 DATA.— 

5 (A) IN GENERAL.—Except as provided in 

6 subparagraph (B), an authorized user that is 

7 provided or sold an analysis or data under 

8 paragraph (1) or (2) shall not redisclose or 

9 make public such analysis or data or any anal10 ysis using such data. 

11 (B) PERMITTED REDISCLOSURE.—A pro12 vider of services or supplier that is provided or 

13 sold an analysis or data under paragraph (1) or 

14 (2) may, as determined by the Secretary, redis15 close such analysis or data for the purposes of 

16 performance improvement and care coordination 

17 activities but shall not make public such anal18 ysis or data or any analysis using such data. 

19 (6) OPPORTUNITY FOR PROVIDERS OF SERV20 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali21 fied entity providing or selling an analysis to an au22 thorized user under paragraph (1), to the extent 

23 that such analysis would individually identify a pro24 vider of services or supplier who is not being pro25 vided or sold such analysis, such qualified entity 


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1 shall provide such provider or supplier with the op2 portunity to appeal and correct errors in the manner 

3 described in section 1874(e)(4)(C)(ii) of the Social 

4 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

5 (7) ASSESSMENT FOR A BREACH.— 

6 (A) IN GENERAL.—In the case of a breach 

7 of a data use agreement under this section or 

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

9 U.S.C. 1395kk(e)), the Secretary shall impose 

10 an assessment on the qualified entity both in 

11 the case of— 

12 (i) an agreement between the Sec13 retary and a qualified entity; and 

14 (ii) an agreement between a qualified 

15 entity and an authorized user. 

16 (B) ASSESSMENT.—The assessment under 

17 subparagraph (A) shall be an amount up to 

18 $100 for each individual entitled to, or enrolled 

19 for, benefits under part A of title XVIII of the 

20 Social Security Act or enrolled for benefits 

21 under part B of such title— 

22 (i) in the case of an agreement de23 scribed in subparagraph (A)(i), for whom 

24 the Secretary provided data on to the 

25 qualified entity under paragraph (2); and 


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1 (ii) in the case of an agreement de2 scribed in subparagraph (A)(ii), for whom 

3 the qualified entity provided data on to the 

4 authorized user under paragraph (2). 

5 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

6 Any amounts collected pursuant to this para7 graph shall be deposited in Federal Supple8 mentary Medical Insurance Trust Fund under 

9 section 1841 of the Social Security Act (42 

10 U.S.C. 1395t). 

11 (8) ANNUAL REPORTS.—Any qualified entity 

12 that provides or sells an analysis or data under 

13 paragraph (1) or (2) shall annually submit to the 

14 Secretary a report that includes— 

15 (A) a summary of the analyses provided or 

16 sold, including the number of such analyses, the 

17 number of purchasers of such analyses, and the 

18 total amount of fees received for such analyses; 

19 (B) a description of the topics and pur20 poses of such analyses; 

21 (C) information on the entities who re22 ceived the data under paragraph (2), the uses 

23 of the data, and the total amount of fees re24 ceived for providing, selling, or sharing the 

25 data; and 


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1 (D) other information determined appro2 priate by the Secretary. 

3 (9) DEFINITIONS.—In this subsection and sub4 section (b): 

5 (A) AUTHORIZED USER.—The term ‘‘au6 thorized user’’ means the following: 

7 (i) A provider of services. 

8 (ii) A supplier. 

9 (iii) An employer (as defined in sec10 tion 3(5) of the Employee Retirement In11 surance Security Act of 1974). 

12 (iv) A health insurance issuer (as de13 fined in section 2791 of the Public Health 

14 Service Act). 

15 (v) A medical society or hospital asso16 ciation. 

17 (vi) Any entity not described in 

18 clauses (i) through (v) that is approved by 

19 the Secretary (other than an employer or 

20 health insurance issuer not described in 

21 clauses (iii) and (iv), respectively, as deter22 mined by the Secretary). 

23 (B) PROVIDER OF SERVICES.—The term 

24 ‘‘provider of services’’ has the meaning given 


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1 such term in section 1861(u) of the Social Se2 curity Act (42 U.S.C. 1395x(u)). 

3 (C) QUALIFIED ENTITY.—The term ‘‘quali4 fied entity’’ has the meaning given such term in 

5 section 1874(e)(2) of the Social Security Act 

6 (42 U.S.C. 1395kk(e)). 

7 (D) SECRETARY.—The term ‘‘Secretary’’ 

8 means the Secretary of Health and Human 

9 Services. 

10 (E) SUPPLIER.—The term ‘‘supplier’’ has 

11 the meaning given such term in section 1861(d) 

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

13 1395x(d)). 

14 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

15 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

16 IMPROVEMENT.— 

17 (1) ACCESS.— 

18 (A) IN GENERAL.—To the extent con19 sistent with applicable information, privacy, se20 curity, and disclosure laws, beginning July 1, 

21 2015, the Secretary shall, at the request of a 

22 qualified clinical data registry under section 

23 1848(m)(3)(E) of the Social Security Act (42 

24 U.S.C. 1395w–4(m)(3)(E)), provide the data 

25 described in subparagraph (B) (in a form and 


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1 manner determined to be appropriate) to such 

2 qualified clinical data registry for purposes of 

3 linking such data with clinical outcomes data 

4 and performing risk-adjusted, scientifically valid 

5 analyses and research to support quality im6 provement or patient safety, provided that any 

7 public reporting of such analyses or research 

8 that identifies a provider of services or supplier 

9 shall only be conducted with the opportunity of 

10 such provider or supplier to appeal and correct 

11 errors in the manner described in subsection 

12 (a)(6). 

13 (B) DATA DESCRIBED.—The data de14 scribed in this subparagraph is— 

15 (i) claims data under the Medicare 

16 program under title XVIII of the Social 

17 Security Act; and 

18 (ii) if the Secretary determines appro19 priate, claims data under the Medicaid 

20 program under title XIX of such Act and 

21 the State Children’s Health Insurance Pro22 gram under title XXI of such Act. 

23 (2) FEE.—Data described in paragraph (1)(B) 

24 shall be provided to a qualified clinical data registry 

25 under paragraph (1) at a fee equal to the cost of 


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1 providing such data. Any fee collected pursuant to 

2 the preceding sentence shall be deposited in the Cen3 ters for Medicare & Medicaid Services Program 

4 Management Account. 

5 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

6 ENTITIES.—Section 1874(e) of the Social Security Act 

7 (42 U.S.C. 1395kk(e)) is amended— 

8 (1) in the subsection heading, by striking 

9 ‘‘MEDICARE’’; and 

10 (2) in paragraph (3)— 

11 (A) by inserting after the first sentence the 

12 following new sentence: ‘‘Beginning July 1, 

13 2015, if the Secretary determines appropriate, 

14 the data described in this paragraph may also 

15 include standardized extracts (as determined by 

16 the Secretary) of claims data under titles XIX 

17 and XXI for assistance provided under such ti18 tles for one or more specified geographic areas 

19 and time periods requested by a qualified enti20 ty.’’; and 

21 (B) in the last sentence, by inserting ‘‘or 

22 under titles XIX or XXI’’ before the period at 

23 the end. 


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1 (d) REVISION OF PLACEMENT OF FEES.—Section 

2 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

3 1395kk(e)(4)(A)) is amended, in the second sentence— 

4 (1) by inserting ‘‘, for periods prior to July 1, 

5 2015,’’ after ‘‘deposited’’; and 

6 (2) by inserting the following before the period 

7 at the end: ‘‘, and, beginning July 1, 2015, into the 

8 Centers for Medicare & Medicaid Services Program 

9 Management Account’’. 

10 SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER 

11 PROVISIONS. 

12 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT13 OUT TO PRIVATE CONTRACT.— 

14 (1) INDEFINITE, CONTINUING AUTOMATIC EX15 TENSION OF OPT OUT ELECTION.— 

16 (A) IN GENERAL.—Section 1802(b)(3) of 

17 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

18 is amended— 

19 (i) in subparagraph (B)(ii), by strik20 ing ‘‘during the 2-year period beginning on 

21 the date the affidavit is signed’’ and insert22 ing ‘‘during the applicable 2-year period 

23 (as defined in subparagraph (D))’’; 

24 (ii) in subparagraph (C), by striking 

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1 paragraph (B)(ii)’’ and inserting ‘‘during 

2 the applicable 2-year period’’; and 

3 (iii) by adding at the end the fol4 lowing new subparagraph: 

5 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

6 EFFECTIVENESS OF AFFIDAVITS.—In this sub7 section, the term ‘applicable 2-year period’ 

8 means, with respect to an affidavit of a physi9 cian or practitioner under subparagraph (B), 

10 the 2-year period beginning on the date the af11 fidavit is signed and includes each subsequent 

12 2-year period unless the physician or practi13 tioner involved provides notice to the Secretary 

14 (in a form and manner specified by the Sec15 retary), not later than 30 days before the end 

16 of the previous 2-year period, that the physician 

17 or practitioner does not want to extend the ap18 plication of the affidavit for such subsequent 2- 

19 year period.’’. 

20 (B) EFFECTIVE DATE.—The amendments 

21 made by subparagraph (A) shall apply to affi22 davits entered into on or after the date that is 

23 60 days after the date of the enactment of this 

24 Act. 


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1 (2) PUBLIC AVAILABILITY OF INFORMATION ON

2 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 

3 1802(b) of the Social Security Act (42 U.S.C. 

4 1395a(b)) is amended— 

5 (A) in paragraph (5), by adding at the end 

6 the following new subparagraph: 

7 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

8 The term ‘opt-out physician or practitioner’ means 

9 a physician or practitioner who has in effect an affi10 davit under paragraph (3)(B).’’; 

11 (B) by redesignating paragraph (5) as 

12 paragraph (6); and 

13 (C) by inserting after paragraph (4) the 

14 following new paragraph: 

15 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

16 PHYSICIANS AND PRACTITIONERS.— 

17 ‘‘(A) IN GENERAL.—Beginning not later 

18 than February 1, 2015, the Secretary shall 

19 make publicly available through an appropriate 

20 publicly accessible website of the Department of 

21 Health and Human Services information on the 

22 number and characteristics of opt-out physi23 cians and practitioners and shall update such 

24 information on such website not less often than 

25 annually. 


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1 ‘‘(B) INFORMATION TO BE INCLUDED.— 

2 The information to be made available under 

3 subparagraph (A) shall include at least the fol4 lowing with respect to opt-out physicians and 

5 practitioners: 

6 ‘‘(i) Their number. 

7 ‘‘(ii) Their physician or professional 

8 specialty or other designation. 

9 ‘‘(iii) Their geographic distribution. 

10 ‘‘(iv) The timing of their becoming 

11 opt-out physicians and practitioners, rel12 ative to when they first entered practice 

13 and with respect to applicable 2-year peri14 ods. 

15 ‘‘(v) The proportion of such physi16 cians and practitioners who billed for 

17 emergency or urgent care services.’’. 

18 (b) GAINSHARING STUDY AND REPORT.—Not later 

19 than 6 months after the date of the enactment of this Act, 

20 the Secretary of Health and Human Services, in consulta21 tion with the Inspector General of the Department of 

22 Health and Human Services, shall submit to Congress a 

23 report with legislative recommendations to amend existing 

24 fraud and abuse laws, through exceptions, safe harbors, 

25 or other narrowly targeted provisions, to permit 


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1 gainsharing or similar arrangements between physicians 

2 and hospitals that improve care while reducing waste and 

3 increasing efficiency. The report shall— 

4 (1) consider whether such provisions should 

5 apply to ownership interests, compensation arrange6 ments, or other relationships; 

7 (2) describe how the recommendations address 

8 accountability, transparency, and quality, including 

9 how best to limit inducements to stint on care, dis10 charge patients prematurely, or otherwise reduce or 

11 limit medically necessary care; and 

12 (3) consider whether a portion of any savings 

13 generated by such arrangements should accrue to 

14 the Medicare program under title XVIII of the So15 cial Security Act. 

16 (c) PROMOTING INTEROPERABILITY OF ELECTRONIC

17 HEALTH RECORD SYSTEMS.— 

18 (1) RECOMMENDATIONS FOR ACHIEVING WIDE19 SPREAD EHR INTEROPERABILITY.— 

20 (A) OBJECTIVE.—As a consequence of a 

21 significant Federal investment in the implemen22 tation of health information technology through 

23 the Medicare and Medicaid EHR incentive pro24 grams, Congress declares it a national objective 

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1 mation through interoperable certified EHR 

2 technology nationwide by December 31, 2017. 

3 (B) DEFINITIONS.—In this paragraph: 

4 (i) WIDESPREAD INTEROPER5 ABILITY.—The term ‘‘widespread inter6 operability’’ means interoperability between 

7 certified EHR technology systems em8 ployed by meaningful EHR users under 

9 the Medicare and Medicaid EHR incentive 

10 programs and other clinicians and health 

11 care providers on a nationwide basis. 

12 (ii) INTEROPERABILITY.—The term 

13 ‘‘interoperability’’ means the ability of two 

14 or more health information systems or 

15 components to exchange clinical and other 

16 information and to use the information 

17 that has been exchanged using common 

18 standards as to provide access to longitu19 dinal information for health care providers 

20 in order to facilitate coordinated care and 

21 improved patient outcomes. 

22 (C) ESTABLISHMENT OF METRICS.—Not 

23 later than July 1, 2015, and in consultation 

24 with stakeholders, the Secretary shall establish 

25 metrics to be used to determine if and to the 


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1 extent that the objective described in subpara2 graph (A) has been achieved. 

3 (D) RECOMMENDATIONS IF OBJECTIVE

4 NOT ACHIEVED.—If the Secretary of Health 

5 and Human Services determines that the objec6 tive described in subparagraph (A) has not been 

7 achieved by December 31, 2017, then the Sec8 retary shall submit to Congress a report, by not 

9 later than December 31, 2018, that identifies 

10 barriers to such objective and recommends ac11 tions that the Federal Government can take to 

12 achieve such objective. Such recommended ac13 tions may include recommendations— 

14 (i) to adjust payments for not being 

15 meaningful EHR users under the Medicare 

16 EHR incentive programs; and 

17 (ii) for criteria for decertifying cer18 tified EHR technology products. 

19 (2) PREVENTING BLOCKING THE SHARING OF

20 INFORMATION.— 

21 (A) FOR MEANINGFUL EHR PROFES22 SIONALS.—Section 1848(o)(2)(A)(ii) of the So23 cial Security Act (42 U.S.C. 1395w– 

24 4(o)(2)(A)(ii)) is amended by inserting before 

25 the period at the end the following: ‘‘, and the 


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1 professional demonstrates (through a process 

2 specified by the Secretary, such as the use of an 

3 attestation) that the professional has not know4 ingly and willfully taken any action to limit or 

5 restrict the compatibility or interoperability of 

6 the certified EHR technology’’. 

7 (B) FOR MEANINGFUL EHR HOSPITALS.— 

8 Section 1886(n)(3)(A)(ii) of the Social Security 

9 Act (42 U.S.C. 1395ww(n)(3)(A)(ii)) is amend10 ed by inserting before the period at the end the 

11 following: ‘‘, and the hospital demonstrates 

12 (through a process specified by the Secretary, 

13 such as the use of an attestation) that the hos14 pital has not knowingly and willfully taken any 

15 action to limit or restrict the compatibility or 

16 interoperability of the certified EHR tech17 nology’’. 

18 (C) EFFECTIVE DATE.—The amendments 

19 made by this subsection shall apply to meaning20 ful EHR users as of the date that is one year 

21 after the date of the enactment of this Act. 

22 (3) STUDY AND REPORT ON THE FEASIBILITY

23 OF ESTABLISHING A WEBSITE TO COMPARE CER24 TIFIED EHR TECHNOLOGY PRODUCTS.— 


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1 (A) STUDY.—The Secretary shall conduct 

2 a study to examine the feasibility of estab3 lishing mechanisms that includes aggregated re4 sults of surveys of meaningful EHR users on 

5 the functionality of certified EHR technology 

6 products to enable such users to directly com7 pare the functionality and other features of 

8 such products. Such information may be made 

9 available through contracts with physician, hos10 pital, or other organizations that maintain such 

11 comparative information. 

12 (B) REPORT.—Not later than 1 year after 

13 the date of the enactment of this Act, the Sec14 retary shall submit to Congress a report on the 

15 website. The report shall include information on 

16 the benefits of, and resources needed to develop 

17 and maintain, such a website. 

18 (4) DEFINITIONS.—In this subsection: 

19 (A) The term ‘‘certified EHR technology’’ 

20 has the meaning given such term in section 

21 1848(o)(4) of the Social Security Act (42 

22 U.S.C. 1395w–4(o)(4)). 

23 (B) The term ‘‘meaningful EHR user’’ has 

24 the meaning given such term under the Medi25 care EHR incentive programs. 


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1 (C) The term ‘‘Medicare and Medicaid 

2 EHR incentive programs’’ means— 

3 (i) in the case of the Medicare pro4 gram under title XVIII of the Social Secu5 rity Act, the incentive programs under sec6 tion 1814(l)(3), section 1848(o), sub7 sections (l) and (m) of section 1853, and 

8 section 1886(n) of the Social Security Act 

9 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

10 1395w–23, 1395ww(n)); and 

11 (ii) in the case of the Medicaid pro12 gram under title XIX of such Act, the in13 centive program under subsections 

14 (a)(3)(F) and (t) of section 1903 of such 

15 Act (42 U.S.C. 1396b). 

16 (D) The term ‘‘Secretary’’ means the Sec17 retary of Health and Human Services. 

18 (d) GAO STUDIES AND REPORTS ON THE USE OF

19 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE20 MOTE PATIENT MONITORING SERVICES.— 

21 (1) STUDY ON TELEHEALTH SERVICES.—The 

22 Comptroller General of the United States shall con23 duct a study on the following: 

24 (A) How the definition of telehealth across 

25 various Federal programs and Federal efforts 


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1 can inform the use of telehealth in the Medicare 

2 program under title XVIII of the Social Secu3 rity Act (42 U.S.C. 1395 et seq.). 

4 (B) Issues that can facilitate or inhibit the 

5 use of telehealth under the Medicare program 

6 under such title, including oversight and profes7 sional licensure, changing technology, privacy 

8 and security, infrastructure requirements, and 

9 varying needs across urban and rural areas. 

10 (C) Potential implications of greater use of 

11 telehealth with respect to payment and delivery 

12 system transformations under the Medicare 

13 program under such title XVIII and the Med14 icaid program under title XIX of such Act (42 

15 U.S.C. 1396 et seq.). 

16 (D) How the Centers for Medicare & Med17 icaid Services conducts oversight of payments 

18 made under the Medicare program under such 

19 title XVIII to providers for telehealth services. 

20 (2) STUDY ON REMOTE PATIENT MONITORING

21 SERVICES.— 

22 (A) IN GENERAL.—The Comptroller Gen23 eral of the United States shall conduct a 

24 study— 


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1 (i) of the dissemination of remote pa2 tient monitoring technology in the private 

3 health insurance market; 

4 (ii) of the financial incentives in the 

5 private health insurance market relating to 

6 adoption of such technology; 

7 (iii) of the barriers to adoption of 

8 such services under the Medicare program 

9 under title XVIII of the Social Security 

10 Act; 

11 (iv) that evaluates the patients, condi12 tions, and clinical circumstances that could 

13 most benefit from remote patient moni14 toring services; and 

15 (v) that evaluates the challenges re16 lated to establishing appropriate valuation 

17 for remote patient monitoring services 

18 under the Medicare physician fee schedule 

19 under section 1848 of the Social Security 

20 Act (42 U.S.C. 1395w–4) in order to accu21 rately reflect the resources involved in fur22 nishing such services. 

23 (B) DEFINITIONS.—For purposes of this 

24 paragraph: 


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1 (i) REMOTE PATIENT MONITORING

2 SERVICES.—The term ‘‘remote patient 

3 monitoring services’’ means services fur4 nished through remote patient monitoring 

5 technology. 

6 (ii) REMOTE PATIENT MONITORING

7 TECHNOLOGY.—The term ‘‘remote patient 

8 monitoring technology’’ means a coordi9 nated system that uses one or more home10 based or mobile monitoring devices that 

11 automatically transmit vital sign data or 

12 information on activities of daily living and 

13 may include responses to assessment ques14 tions collected on the devices wirelessly or 

15 through a telecommunications connection 

16 to a server that complies with the Federal 

17 regulations (concerning the privacy of indi18 vidually identifiable health information) 

19 promulgated under section 264(c) of the 

20 Health Insurance Portability and Account21 ability Act of 1996, as part of an estab22 lished plan of care for that patient that in23 cludes the review and interpretation of that 

24 data by a health care professional. 


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1 (3) REPORTS.—Not later than 24 months after 

2 the date of the enactment of this Act, the Comp3 troller General shall submit to Congress— 

4 (A) a report containing the results of the 

5 study conducted under paragraph (1); and 

6 (B) a report containing the results of the 

7 study conducted under paragraph (2). 

8 A report required under this paragraph shall be sub9 mitted together with recommendations for such leg10 islation and administrative action as the Comptroller 

11 General determines appropriate. The Comptroller 

12 General may submit one report containing the re13 sults described in subparagraphs (A) and (B) and 

14 the recommendations described in the previous sen15 tence. 

16 (e) RULE OF CONSTRUCTION REGARDING

17 HEALTHCARE PROVIDER STANDARDS OF CARE.— 

18 (1) MAINTENANCE OF STATE STANDARDS.— 

19 The development, recognition, or implementation of 

20 any guideline or other standard under any Federal 

21 health care provision shall not be construed— 

22 (A) to establish the standard of care or 

23 duty of care owed by a health care provider to 

24 a patient in any medical malpractice or medical 

25 product liability action or claim; or 


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1 (B) to preempt any standard of care or 

2 duty of care, owed by a health care provider to 

3 a patient, duly established under State or com4 mon law. 

5 (2) DEFINITIONS.—For purposes of this sub6 section: 

7 (A) FEDERAL HEALTH CARE PROVISION.— 

8 The term ‘‘Federal health care provision’’ 

9 means any provision of the Patient Protection 

10 and Affordable Care Act (Public Law 111– 

11 148), title I or subtitle B of title II of the 

12 Health Care and Education Reconciliation Act 

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

14 or XIX of the Social Security Act. 

15 (B) HEALTH CARE PROVIDER.—The term 

16 ‘‘health care provider’’ means any individual or 

17 entity— 

18 (i) licensed, registered, or certified 

19 under Federal or State laws or regulations 

20 to provide health care services; or 

21 (ii) required to be so licensed, reg22 istered, or certified but that is exempted 

23 by other statute or regulation. 

24 (C) MEDICAL MALPRACTICE OR MEDICAL

25 PRODUCT LIABILITY ACTION OR CLAIM.—The 


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1 term ‘‘medical malpractice or medical product 

2 liability action or claim’’ means a medical mal3 practice action or claim (as defined in section 

4 431(7) of the Health Care Quality Improve5 ment Act of 1986 (42 U.S.C. 11151(7))) and 

6 includes a liability action or claim relating to a 

7 health care provider’s prescription or provision 

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

9 terms are defined in section 201 of the Federal 

10 Food, Drug, and Cosmetic Act or section 351 

11 of the Public Health Service Act). 

12 (D) STATE.—The term ‘‘State’’ includes 

13 the District of Columbia, Puerto Rico, and any 

14 other commonwealth, possession, or territory of 

15 the United States. 

16 (3) PRESERVATION OF STATE LAW.—No provi17 sion of the Patient Protection and Affordable Care 

18 Act (Public Law 111–148), title I or subtitle B of 

19 title II of the Health Care and Education Reconcili20 ation Act of 2010 (Public Law 111–152), or title 

21 XVIII or XIX of the Social Security Act shall be 

22 construed to preempt any State or common law gov23 erning medical professional or medical product liabil24 ity actions or claims. 


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1 SEC. 10. DELAY IN IMPLEMENTATION OF PENALTY FOR 

2 FAILURE TO COMPLY WITH INDIVIDUAL 

3 HEALTH INSURANCE MANDATE. 

4 (a) IN GENERAL.—Section 5000A(c) of the Internal 

5 Revenue Code of 1986 is amended by adding at the end 

6 the following new paragraph: 

7 ‘‘(5) DELAY IN IMPLEMENTATION OF PEN8 ALTY.—Notwithstanding any other provision of this 

9 subsection, the monthly penalty amount with respect 

10 to any taxpayer for any month beginning before 

11 January 1, 2019, shall be zero.’’. 

12 (b) DELAY OF CERTAIN PHASE INS AND INDEX13 ING.— 

14 (1) PHASE IN OF PERCENTAGE OF INCOME LIM15 ITATION.—Section 5000A(c)(2)(B) of such Code is 

16 amended— 

17 (A) by striking ‘‘2014’’ in clause (i) and 

18 inserting ‘‘2019’’, and 

19 (B) by striking ‘‘2015’’ in clauses (ii) and 

20 (iii) and inserting ‘‘2020’’. 

21 (2) PHASE IN OF APPLICABLE DOLLAR

22 AMOUNT.—Section 5000A(c)(3)(B) of such Code is 

23 amended— 

24 (A) by striking ‘‘2014’’ and inserting 

25 ‘‘2019’’, and 


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1 (B) by striking ‘‘2015’’ (before amendment 

2 by subparagraph (A)) and inserting ‘‘2020’’. 

3 (3) INDEXING OF APPLICABLE DOLLAR

4 AMOUNT.—Section 5000A(c)(3)(D) of such Code is 

5 amended— 

6 (A) by striking ‘‘2016’’ in the matter pre7 ceding clause (i) and inserting ‘‘2021’’, and 

8 (B) by striking ‘‘2015’’ in clause (ii) and 

9 inserting ‘‘2020’’. 

10 (4) INDEXING OF EXEMPTION BASED ON

11 HOUSEHOLD INCOME.—Section 5000A(e)(1)(D) of 

12 such Code is amended— 

13 (A) by striking ‘‘2014’’ (before amendment 

14 by subparagraph (B)) and inserting ‘‘2019’’, 

15 and 

16 (B) by striking ‘‘2013’’ and inserting 

17 ‘‘2018’’. 

18 (c) EFFECTIVE DATE.—The amendments made by 

19 this section shall apply to months beginning after Decem20 ber 31, 2013. 

Passed the House of Representatives March 14, 

2014. 

Attest: KAREN L. HAAS, 

Clerk. 


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