I 

113TH CONGRESS 

2D SESSION H. R. 4015 

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

sustainable growth rate and improve Medicare payments for physicians 

and other professionals, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 6, 2014 

Mr. BURGESS (for himself, Mr. UPTON, Mr. CAMP, Mr. WAXMAN, Mr. LEVIN, 

Mr. PITTS, Mr. BRADY of Texas, Mr. PALLONE, Mr. MCDERMOTT, and 

Mr. BOUSTANY) introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committees 

on Ways and Means and the Judiciary, for a period to be subsequently 

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

A BILL 

To amend title XVIII of the Social Security Act to repeal 

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

and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

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


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. 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. 

3 SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE 

4 (SGR) AND IMPROVING MEDICARE PAYMENT 

5 FOR PHYSICIANS’ SERVICES. 

6 (a) STABILIZING FEE UPDATES.— 

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

9 (42 U.S.C. 1395w–4) is amended— 

10 (A) in subsection (d)— 

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

12 ‘‘or a subsequent paragraph’’ after ‘‘para13 graph (4)’’; and 

14 (ii) in paragraph (4)— 

15 (I) in the heading, by inserting 

16 ‘‘AND ENDING WITH 2013’’ after 

17 ‘‘YEARS BEGINNING WITH 2001’’; and 

18 (II) in subparagraph (A), by in19 serting ‘‘and ending with 2013’’ after 

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


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1 (B) in subsection (f)— 

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

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

4 year’’; and 

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

6 preceding subparagraph (A), by inserting 

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

8 with 2000’’. 

9 (2) UPDATE OF RATES FOR APRIL THROUGH

10 DECEMBER OF 2014, 2015, AND SUBSEQUENT

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

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

13 striking paragraph (15) and inserting the following 

14 new paragraphs: 

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

16 update to the single conversion factor established in 

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

18 year through 2018 shall be 0.5 percent. 

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

20 update to the single conversion factor established in 

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

22 year through 2023 shall be zero percent. 

23 ‘‘(17) UPDATE FOR 2024 AND SUBSEQUENT

24 YEARS.—The update to the single conversion factor 


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

2 subsequent year shall be— 

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

4 qualifying APM participant (as defined in sec5 tion 1833(z)(2)) for such year, 1.0 percent; and 

6 ‘‘(B) for other items and services, 0.5 per7 cent.’’. 

8 (3) MEDPAC REPORTS.— 

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

10 1, 2016, the Medicare Payment Advisory Com11 mission shall submit to Congress a report on 

12 the relationship between— 

13 (i) physician and other health profes14 sional utilization and expenditures (and the 

15 rate of increase of such utilization and ex16 penditures) of items and services for which 

17 payment is made under section 1848 of the 

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

19 and 

20 (ii) total utilization and expenditures 

21 (and the rate of increase of such utilization 

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

23 of title XVIII of such Act. 

24 Such report shall include a methodology to de25 scribe such relationship and the impact of 


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1 changes in such physician and other health pro2 fessional practice and service ordering patterns 

3 on total utilization and expenditures under 

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

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

6 1, 2020, the Medicare Payment Advisory Com7 mission shall submit to Congress a report on 

8 the relationship described in subparagraph (A), 

9 including the results determined from applying 

10 the methodology included in the report sub11 mitted under such subparagraph. 

12 (C) REPORT ON UPDATE TO PHYSICIANS’ 

13 SERVICES UNDER MEDICARE.—Not later than 

14 July 1, 2018, the Medicare Payment Advisory 

15 Commission shall submit to Congress a report 

16 on— 

17 (i) the payment update for profes18 sional services applied under the Medicare 

19 program under title XVIII of the Social 

20 Security Act for the period of years 2014 

21 through 2018; 

22 (ii) the effect of such update on the 

23 efficiency, economy, and quality of care 

24 provided under such program; 


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1 (iii) the effect of such update on en2 suring a sufficient number of providers to 

3 maintain access to care by Medicare bene4 ficiaries; and 

5 (iv) recommendations for any future 

6 payment updates for professional services 

7 under such program to ensure adequate 

8 access to care is maintained for Medicare 

9 beneficiaries. 

10 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

11 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN12 CENTIVE PAYMENT SYSTEM.— 

13 (1) EHR MEANINGFUL USE INCENTIVE PRO14 GRAM.— 

15 (A) SUNSETTING SEPARATE MEANINGFUL

16 USE PAYMENT ADJUSTMENTS.—Section 

17 1848(a)(7)(A) of the Social Security Act (42 

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

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

20 subsequent payment year’’ and inserting 

21 ‘‘or 2017’’; 

22 (ii) in clause (ii)— 

23 (I) in the matter preceding sub24 clause (I), by striking ‘‘Subject to 

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


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

2 at the end ‘‘and’’; 

3 (III) in subclause (II), by strik4 ing ‘‘; and’’ and inserting a period; 

5 and 

6 (IV) by striking subclause (III); 

7 and 

8 (iii) by striking clause (iii). 

9 (B) CONTINUATION OF MEANINGFUL USE

10 DETERMINATIONS FOR MIPS.—Section 

11 1848(o)(2) of the Social Security Act (42 

12 U.S.C. 1395w–4(o)(2)) is amended— 

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

14 preceding clause (i)— 

15 (I) by striking ‘‘For purposes of 

16 paragraph (1), an’’ and inserting 

17 ‘‘An’’; and 

18 (II) by inserting ‘‘, or pursuant 

19 to subparagraph (D) for purposes of 

20 subsection (q), for a performance pe21 riod under such subsection for a year’’ 

22 after ‘‘under such subsection for a 

23 year’’; and 

24 (ii) by adding at the end the following 

25 new subparagraph: 


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1 ‘‘(D) CONTINUED APPLICATION FOR PUR2 POSES OF MIPS.—With respect to 2018 and 

3 each subsequent payment year, the Secretary 

4 shall, for purposes of subsection (q) and in ac5 cordance with paragraph (1)(F) of such sub6 section, determine whether an eligible profes7 sional who is a MIPS eligible professional (as 

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

9 a meaningful EHR user under this paragraph 

10 for the performance period under subsection (q) 

11 for such year.’’. 

12 (2) QUALITY REPORTING.— 

13 (A) SUNSETTING SEPARATE QUALITY RE14 PORTING INCENTIVES.—Section 1848(a)(8)(A) 

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

16 4(a)(8)(A)) is amended— 

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

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

19 and 

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

21 each subsequent year’’. 

22 (B) CONTINUATION OF QUALITY MEAS23 URES AND PROCESSES FOR MIPS.—Section 

24 1848 of the Social Security Act (42 U.S.C. 

25 1395w–4) is amended— 


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

2 end the following 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 provisions of 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.’’; and 

12 (ii) in subsection (m)— 

13 (I) by redesignating paragraph 

14 (7) added by section 10327(a) of Pub15 lic Law 111–148 as paragraph (8); 

16 and 

17 (II) by adding at the end the fol18 lowing new paragraph: 

19 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

20 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN21 TEERING TO REPORT.—The Secretary shall, in ac22 cordance with subsection (q)(1)(F), carry out the 

23 processes under this subsection— 

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


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

2 MIPS eligible professionals (as defined in sub3 section (q)(1)(C)) for the year involved.’’. 

4 (3) VALUE-BASED PAYMENTS.— 

5 (A) SUNSETTING SEPARATE VALUE-BASED

6 PAYMENTS.—Clause (iii) of section 

7 1848(p)(4)(B) of the Social Security Act (42 

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

9 as follows: 

10 ‘‘(iii) APPLICATION.—The Secretary 

11 shall apply the payment modifier estab12 lished under this subsection for items and 

13 services furnished on or after January 1, 

14 2015, but before January 1, 2018, with re15 spect to specific physicians and groups of 

16 physicians the Secretary determines appro17 priate. Such payment modifier shall not be 

18 applied for items and services furnished on 

19 or after January 1, 2018.’’. 

20 (B) CONTINUATION OF VALUE-BASED PAY21 MENT MODIFIER MEASURES FOR MIPS.—Section 

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

23 1395w–4(p)) is amended— 

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

25 end the following new subparagraph: 


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1 ‘‘(C) CONTINUED APPLICATION FOR PUR2 POSES OF MIPS.—The Secretary shall, in ac3 cordance with subsection (q)(1)(F), carry out 

4 subparagraph (B) for purposes of subsection 

5 (q).’’; and 

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

7 end the following: ‘‘With respect to 2018 

8 and each subsequent year, the Secretary 

9 shall, in accordance with subsection 

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

11 purposes of subsection (q).’’. 

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

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

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

15 adding at the end the following new subsection: 

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

17 ‘‘(1) ESTABLISHMENT.— 

18 ‘‘(A) IN GENERAL.—Subject to the suc19 ceeding provisions of this subsection, the Sec20 retary shall establish an eligible professional 

21 Merit-based Incentive Payment System (in this 

22 subsection referred to as the ‘MIPS’) under 

23 which the Secretary shall— 

24 ‘‘(i) develop a methodology for assess25 ing the total performance of each MIPS elVerDate Mar 15 2010 23:32 Feb 07, 2014 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.IH H4015

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1 igible professional according to perform2 ance standards under paragraph (3) for a 

3 performance period (as established under 

4 paragraph (4)) for a year; 

5 ‘‘(ii) using such methodology, provide 

6 for a composite performance score in ac7 cordance with paragraph (5) for each such 

8 professional for each performance period; 

9 and 

10 ‘‘(iii) use such composite performance 

11 score of the MIPS eligible professional for 

12 a performance period for a year to deter13 mine and apply a MIPS adjustment factor 

14 (and, as applicable, an additional MIPS 

15 adjustment factor) under paragraph (6) to 

16 the professional for the year. 

17 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

18 MIPS shall apply to payments for items and 

19 services furnished on or after January 1, 2018. 

20 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE21 FINED.— 

22 ‘‘(i) IN GENERAL.—For purposes of 

23 this subsection, subject to clauses (ii) and 

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

25 means— 


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1 ‘‘(I) for the first and second 

2 years for which the MIPS applies to 

3 payments (and for the performance 

4 period for such first and second year), 

5 a physician (as defined in section 

6 1861(r)), a physician assistant, nurse 

7 practitioner, and clinical nurse spe8 cialist (as such terms are defined in 

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

10 registered nurse anesthetist (as de11 fined in section 1861(bb)(2)) and a 

12 group that includes such profes13 sionals; and 

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

15 the MIPS applies to payments (and 

16 for the performance period for such 

17 third year) and for each succeeding 

18 year (and for the performance period 

19 for each such year), the professionals 

20 described in subclause (I) and such 

21 other eligible professionals (as defined 

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

23 by the Secretary and a group that in24 cludes such professionals. 


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1 ‘‘(ii) EXCLUSIONS.—For purposes of 

2 clause (i), the term ‘MIPS eligible profes3 sional’ does not include, with respect to a 

4 year, an eligible professional (as defined in 

5 subsection (k)(3)(B)) who— 

6 ‘‘(I) is a qualifying APM partici7 pant (as defined in section 

8 1833(z)(2)); 

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

10 partial qualifying APM participant (as 

11 defined in clause (iii)) for the most re12 cent period for which data are avail13 able and who, for the performance pe14 riod with respect to such year, does 

15 not report on applicable measures and 

16 activities described in paragraph 

17 (2)(B) that are required to be re18 ported by such a professional under 

19 the MIPS; or 

20 ‘‘(III) for the performance period 

21 with respect to such year, does not ex22 ceed the low-volume threshold meas23 urement selected under clause (iv). 

24 ‘‘(iii) PARTIAL QUALIFYING APM PAR25 TICIPANT.—For purposes of this subparaVerDate Mar 15 2010 23:32 Feb 07, 2014 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.IH H4015

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1 graph, the term ‘partial qualifying APM 

2 participant’ means, with respect to a year, 

3 an eligible professional for whom the Sec4 retary determines the minimum payment 

5 percentage (or percentages), as applicable, 

6 described in paragraph (2) of section 

7 1833(z) for such year have not been satis8 fied, but who would be considered a quali9 fying APM participant (as defined in such 

10 paragraph) for such year if— 

11 ‘‘(I) with respect to 2018 and 

12 2019, the reference in subparagraph 

13 (A) of such paragraph to 25 percent 

14 was instead a reference to 20 percent; 

15 ‘‘(II) with respect to 2020 and 

16 2021— 

17 ‘‘(aa) the reference in sub18 paragraph (B)(i) of such para19 graph to 50 percent was instead 

20 a reference to 40 percent; and 

21 ‘‘(bb) the references in sub22 paragraph (B)(ii) of such para23 graph to 50 percent and 25 per24 cent of such paragraph were inVerDate Mar 15 2010 23:32 Feb 07, 2014 Jkt 039200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.IH H4015

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1 stead references to 40 percent 

2 and 20 percent, respectively; and 

3 ‘‘(III) with respect to 2022 and 

4 subsequent years— 

5 ‘‘(aa) the reference in sub6 paragraph (C)(i) of such para7 graph to 75 percent was instead 

8 a reference to 50 percent; and 

9 ‘‘(bb) the references in sub10 paragraph (C)(ii) of such para11 graph to 75 percent and 25 per12 cent of such paragraph were in13 stead references to 50 percent 

14 and 20 percent, respectively. 

15 ‘‘(iv) SELECTION OF LOW-VOLUME

16 THRESHOLD MEASUREMENT.—The Sec17 retary shall select a low-volume threshold 

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

19 which may include one or more or a com20 bination of the following: 

21 ‘‘(I) The minimum number (as 

22 determined by the Secretary) of indi23 viduals enrolled under this part who 

24 are treated by the eligible professional 

25 for the performance period involved. 


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1 ‘‘(II) The minimum number (as 

2 determined by the Secretary) of items 

3 and services furnished to individuals 

4 enrolled under this part by such pro5 fessional for such performance period. 

6 ‘‘(III) The minimum amount (as 

7 determined by the Secretary) of al8 lowed charges billed by such profes9 sional under this part for such per10 formance period. 

11 ‘‘(v) TREATMENT OF NEW MEDICARE

12 ENROLLED ELIGIBLE PROFESSIONALS.—In 

13 the case of a professional who first be14 comes a Medicare enrolled eligible profes15 sional during the performance period for a 

16 year (and had not previously submitted 

17 claims under this title such as a person, an 

18 entity, or a part of a physician group or 

19 under a different billing number or tax 

20 identifier), such professional shall not be 

21 treated under this subsection as a MIPS 

22 eligible professional until the subsequent 

23 year and performance period for such sub24 sequent year. 


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

2 items and services furnished during a year 

3 by an individual who is not a MIPS eligible 

4 professional (including pursuant to clauses 

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

6 case shall a MIPS adjustment factor (or 

7 additional MIPS adjustment factor) under 

8 paragraph (6) apply to such individual for 

9 such year. 

10 ‘‘(vii) PARTIAL QUALIFYING APM PAR11 TICIPANT CLARIFICATIONS.— 

12 ‘‘(I) TREATMENT AS MIPS ELIGI13 BLE PROFESSIONAL.—In the case of 

14 an eligible professional who is a par15 tial qualifying APM participant, with 

16 respect to a year, and who for the 

17 performance period for such year re18 ports on applicable measures and ac19 tivities described in paragraph (2)(B) 

20 that are required to be reported by 

21 such a professional under the MIPS, 

22 such eligible professional is considered 

23 to be a MIPS eligible professional 

24 with respect to such year. 


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1 ‘‘(II) NOT ELIGIBLE FOR QUALI2 FYING APM PARTICIPANT PAY3 MENTS.—In no case shall an eligible 

4 professional who is a partial quali5 fying APM participant, with respect 

6 to a year, be considered a qualifying 

7 APM participant (as defined in para8 graph (2) of section 1833(z)) for such 

9 year or be eligible for the additional 

10 payment under paragraph (1) of such 

11 section for such year. 

12 ‘‘(D) APPLICATION TO GROUP PRAC13 TICES.— 

14 ‘‘(i) IN GENERAL.—Under the MIPS: 

15 ‘‘(I) QUALITY PERFORMANCE

16 CATEGORY.—The Secretary shall es17 tablish and apply a process that in18 cludes features of the provisions of 

19 subsection (m)(3)(C) for MIPS eligi20 ble professionals in a group practice 

21 with respect to assessing performance 

22 of such group with respect to the per23 formance category described in clause 

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


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1 ‘‘(II) OTHER PERFORMANCE CAT2 EGORIES.—The Secretary may estab3 lish and apply a process that includes 

4 features of the provisions of sub5 section (m)(3)(C) for MIPS eligible 

6 professionals in a group practice with 

7 respect to assessing the performance 

8 of such group with respect to the per9 formance categories described in 

10 clauses (ii) through (iv) of such para11 graph. 

12 ‘‘(ii) ENSURING COMPREHENSIVENESS

13 OF GROUP PRACTICE ASSESSMENT.—The 

14 process established under clause (i) shall to 

15 the extent practicable reflect the range of 

16 items and services furnished by the MIPS 

17 eligible professionals in the group practice 

18 involved. 

19 ‘‘(iii) CLARIFICATION.—MIPS eligible 

20 professionals electing to be a virtual group 

21 under paragraph (5)(I) shall not be consid22 ered MIPS eligible professionals in a group 

23 practice for purposes of applying this sub24 paragraph. 


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1 ‘‘(E) USE OF REGISTRIES.—Under the 

2 MIPS, the Secretary shall encourage the use of 

3 qualified clinical data registries pursuant to 

4 subsection (m)(3)(E) in carrying out this sub5 section. 

6 ‘‘(F) APPLICATION OF CERTAIN PROVI7 SIONS.—In applying a provision of subsection 

8 (k), (m), (o), or (p) for purposes of this sub9 section, the Secretary shall— 

10 ‘‘(i) adjust the application of such 

11 provision to ensure the provision is con12 sistent with the provisions of this sub13 section; and 

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

15 extent that the provision is duplicative with 

16 a provision of this subsection. 

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

18 ‘‘(i) RISK FACTORS.—Taking into ac19 count the relevant studies conducted and 

20 recommendations made in reports under 

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

22 Medicare Provider Payment Modernization 

23 Act of 2014, the Secretary, on an ongoing 

24 basis, shall estimate how an individual’s 

25 health status and other risk factors affect 


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1 quality and resource use outcome measures 

2 and, as feasible, shall incorporate informa3 tion from quality and resource use outcome 

4 measurement (including care episode and 

5 patient condition groups) into the MIPS. 

6 ‘‘(ii) ACCOUNTING FOR OTHER FAC7 TORS IN PAYMENT ADJUSTMENTS.—Tak8 ing into account the studies conducted and 

9 recommendations made in reports under 

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

11 Medicare Provider Payment Modernization 

12 Act of 2014 and other information as ap13 propriate, the Secretary shall account for 

14 identified factors with an effect on quality 

15 and resource use outcome measures when 

16 determining payment adjustments, com17 posite performance scores, scores for per18 formance categories, or scores for meas19 ures or activities under the MIPS. 

20 ‘‘(2) MEASURES AND ACTIVITIES UNDER PER21 FORMANCE CATEGORIES.— 

22 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

23 the MIPS, the Secretary shall use the following 

24 performance categories (each of which is re25 ferred to in this subsection as a performance 


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1 category) in determining the composite per2 formance score under paragraph (5): 

3 ‘‘(i) Quality. 

4 ‘‘(ii) Resource use. 

5 ‘‘(iii) Clinical practice improvement 

6 activities. 

7 ‘‘(iv) Meaningful use of certified EHR 

8 technology. 

9 ‘‘(B) MEASURES AND ACTIVITIES SPECI10 FIED FOR EACH CATEGORY.—For purposes of 

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

12 (C), measures and activities specified for a per13 formance period (as established under para14 graph (4)) for a year are as follows: 

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

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

17 the quality measures included in the final 

18 measures list published under subpara19 graph (D)(i) for such year and the list of 

20 quality measures described in subpara21 graph (D)(vi) used by qualified clinical 

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

23 ‘‘(ii) RESOURCE USE.—For the per24 formance category described in subpara25 graph (A)(ii), the measurement of resource 


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1 use for such period under subsection 

2 (p)(3), using the methodology under sub3 section (r) as appropriate, and, as feasible 

4 and applicable, accounting for the cost of 

5 drugs under part D. 

6 ‘‘(iii) CLINICAL PRACTICE IMPROVE7 MENT ACTIVITIES.—For the performance 

8 category described in subparagraph 

9 (A)(iii), clinical practice improvement ac10 tivities (as defined in subparagraph 

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

12 by the Secretary for such period, which 

13 shall include at least the following: 

14 ‘‘(I) The subcategory of expanded 

15 practice access, which shall include ac16 tivities such as same day appoint17 ments for urgent needs and after 

18 hours access to clinician advice. 

19 ‘‘(II) The subcategory of popu20 lation management, which shall in21 clude activities such as monitoring 

22 health conditions of individuals to pro23 vide timely health care interventions 

24 or participation in a qualified clinical 

25 data registry. 


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1 ‘‘(III) The subcategory of care 

2 coordination, which shall include ac3 tivities such as timely communication 

4 of test results, timely exchange of 

5 clinical information to patients and 

6 other providers, and use of remote 

7 monitoring or telehealth. 

8 ‘‘(IV) The subcategory of bene9 ficiary engagement, which shall in10 clude activities such as the establish11 ment of care plans for individuals 

12 with complex care needs, beneficiary 

13 self-management assessment and 

14 training, and using shared decision15 making mechanisms. 

16 ‘‘(V) The subcategory of patient 

17 safety and practice assessment, such 

18 as through use of clinical or surgical 

19 checklists and practice assessments 

20 related to maintaining certification. 

21 ‘‘(VI) The subcategory of partici22 pation in an alternative payment 

23 model (as defined in section 

24 1833(z)(3)(C)). 


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1 In establishing activities under this clause, 

2 the Secretary shall give consideration to 

3 the circumstances of small practices (con4 sisting of 15 or fewer professionals) and 

5 practices located in rural areas and in 

6 health professional shortage areas (as des7 ignated under section 332(a)(1)(A) of the 

8 Public Health Service Act). 

9 ‘‘(iv) MEANINGFUL EHR USE.—For 

10 the performance category described in sub11 paragraph (A)(iv), the requirements estab12 lished for such period under subsection 

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

14 professional is a meaningful EHR user. 

15 ‘‘(C) ADDITIONAL PROVISIONS.— 

16 ‘‘(i) EMPHASIZING OUTCOME MEAS17 URES UNDER THE QUALITY PERFORMANCE

18 CATEGORY.—In applying subparagraph 

19 (B)(i), the Secretary shall, as feasible, em20 phasize the application of outcome meas21 ures. 

22 ‘‘(ii) APPLICATION OF ADDITIONAL

23 SYSTEM MEASURES.—The Secretary may 

24 use measures used for a payment system 

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1 ures for inpatient hospitals, for purposes of 

2 the performance categories described in 

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

4 For purposes of the previous sentence, the 

5 Secretary may not use measures for hos6 pital outpatient departments, except in the 

7 case of emergency physicians. 

8 ‘‘(iii) GLOBAL AND POPULATION9 BASED MEASURES.—The Secretary may 

10 use global measures, such as global out11 come measures, and population-based 

12 measures for purposes of the performance 

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

14 ‘‘(iv) APPLICATION OF MEASURES AND

15 ACTIVITIES TO NON-PATIENT-FACING PRO16 FESSIONALS.—In carrying out this para17 graph, with respect to measures and activi18 ties specified in subparagraph (B) for per19 formance categories described in subpara20 graph (A), the Secretary— 

21 ‘‘(I) shall give consideration to 

22 the circumstances of professional 

23 types (or subcategories of those types 

24 determined by practice characteris25 tics) who typically furnish services 


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1 that do not involve face-to-face inter2 action with a patient; and 

3 ‘‘(II) may, to the extent feasible 

4 and appropriate, take into account 

5 such circumstances and apply under 

6 this subsection with respect to MIPS 

7 eligible professionals of such profes8 sional types or subcategories, alter9 native measures or activities that ful10 fill the goals of the applicable per11 formance category. 

12 In carrying out the previous sentence, the 

13 Secretary shall consult with professionals 

14 of such professional types or subcategories. 

15 ‘‘(v) CLINICAL PRACTICE IMPROVE16 MENT ACTIVITIES.— 

17 ‘‘(I) REQUEST FOR INFORMA18 TION.—In initially applying subpara19 graph (B)(iii), the Secretary shall use 

20 a request for information to solicit 

21 recommendations from stakeholders to 

22 identify activities described in such 

23 subparagraph and specifying criteria 

24 for such activities. 


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1 ‘‘(II) CONTRACT AUTHORITY FOR

2 CLINICAL PRACTICE IMPROVEMENT

3 ACTIVITIES PERFORMANCE CAT4 EGORY.—In applying subparagraph 

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

6 with entities to assist the Secretary 

7 in— 

8 ‘‘(aa) identifying activities 

9 described in subparagraph 

10 (B)(iii); 

11 ‘‘(bb) specifying criteria for 

12 such activities; and 

13 ‘‘(cc) determining whether a 

14 MIPS eligible professional meets 

15 such criteria. 

16 ‘‘(III) CLINICAL PRACTICE IM17 PROVEMENT ACTIVITIES DEFINED.— 

18 For purposes of this subsection, the 

19 term ‘clinical practice improvement 

20 activity’ means an activity that rel21 evant eligible professional organiza22 tions and other relevant stakeholders 

23 identify as improving clinical practice 

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1 ecuted, is likely to result in improved 

2 outcomes. 

3 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

4 AVAILABLE FOR MIPS ASSESSMENT.— 

5 ‘‘(i) IN GENERAL.—Under the MIPS, 

6 the Secretary, through notice and comment 

7 rulemaking and subject to the succeeding 

8 clauses of this subparagraph, shall, with 

9 respect to the performance period for a 

10 year, establish an annual final list of qual11 ity measures from which MIPS eligible 

12 professionals may choose for purposes of 

13 assessment under this subsection for such 

14 performance period. Pursuant to the pre15 vious sentence, the Secretary shall— 

16 ‘‘(I) not later than November 1 

17 of the year prior to the first day of 

18 the first performance period under the 

19 MIPS, establish and publish in the 

20 Federal Register a final list of quality 

21 measures; and 

22 ‘‘(II) not later than November 1 

23 of the year prior to the first day of 

24 each subsequent performance period, 

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1 ures from the previous year (and pub2 lish such updated final list in the Fed3 eral Register), by— 

4 ‘‘(aa) removing from such 

5 list, as appropriate, quality meas6 ures, which may include the re7 moval of measures that are no 

8 longer meaningful (such as meas9 ures that are topped out); 

10 ‘‘(bb) adding to such list, as 

11 appropriate, new quality meas12 ures; and 

13 ‘‘(cc) determining whether 

14 or not quality measures on such 

15 list that have undergone sub16 stantive changes should be in17 cluded in the updated list. 

18 ‘‘(ii) CALL FOR QUALITY MEAS19 URES.— 

20 ‘‘(I) IN GENERAL.—Eligible pro21 fessional organizations and other rel22 evant stakeholders shall be requested 

23 to identify and submit quality meas24 ures to be considered for selection 

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1 nual list of quality measures published 

2 under clause (i) and to identify and 

3 submit updates to the measures on 

4 such list. For purposes of the previous 

5 sentence, measures may be submitted 

6 regardless of whether such measures 

7 were previously published in a pro8 posed rule or endorsed by an entity 

9 with a contract under section 1890(a). 

10 ‘‘(II) ELIGIBLE PROFESSIONAL

11 ORGANIZATION DEFINED.—In this 

12 subparagraph, the term ‘eligible pro13 fessional organization’ means a pro14 fessional organization as defined by 

15 nationally recognized multispecialty 

16 boards of certification or equivalent 

17 certification boards. 

18 ‘‘(iii) REQUIREMENTS.—In selecting 

19 quality measures for inclusion in the an20 nual final list under clause (i), the Sec21 retary shall— 

22 ‘‘(I) provide that, to the extent 

23 practicable, all quality domains (as 

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

25 addressed by such measures; and 


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1 ‘‘(II) ensure that such selection 

2 is consistent with the process for se3 lection of measures under subsections 

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

5 ‘‘(iv) PEER REVIEW.—Before includ6 ing a new measure or a measure described 

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

8 measures published under clause (i) for a 

9 year, the Secretary shall submit for publi10 cation in applicable specialty-appropriate 

11 peer-reviewed journals such measure and 

12 the method for developing and selecting 

13 such measure, including clinical and other 

14 data supporting such measure. 

15 ‘‘(v) MEASURES FOR INCLUSION.— 

16 The final list of quality measures published 

17 under clause (i) shall include, as applica18 ble, measures under subsections (k), (m), 

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

20 from among— 

21 ‘‘(I) measures endorsed by a con22 sensus-based entity; 

23 ‘‘(II) measures developed under 

24 subsection (s); and 


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1 ‘‘(III) measures submitted under 

2 clause (ii)(I). 

3 Any measure selected for inclusion in such 

4 list that is not endorsed by a consensus5 based entity shall have a focus that is evi6 dence-based. 

7 ‘‘(vi) EXCEPTION FOR QUALIFIED

8 CLINICAL DATA REGISTRY MEASURES.— 

9 Measures used by a qualified clinical data 

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

11 not be subject to the requirements under 

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

13 shall publish the list of measures used by 

14 such qualified clinical data registries on 

15 the Internet website of the Centers for 

16 Medicare & Medicaid Services. 

17 ‘‘(vii) EXCEPTION FOR EXISTING

18 QUALITY MEASURES.—Any quality meas19 ure specified by the Secretary under sub20 section (k) or (m), including under sub21 section (m)(3)(E), and any measure of 

22 quality of care established under sub23 section (p)(2) for the reporting period 

24 under the respective subsection beginning 


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1 before the first performance period under 

2 the MIPS— 

3 ‘‘(I) shall not be subject to the 

4 requirements under clause (i) (except 

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

6 (II) of such clause) or to the require7 ment under clause (iv); and 

8 ‘‘(II) shall be included in the 

9 final list of quality measures pub10 lished under clause (i) unless removed 

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

12 ‘‘(viii) CONSULTATION WITH REL13 EVANT ELIGIBLE PROFESSIONAL ORGANI14 ZATIONS AND OTHER RELEVANT STAKE15 HOLDERS.—Relevant eligible professional 

16 organizations and other relevant stake17 holders, including State and national med18 ical societies, shall be consulted in carrying 

19 out this subparagraph. 

20 ‘‘(ix) OPTIONAL APPLICATION.—The 

21 process under section 1890A is not re22 quired to apply to the selection of meas23 ures under this subparagraph. 

24 ‘‘(3) PERFORMANCE STANDARDS.— 


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

2 the Secretary shall establish performance stand3 ards with respect to measures and activities 

4 specified under paragraph (2)(B) for a perform5 ance period (as established under paragraph 

6 (4)) for a year. 

7 ‘‘(B) CONSIDERATIONS IN ESTABLISHING

8 STANDARDS.—In establishing such performance 

9 standards with respect to measures and activi10 ties specified under paragraph (2)(B), the Sec11 retary shall consider the following: 

12 ‘‘(i) Historical performance standards. 

13 ‘‘(ii) Improvement. 

14 ‘‘(iii) The opportunity for continued 

15 improvement. 

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

17 shall establish a performance period (or periods) for 

18 a year (beginning with the year described in para19 graph (1)(B)). Such performance period (or periods) 

20 shall begin and end prior to the beginning of such 

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

22 subsection, such performance period (or periods) for 

23 a year shall be referred to as the performance period 

24 for the year. 

25 ‘‘(5) COMPOSITE PERFORMANCE SCORE.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this paragraph and taking 

3 into account, as available and applicable, para4 graph (1)(G), the Secretary shall develop a 

5 methodology for assessing the total performance 

6 of each MIPS eligible professional according to 

7 performance standards under paragraph (3) 

8 with respect to applicable measures and activi9 ties specified in paragraph (2)(B) with respect 

10 to each performance category applicable to such 

11 professional for a performance period (as estab12 lished under paragraph (4)) for a year. Using 

13 such methodology, the Secretary shall provide 

14 for a composite assessment (using a scoring 

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

16 the performance period for such year. In this 

17 subsection such a composite assessment for 

18 such a professional with respect to a perform19 ance period shall be referred to as the ‘com20 posite performance score’ for such professional 

21 for such performance period. 

22 ‘‘(B) INCENTIVE TO REPORT; ENCOUR23 AGING USE OF CERTIFIED EHR TECHNOLOGY

24 FOR REPORTING QUALITY MEASURES.— 


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1 ‘‘(i) INCENTIVE TO REPORT.—Under 

2 the methodology established under sub3 paragraph (A), the Secretary shall provide 

4 that in the case of a MIPS eligible profes5 sional who fails to report on an applicable 

6 measure or activity that is required to be 

7 reported by the professional, the profes8 sional shall be treated as achieving the 

9 lowest potential score applicable to such 

10 measure or activity. 

11 ‘‘(ii) ENCOURAGING USE OF CER12 TIFIED EHR TECHNOLOGY AND QUALIFIED

13 CLINICAL DATA REGISTRIES FOR REPORT14 ING QUALITY MEASURES.—Under the 

15 methodology established under subpara16 graph (A), the Secretary shall— 

17 ‘‘(I) encourage MIPS eligible 

18 professionals to report on applicable 

19 measures with respect to the perform20 ance category described in paragraph 

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

22 EHR technology and qualified clinical 

23 data registries; and 

24 ‘‘(II) with respect to a perform25 ance period, with respect to a year, 


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1 for which a MIPS eligible professional 

2 reports such measures through the 

3 use of such EHR technology, treat 

4 such professional as satisfying the 

5 clinical quality measures reporting re6 quirement described in subsection 

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

8 ‘‘(C) CLINICAL PRACTICE IMPROVEMENT

9 ACTIVITIES PERFORMANCE SCORE.— 

10 ‘‘(i) RULE FOR ACCREDITATION.—A 

11 MIPS eligible professional who is in a 

12 practice that is certified as a patient-cen13 tered medical home or comparable spe14 cialty practice pursuant to subsection 

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

16 period shall be given the highest potential 

17 score for the performance category de18 scribed in paragraph (2)(A)(iii) for such 

19 period. 

20 ‘‘(ii) APM PARTICIPATION.—Partici21 pation by a MIPS eligible professional in 

22 an alternative payment model (as defined 

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

24 performance period shall earn such eligible 

25 professional a minimum score of one-half 


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1 of the highest potential score for the per2 formance category described in paragraph 

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

4 ‘‘(iii) SUBCATEGORIES.—A MIPS eli5 gible professional shall not be required to 

6 perform activities in each subcategory 

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

8 in an alternative payment model in order 

9 to achieve the highest potential score for 

10 the performance category described in 

11 paragraph (2)(A)(iii). 

12 ‘‘(D) ACHIEVEMENT AND IMPROVE13 MENT.— 

14 ‘‘(i) TAKING INTO ACCOUNT IMPROVE15 MENT.—Beginning with the second year to 

16 which the MIPS applies, in addition to the 

17 achievement of a MIPS eligible profes18 sional, if data sufficient to measure im19 provement is available, the methodology 

20 developed under subparagraph (A)— 

21 ‘‘(I) in the case of the perform22 ance score for the performance cat23 egory described in clauses (i) and (ii) 

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


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1 account the improvement of the pro2 fessional; and 

3 ‘‘(II) in the case of performance 

4 scores for other performance cat5 egories, may take into account the im6 provement of the professional. 

7 ‘‘(ii) ASSIGNING HIGHER WEIGHT FOR

8 ACHIEVEMENT.—Beginning with the 

9 fourth year to which the MIPS applies, 

10 under the methodology developed under 

11 subparagraph (A), the Secretary may as12 sign a higher scoring weight under sub13 paragraph (F) with respect to the achieve14 ment of a MIPS eligible professional than 

15 with respect to any improvement of such 

16 professional applied under clause (i) with 

17 respect to a measure, activity, or category 

18 described in paragraph (2). 

19 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

20 CATEGORIES.— 

21 ‘‘(i) IN GENERAL.—Under the meth22 odology developed under subparagraph (A), 

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

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

25 score shall be determined as follows: 


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1 ‘‘(I) QUALITY.— 

2 ‘‘(aa) IN GENERAL.—Sub3 ject to item (bb), thirty percent 

4 of such score shall be based on 

5 performance with respect to the 

6 category described in clause (i) of 

7 paragraph (2)(A). In applying 

8 the previous sentence, the Sec9 retary shall, as feasible, encour10 age the application of outcome 

11 measures within such category. 

12 ‘‘(bb) FIRST 2 YEARS.—For 

13 the first and second years for 

14 which the MIPS applies to pay15 ments, the percentage applicable 

16 under item (aa) shall be in17 creased in a manner such that 

18 the total percentage points of the 

19 increase under this item for the 

20 respective year equals the total 

21 number of percentage points by 

22 which the percentage applied 

23 under subclause (II)(bb) for the 

24 respective year is less than 30 

25 percent. 


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1 ‘‘(II) RESOURCE USE.— 

2 ‘‘(aa) IN GENERAL.—Sub3 ject to item (bb), thirty percent 

4 of such score shall be based on 

5 performance with respect to the 

6 category described in clause (ii) 

7 of paragraph (2)(A). 

8 ‘‘(bb) FIRST 2 YEARS.—For 

9 the first year for which the MIPS 

10 applies to payments, not more 

11 than 10 percent of such score 

12 shall be based on performance 

13 with respect to the category de14 scribed in clause (ii) of para15 graph (2)(A). For the second 

16 year for which the MIPS applies 

17 to payments, not more than 15 

18 percent of such score shall be 

19 based on performance with re20 spect to the category described in 

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

22 ‘‘(III) CLINICAL PRACTICE IM23 PROVEMENT ACTIVITIES.—Fifteen 

24 percent of such score shall be based 

25 on performance with respect to the 


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1 category described in clause (iii) of 

2 paragraph (2)(A). 

3 ‘‘(IV) MEANINGFUL USE OF CER4 TIFIED EHR TECHNOLOGY.—Twenty5 five percent of such score shall be 

6 based on performance with respect to 

7 the category described in clause (iv) of 

8 paragraph (2)(A). 

9 ‘‘(ii) AUTHORITY TO ADJUST PER10 CENTAGES IN CASE OF HIGH EHR MEAN11 INGFUL USE ADOPTION.—In any year in 

12 which the Secretary estimates that the pro13 portion of eligible professionals (as defined 

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

15 EHR users (as determined under sub16 section (o)(2)) is 75 percent or greater, the 

17 Secretary may reduce the percent applica18 ble under clause (i)(IV), but not below 15 

19 percent. If the Secretary makes such re20 duction for a year, subject to subclauses 

21 (I)(bb) and (II)(bb) of clause (i), the per22 centages applicable under one or more of 

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

24 for such year shall be increased in a man25 ner such that the total percentage points 


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1 of the increase under this clause for such 

2 year equals the total number of percentage 

3 points reduced under the preceding sen4 tence for such year. 

5 ‘‘(F) CERTAIN FLEXIBILITY FOR

6 WEIGHTING PERFORMANCE CATEGORIES, MEAS7 URES, AND ACTIVITIES.—Under the method8 ology under subparagraph (A), if there are not 

9 sufficient measures and clinical practice im10 provement activities applicable and available to 

11 each type of eligible professional involved, the 

12 Secretary shall assign different scoring weights 

13 (including a weight of 0)— 

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

15 weights specified in subparagraph (E), for 

16 each performance category based on the 

17 extent to which the category is applicable 

18 to the type of eligible professional involved; 

19 and 

20 ‘‘(ii) for each measure and activity 

21 specified under paragraph (2)(B) with re22 spect to each such category based on the 

23 extent to which the measure or activity is 

24 applicable and available to the type of eli25 gible professional involved. 


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

2 performance category described in paragraph 

3 (2)(A)(ii) shall include results from the method4 ology described in subsection (r)(5), as appro5 priate. 

6 ‘‘(H) INCLUSION OF QUALITY MEASURE

7 DATA FROM OTHER PAYERS.—In applying sub8 sections (k), (m), and (p) with respect to meas9 ures described in paragraph (2)(B)(i), analysis 

10 of the performance category described in para11 graph (2)(A)(i) may include data submitted by 

12 MIPS eligible professionals with respect to 

13 items and services furnished to individuals who 

14 are not individuals entitled to benefits under 

15 part A or enrolled under part B. 

16 ‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS

17 FOR CERTAIN ASSESSMENT PURPOSES.— 

18 ‘‘(i) IN GENERAL.—In the case of 

19 MIPS eligible professionals electing to be a 

20 virtual group under clause (ii) with respect 

21 to a performance period for a year, for 

22 purposes of applying the methodology 

23 under subparagraph (A)— 

24 ‘‘(I) the assessment of perform25 ance provided under such methodology 


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1 with respect to the performance cat2 egories described in clauses (i) and 

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

4 applied to each such professional in 

5 such group for such performance pe6 riod shall be with respect to the com7 bined performance of all such profes8 sionals in such group for such period; 

9 and 

10 ‘‘(II) the composite score pro11 vided under this paragraph for such 

12 performance period with respect to 

13 each such performance category for 

14 each such MIPS eligible professional 

15 in such virtual group shall be based 

16 on the assessment of the combined 

17 performance under subclause (I) for 

18 the performance category and per19 formance period. 

20 ‘‘(ii) ELECTION OF PRACTICES TO BE

21 A VIRTUAL GROUP.—The Secretary shall, 

22 in accordance with clause (iii), establish 

23 and have in place a process to allow an in24 dividual MIPS eligible professional or a 

25 group practice consisting of not more than 


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1 10 MIPS eligible professionals to elect, 

2 with respect to a performance period for a 

3 year, for such individual MIPS eligible pro4 fessional or all such MIPS eligible profes5 sionals in such group practice, respectively, 

6 to be a virtual group under this subpara7 graph with at least one other such indi8 vidual MIPS eligible professional or group 

9 practice making such an election. Such a 

10 virtual group may be based on geographic 

11 areas or on provider specialties defined by 

12 nationally recognized multispecialty boards 

13 of certification or equivalent certification 

14 boards and such other eligible professional 

15 groupings in order to capture classifica16 tions of providers across eligible profes17 sional organizations and other practice 

18 areas or categories. 

19 ‘‘(iii) REQUIREMENTS.—The process 

20 under clause (ii)— 

21 ‘‘(I) shall provide that an election 

22 under such clause, with respect to a 

23 performance period, shall be made be24 fore or during the beginning of such 

25 performance period and may not be 


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1 changed during such performance pe2 riod; 

3 ‘‘(II) shall provide that a practice 

4 described in such clause, and each 

5 MIPS eligible professional in such 

6 practice, may elect to be in no more 

7 than one virtual group for a perform8 ance period; and 

9 ‘‘(III) may provide that a virtual 

10 group may be combined at the tax 

11 identification number level. 

12 ‘‘(6) MIPS PAYMENTS.— 

13 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak14 ing into account paragraph (1)(G), the Sec15 retary shall specify a MIPS adjustment factor 

16 for each MIPS eligible professional for a year. 

17 Such MIPS adjustment factor for a MIPS eligi18 ble professional for a year shall be in the form 

19 of a percent and shall be determined— 

20 ‘‘(i) by comparing the composite per21 formance score of the eligible professional 

22 for such year to the performance threshold 

23 established under subparagraph (D)(i) for 

24 such year; 


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1 ‘‘(ii) in a manner such that the ad2 justment factors specified under this sub3 paragraph for a year result in differential 

4 payments under this paragraph reflecting 

5 that— 

6 ‘‘(I) MIPS eligible professionals 

7 with composite performance scores for 

8 such year at or above such perform9 ance threshold for such year receive 

10 zero or positive incentive payment ad11 justment factors for such year in ac12 cordance with clause (iii), with such 

13 professionals having higher composite 

14 performance scores receiving higher 

15 adjustment factors; and 

16 ‘‘(II) MIPS eligible professionals 

17 with composite performance scores for 

18 such year below such performance 

19 threshold for such year receive nega20 tive payment adjustment factors for 

21 such year in accordance with clause 

22 (iv), with such professionals having 

23 lower composite performance scores 

24 receiving lower adjustment factors; 


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1 ‘‘(iii) in a manner such that MIPS eli2 gible professionals with composite scores 

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

4 subject to clauses (i) and (ii) of subpara5 graph (F), receive a zero or positive ad6 justment factor on a linear sliding scale 

7 such that an adjustment factor of 0 per8 cent is assigned for a score at the perform9 ance threshold and an adjustment factor of 

10 the applicable percent specified in subpara11 graph (B) is assigned for a score of 100; 

12 and 

13 ‘‘(iv) in a manner such that— 

14 ‘‘(I) subject to subclause (II), 

15 MIPS eligible professionals with com16 posite performance scores described in 

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

18 negative payment adjustment factor 

19 on a linear sliding scale such that an 

20 adjustment factor of 0 percent is as21 signed for a score at the performance 

22 threshold and an adjustment factor of 

23 the negative of the applicable percent 

24 specified in subparagraph (B) is as25 signed for a score of 0; and 


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1 ‘‘(II) MIPS eligible professionals 

2 with composite performance scores 

3 that are equal to or greater than 0, 

but not greater than 1 4 ⁄4 of the per5 formance threshold specified under 

6 subparagraph (D)(i) for such year, re7 ceive a negative payment adjustment 

8 factor that is equal to the negative of 

9 the applicable percent specified in 

10 subparagraph (B) for such year. 

11 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

12 For purposes of this paragraph, the term ‘ap13 plicable percent’ means— 

14 ‘‘(i) for 2018, 4 percent; 

15 ‘‘(ii) for 2019, 5 percent; 

16 ‘‘(iii) for 2020, 7 percent; and 

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

18 9 percent. 

19 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC20 TORS FOR EXCEPTIONAL PERFORMANCE.— 

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

22 MIPS eligible professional with a com23 posite performance score for a year at or 

24 above the additional performance threshold 

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


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1 in addition to the MIPS adjustment factor 

2 under subparagraph (A) for the eligible 

3 professional for such year, subject to the 

4 availability of funds under clause (ii), the 

5 Secretary shall specify an additional posi6 tive MIPS adjustment factor for such pro7 fessional and year. Such additional MIPS 

8 adjustment factors shall be determined by 

9 the Secretary in a manner such that pro10 fessionals having higher composite per11 formance scores above the additional per12 formance threshold receive higher addi13 tional MIPS adjustment factors. 

14 ‘‘(ii) ADDITIONAL FUNDING POOL.— 

15 For 2018 and each subsequent year 

16 through 2023, there is appropriated from 

17 the Federal Supplementary Medical Insur18 ance Trust Fund $500,000,000 for MIPS 

19 payments under this paragraph resulting 

20 from the application of the additional 

21 MIPS adjustment factors under clause (i). 

22 ‘‘(D) ESTABLISHMENT OF PERFORMANCE

23 THRESHOLDS.— 

24 ‘‘(i) PERFORMANCE THRESHOLD.— 

25 For each year of the MIPS, the Secretary 


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1 shall compute a performance threshold 

2 with respect to which the composite per3 formance score of MIPS eligible profes4 sionals shall be compared for purposes of 

5 determining adjustment factors under sub6 paragraph (A) that are positive, negative, 

7 and zero. Such performance threshold for 

8 a year shall be the mean or median (as se9 lected by the Secretary) of the composite 

10 performance scores for all MIPS eligible 

11 professionals with respect to a prior period 

12 specified by the Secretary. The Secretary 

13 may reassess the selection under the pre14 vious sentence every 3 years. 

15 ‘‘(ii) ADDITIONAL PERFORMANCE

16 THRESHOLD FOR EXCEPTIONAL PERFORM17 ANCE.—In addition to the performance 

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

19 the MIPS, the Secretary shall compute an 

20 additional performance threshold for pur21 poses of determining the additional MIPS 

22 adjustment factors under subparagraph 

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

24 shall apply either of the following methods 


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1 for computing such additional performance 

2 threshold for such a year: 

3 ‘‘(I) The threshold shall be the 

4 score that is equal to the 25th per5 centile of the range of possible com6 posite performance scores above the 

7 performance threshold with respect to 

8 the prior period described in clause 

9 (i). 

10 ‘‘(II) The threshold shall be the 

11 score that is equal to the 25th per12 centile of the actual composite per13 formance scores for MIPS eligible 

14 professionals with composite perform15 ance scores at or above the perform16 ance threshold with respect to the 

17 prior period described in clause (i). 

18 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

19 YEARS.—With respect to each of the first 

20 two years to which the MIPS applies, the 

21 Secretary shall, prior to the performance 

22 period for such years, establish a perform23 ance threshold for purposes of determining 

24 MIPS adjustment factors under subpara25 graph (A) and a threshold for purposes of 


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1 determining additional MIPS adjustment 

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

3 such performance threshold shall— 

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

5 such performance periods; and 

6 ‘‘(II) take into account— 

7 ‘‘(aa) data available with re8 spect to performance on meas9 ures and activities that may be 

10 used under the performance cat11 egories under subparagraph 

12 (2)(B); and 

13 ‘‘(bb) other factors deter14 mined appropriate by the Sec15 retary. 

16 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

17 FACTORS.—In the case of items and services 

18 furnished by a MIPS eligible professional dur19 ing a year (beginning with 2018), the amount 

20 otherwise paid under this part with respect to 

21 such items and services and MIPS eligible pro22 fessional for such year, shall be multiplied by— 

23 ‘‘(i) 1, plus 

24 ‘‘(ii) the sum of— 


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1 ‘‘(I) the MIPS adjustment factor 

2 determined under subparagraph (A) 

3 divided by 100, and 

4 ‘‘(II) as applicable, the additional 

5 MIPS adjustment factor determined 

6 under subparagraph (C)(i) divided by 

7 100. 

8 ‘‘(F) AGGREGATE APPLICATION OF MIPS

9 ADJUSTMENT FACTORS.— 

10 ‘‘(i) APPLICATION OF SCALING FAC11 TOR.— 

12 ‘‘(I) IN GENERAL.—With respect 

13 to positive MIPS adjustment factors 

14 under subparagraph (A)(ii)(I) for eli15 gible professionals whose composite 

16 performance score is above the per17 formance threshold under subpara18 graph (D)(i) for such year, subject to 

19 subclause (II), the Secretary shall in20 crease or decrease such adjustment 

21 factors by a scaling factor in order to 

22 ensure that the budget neutrality re23 quirement of clause (ii) is met. 


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1 ‘‘(II) SCALING FACTOR LIMIT.— 

2 In no case may be the scaling factor 

3 applied under this clause exceed 3.0. 

4 ‘‘(ii) BUDGET NEUTRALITY REQUIRE5 MENT.— 

6 ‘‘(I) IN GENERAL.—Subject to 

7 clause (iii), the Secretary shall ensure 

8 that the estimated amount described 

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

10 the estimated amount described in 

11 subclause (III) for such year. 

12 ‘‘(II) AGGREGATE INCREASES.— 

13 The amount described in this sub14 clause is the estimated increase in the 

15 aggregate allowed charges resulting 

16 from the application of positive MIPS 

17 adjustment factors under subpara18 graph (A) (after application of the 

19 scaling factor described in clause (i)) 

20 to MIPS eligible professionals whose 

21 composite performance score for a 

22 year is above the performance thresh23 old under subparagraph (D)(i) for 

24 such year. 


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1 ‘‘(III) AGGREGATE DE2 CREASES.—The amount described in 

3 this subclause is the estimated de4 crease in the aggregate allowed 

5 charges resulting from the application 

6 of negative MIPS adjustment factors 

7 under subparagraph (A) to MIPS eli8 gible professionals whose composite 

9 performance score for a year is below 

10 the performance threshold under sub11 paragraph (D)(i) for such year. 

12 ‘‘(iii) EXCEPTIONS.— 

13 ‘‘(I) In the case that all MIPS el14 igible professionals receive composite 

15 performance scores for a year that are 

16 below the performance threshold 

17 under subparagraph (D)(i) for such 

18 year, the negative MIPS adjustment 

19 factors under subparagraph (A) shall 

20 apply with respect to such MIPS eligi21 ble professionals and the budget neu22 trality requirement of clause (ii) shall 

23 not apply for such year. 

24 ‘‘(II) In the case that, with re25 spect to a year, the application of 


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1 clause (i) results in a scaling factor 

2 equal to the maximum scaling factor 

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

4 factor shall apply and the budget neu5 trality requirement of clause (ii) shall 

6 not apply for such year. 

7 ‘‘(iv) ADDITIONAL INCENTIVE PAY8 MENT ADJUSTMENTS.—In specifying the 

9 MIPS additional adjustment factors under 

10 subparagraph (C)(i) for each applicable 

11 MIPS eligible professional for a year, the 

12 Secretary shall ensure that the estimated 

13 increase in payments under this part re14 sulting from the application of such addi15 tional adjustment factors for MIPS eligible 

16 professionals in a year shall be equal (as 

17 estimated by the Secretary) to the addi18 tional funding pool amount for such year 

19 under subparagraph (C)(ii). 

20 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST21 MENTS.—Under the MIPS, the Secretary shall, not 

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

23 involved, make available to MIPS eligible profes24 sionals the MIPS adjustment factor (and, as appli25 cable, the additional MIPS adjustment factor) under 


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1 paragraph (6) applicable to the eligible professional 

2 for items and services furnished by the professional 

3 for such year. The Secretary may include such infor4 mation in the confidential feedback under paragraph 

5 (12). 

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

7 MIPS adjustment factors and additional MIPS ad8 justment factors under paragraph (6) shall apply 

9 only with respect to the year involved, and the Sec10 retary shall not take into account such adjustment 

11 factors in making payments to a MIPS eligible pro12 fessional under this part in a subsequent year. 

13 ‘‘(9) PUBLIC REPORTING.— 

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

15 in an easily understandable format, make avail16 able on the Physician Compare Internet website 

17 of the Centers for Medicare & Medicaid Serv18 ices the following: 

19 ‘‘(i) Information regarding the per20 formance of MIPS eligible professionals 

21 under the MIPS, which— 

22 ‘‘(I) shall include the composite 

23 score for each such MIPS eligible pro24 fessional and the performance of each 

25 such MIPS eligible professional with 


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1 respect to each performance category; 

2 and 

3 ‘‘(II) may include the perform4 ance of each such MIPS eligible pro5 fessional with respect to each measure 

6 or activity specified in paragraph 

7 (2)(B). 

8 ‘‘(ii) The names of eligible profes9 sionals in eligible alternative payment mod10 els (as defined in section 1833(z)(3)(D)) 

11 and, to the extent feasible, the names of 

12 such eligible alternative payment models 

13 and performance of such models. 

14 ‘‘(B) DISCLOSURE.—The information 

15 made available under this paragraph shall indi16 cate, where appropriate, that publicized infor17 mation may not be representative of the eligible 

18 professional’s entire patient population, the va19 riety of services furnished by the eligible profes20 sional, or the health conditions of individuals 

21 treated. 

22 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB23 MIT CORRECTIONS.—The Secretary shall pro24 vide for an opportunity for a professional de25 scribed in subparagraph (A) to review, and subVerDate Mar 15 2010 23:32 Feb 07, 2014 Jkt 039200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.IH H4015

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1 mit corrections for, the information to be made 

2 public with respect to the professional under 

3 such subparagraph prior to such information 

4 being made public. 

5 ‘‘(D) AGGREGATE INFORMATION.—The 

6 Secretary shall periodically post on the Physi7 cian Compare Internet website aggregate infor8 mation on the MIPS, including the range of 

9 composite scores for all MIPS eligible profes10 sionals and the range of the performance of all 

11 MIPS eligible professionals with respect to each 

12 performance category. 

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

14 consult with stakeholders in carrying out the MIPS, 

15 including for the identification of measures and ac16 tivities under paragraph (2)(B) and the methodolo17 gies developed under paragraphs (5)(A) and (6) and 

18 regarding the use of qualified clinical data registries. 

19 Such consultation shall include the use of a request 

20 for information or other mechanisms determined ap21 propriate. 

22 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC23 TICES AND PRACTICES IN HEALTH PROFESSIONAL

24 SHORTAGE AREAS.— 


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

2 enter into contracts or agreements with appro3 priate entities (such as quality improvement or4 ganizations, regional extension centers (as de5 scribed in section 3012(c) of the Public Health 

6 Service Act), or regional health collaboratives) 

7 to offer guidance and assistance to MIPS eligi8 ble professionals in practices of 15 or fewer pro9 fessionals (with priority given to such practices 

10 located in rural areas, health professional short11 age areas (as designated under in section 

12 332(a)(1)(A) of such Act), and medically under13 served areas, and practices with low composite 

14 scores) with respect to— 

15 ‘‘(i) the performance categories de16 scribed in clauses (i) through (iv) of para17 graph (2)(A); or 

18 ‘‘(ii) how to transition to the imple19 mentation of and participation in an alter20 native payment model as described in sec21 tion 1833(z)(3)(C). 

22 ‘‘(B) FUNDING FOR IMPLEMENTATION.— 

23 ‘‘(i) IN GENERAL.—For purposes of 

24 implementing subparagraph (A), the Sec25 retary shall provide for the transfer from 


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1 the Federal Supplementary Medical Insur2 ance Trust Fund established under section 

3 1841 to the Centers for Medicare & Med4 icaid Services Program Management Ac5 count of $40,000,000 for each of fiscal 

6 years 2015 through 2019. Amounts trans7 ferred under this subparagraph for a fiscal 

8 year shall be available until expended. 

9 ‘‘(ii) TECHNICAL ASSISTANCE.—Of 

10 the amounts transferred pursuant to clause 

11 (i) for each of fiscal years 2015 through 

12 2019, not less than $10,000,000 shall be 

13 made available for each such year for tech14 nical assistance to small practices in health 

15 professional shortage areas (as so des16 ignated) and medically underserved areas. 

17 ‘‘(12) FEEDBACK AND INFORMATION TO IM18 PROVE PERFORMANCE.— 

19 ‘‘(A) PERFORMANCE FEEDBACK.— 

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

21 2016, the Secretary— 

22 ‘‘(I) shall make available timely 

23 (such as quarterly) confidential feed24 back to MIPS eligible professionals on 

25 the performance of such professionals 


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1 with respect to the performance cat2 egories under clauses (i) and (ii) of 

3 paragraph (2)(A); and 

4 ‘‘(II) may make available con5 fidential feedback to each such profes6 sional on the performance of such 

7 professional with respect to the per8 formance categories under clauses (iii) 

9 and (iv) of such paragraph. 

10 ‘‘(ii) MECHANISMS.—The Secretary 

11 may use one or more mechanisms to make 

12 feedback available under clause (i), which 

13 may include use of a web-based portal or 

14 other mechanisms determined appropriate 

15 by the Secretary. With respect to the per16 formance category described in paragraph 

17 (2)(A)(i), feedback under this subpara18 graph shall, to the extent an eligible pro19 fessional chooses to participate in a data 

20 registry for purposes of this subsection (in21 cluding registries under subsections (k) 

22 and (m)), be provided based on perform23 ance on quality measures reported through 

24 the use of such registries. With respect to 

25 any other performance category described 


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

2 encourage provision of feedback through 

3 qualified clinical data registries as de4 scribed in subsection (m)(3)(E)). 

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

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

7 with respect to a MIPS eligible profes8 sional, from periods prior to the current 

9 performance period and may use rolling 

10 periods in order to make illustrative cal11 culations about the performance of such 

12 professional. 

13 ‘‘(iv) DISCLOSURE EXEMPTION.— 

14 Feedback made available under this sub15 paragraph shall be exempt from disclosure 

16 under section 552 of title 5, United States 

17 Code. 

18 ‘‘(v) RECEIPT OF INFORMATION.— 

19 The Secretary may use the mechanisms es20 tablished under clause (ii) to receive infor21 mation from professionals, such as infor22 mation with respect to this subsection. 

23 ‘‘(B) ADDITIONAL INFORMATION.— 

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

25 2017, the Secretary shall make available to 


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1 each MIPS eligible professional informa2 tion, with respect to individuals who are 

3 patients of such MIPS eligible professional, 

4 about items and services for which pay5 ment is made under this title that are fur6 nished to such individuals by other sup7 pliers and providers of services, which may 

8 include information described in clause (ii). 

9 Such information may be made available 

10 under the previous sentence to such MIPS 

11 eligible professionals by mechanisms deter12 mined appropriate by the Secretary, which 

13 may include use of a web-based portal. 

14 Such information may be made available in 

15 accordance with the same or similar terms 

16 as data are made available to accountable 

17 care organizations participating in the 

18 shared savings program under section 

19 1899, including a beneficiary opt-out. 

20 ‘‘(ii) TYPE OF INFORMATION.—For 

21 purposes of clause (i), the information de22 scribed in this clause, is the following: 

23 ‘‘(I) With respect to selected 

24 items and services (as determined ap25 propriate by the Secretary) for which 


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1 payment is made under this title and 

2 that are furnished to individuals, who 

3 are patients of a MIPS eligible profes4 sional, by another supplier or provider 

5 of services during the most recent pe6 riod for which data are available (such 

7 as the most recent three-month pe8 riod), such as the name of such pro9 viders furnishing such items and serv10 ices to such patients during such pe11 riod, the types of such items and serv12 ices so furnished, and the dates such 

13 items and services were so furnished. 

14 ‘‘(II) Historical data, such as 

15 averages and other measures of the 

16 distribution if appropriate, of the 

17 total, and components of, allowed 

18 charges (and other figures as deter19 mined appropriate by the Secretary). 

20 ‘‘(13) REVIEW.— 

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

22 shall establish a process under which a MIPS 

23 eligible professional may seek an informal re24 view of the calculation of the MIPS adjustment 

25 factor applicable to such eligible professional 


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1 under this subsection for a year. The results of 

2 a review conducted pursuant to the previous 

3 sentence shall not be taken into account for 

4 purposes of paragraph (6) with respect to a 

5 year (other than with respect to the calculation 

6 of such eligible professional’s MIPS adjustment 

7 factor for such year or additional MIPS adjust8 ment factor for such year) after the factors de9 termined in subparagraph (A) and subpara10 graph (C) of such paragraph have been deter11 mined for such year. 

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

13 in subparagraph (A), there shall be no adminis14 trative or judicial review under section 1869, 

15 section 1878, or otherwise of the following: 

16 ‘‘(i) The methodology used to deter17 mine the amount of the MIPS adjustment 

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

19 amount of the additional MIPS adjustment 

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

21 determination of such amounts. 

22 ‘‘(ii) The establishment of the per23 formance standards under paragraph (3) 

24 and the performance period under para25 graph (4). 


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1 ‘‘(iii) The identification of measures 

2 and activities specified under paragraph 

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

4 posted on the Physician Compare Internet 

5 website of the Centers for Medicare & 

6 Medicaid Services under paragraph (9). 

7 ‘‘(iv) The methodology developed 

8 under paragraph (5) that is used to cal9 culate performance scores and the calcula10 tion of such scores, including the weighting 

11 of measures and activities under such 

12 methodology.’’. 

13 (2) GAO REPORTS.— 

14 (A) EVALUATION OF ELIGIBLE PROFES15 SIONAL MIPS.—Not later than October 1, 2019, 

16 and October 1, 2022, the Comptroller General 

17 of the United States shall submit to Congress 

18 a report evaluating the eligible professional 

19 Merit-based Incentive Payment System under 

20 subsection (q) of section 1848 of the Social Se21 curity Act (42 U.S.C. 1395w–4), as added by 

22 paragraph (1). Such report shall— 

23 (i) examine the distribution of the 

24 composite performance scores and MIPS 

25 adjustment factors (and additional MIPS 


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1 adjustment factors) for MIPS eligible pro2 fessionals (as defined in subsection 

3 (q)(1)(c) of such section) under such pro4 gram, and patterns relating to such scores 

5 and adjustment factors, including based on 

6 type of provider, practice size, geographic 

7 location, and patient mix; 

8 (ii) provide recommendations for im9 proving such program; 

10 (iii) evaluate the impact of technical 

11 assistance funding under section 

12 1848(q)(11) of the Social Security Act, as 

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

14 professionals to improve within such pro15 gram or successfully transition to an alter16 native payment model (as defined in sec17 tion 1833(z)(3) of the Social Security Act, 

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

19 for such evaluation given to practices lo20 cated in rural areas, health professional 

21 shortage areas (as designated in section 

22 332(a)(1)(a) of the Public Health Service 

23 Act), and medically underserved areas; and 


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1 (iv) provide recommendations for opti2 mizing the use of such technical assistance 

3 funds. 

4 (B) STUDY TO EXAMINE ALIGNMENT OF

5 QUALITY MEASURES USED IN PUBLIC AND PRI6 VATE PROGRAMS.— 

7 (i) IN GENERAL.—Not later than 18 

8 months after the date of the enactment of 

9 this Act, the Comptroller General of the 

10 United States shall submit to Congress a 

11 report that— 

12 (I) compares the similarities and 

13 differences in the use of quality meas14 ures under the original Medicare fee15 for-service program under parts A and 

16 B of title XVIII of the Social Security 

17 Act, the Medicare Advantage program 

18 under part C of such title, selected 

19 State Medicaid programs under title 

20 XIX of such Act, and private payer 

21 arrangements; and 

22 (II) makes recommendations on 

23 how to reduce the administrative bur24 den involved in applying such quality 

25 measures. 


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1 (ii) REQUIREMENTS.—The report 

2 under clause (i) shall— 

3 (I) consider those measures ap4 plicable to individuals entitled to, or 

5 enrolled for, benefits under such part 

6 A, or enrolled under such part B and 

7 individuals under the age of 65; and 

8 (II) focus on those measures that 

9 comprise the most significant compo10 nent of the quality performance cat11 egory of the eligible professional 

12 MIPS incentive program under sub13 section (q) of section 1848 of the So14 cial Security Act (42 U.S.C. 1395w– 

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

16 (C) STUDY ON ROLE OF INDEPENDENT

17 RISK MANAGERS.—Not later than January 1, 

18 2016, the Comptroller General of the United 

19 States shall submit to Congress a report exam20 ining whether entities that pool financial risk 

21 for physician practices, such as independent 

22 risk managers, can play a role in supporting 

23 physician practices, particularly small physician 

24 practices, in assuming financial risk for the 

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1 ine barriers that small physician practices cur2 rently face in assuming financial risk for treat3 ing patients, the types of risk management enti4 ties that could assist physician practices in par5 ticipating in two-sided risk payment models, 

6 and how such entities could assist with risk 

7 management and with quality improvement ac8 tivities. Such report shall also include an anal9 ysis of any existing legal barriers to such ar10 rangements. 

11 (D) STUDY TO EXAMINE RURAL AND

12 HEALTH PROFESSIONAL SHORTAGE AREA AL13 TERNATIVE PAYMENT MODELS.—Not later than 

14 October 1, 2020, and October 1, 2022, the 

15 Comptroller General of the United States shall 

16 submit to Congress a report that examines the 

17 transition of professionals in rural areas, health 

18 professional shortage areas (as designated in 

19 section 332(a)(1)(A) of the Public Health Serv20 ice Act), or medically underserved areas to an 

21 alternative payment model (as defined in sec22 tion 1833(z)(3) of the Social Security Act, as 

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

24 make recommendations for removing adminis25 trative barriers to practices, including small 


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1 practices consisting of 15 or fewer profes2 sionals, in rural areas, health professional 

3 shortage areas, and medically underserved areas 

4 to participation in such models. 

5 (3) FUNDING FOR IMPLEMENTATION.—For 

6 purposes of implementing the provisions of and the 

7 amendments made by this section, the Secretary of 

8 Health and Human Services shall provide for the 

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

10 Medical Insurance Trust Fund established under 

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

12 1395t) to the Centers for Medicare & Medicaid Pro13 gram Management Account for each of the fiscal 

14 years 2014 through 2018. Amounts transferred 

15 under this paragraph shall be available until ex16 pended. 

17 (d) IMPROVING QUALITY REPORTING FOR COM18 POSITE SCORES.— 

19 (1) CHANGES FOR GROUP REPORTING OP20 TION.— 

21 (A) IN GENERAL.—Section 

22 1848(m)(3)(C)(ii)) of the Social Security Act 

23 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

24 by inserting ‘‘and, for 2015 and subsequent 

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


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1 (B) CLARIFICATION OF QUALIFIED CLIN2 ICAL DATA REGISTRY REPORTING TO GROUP

3 PRACTICES.—Section 1848(m)(3)(D) of the So4 cial Security Act (42 U.S.C. 1395w– 

5 4(m)(3)(D)) is amended by inserting ‘‘and, for 

6 2015 and subsequent years, subparagraph (A) 

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

8 (2) CHANGES FOR MULTIPLE REPORTING PERI9 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC10 TORY REPORTING.—Section 1848(m)(5)(F) of the 

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

12 is amended— 

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

14 and inserting ‘‘through reporting periods occur15 ring in 2014’’; and 

16 (B) by inserting ‘‘and, for reporting peri17 ods occurring in 2015 and subsequent years, 

18 the Secretary may establish’’ following ‘‘shall 

19 establish’’. 

20 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

21 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

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

23 1395w–4(n)) is amended by adding at the end the 

24 following new paragraph: 


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

2 under the Program shall not be provided after De3 cember 31, 2016. See subsection (q)(12) for reports 

4 under the eligible professionals Merit-based Incentive 

5 Payment System.’’. 

6 (4) COORDINATION WITH SATISFYING MEANING7 FUL EHR USE CLINICAL QUALITY MEASURE REPORT8 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

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

10 4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub11 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara12 graph (B)(ii)’’. 

13 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

14 (1) INCREASING TRANSPARENCY OF PHYSICIAN

15 FOCUSED PAYMENT MODELS.—Section 1868 of the 

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

17 by adding at the end the following new subsection: 

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

19 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 

20 ‘‘(A) ESTABLISHMENT.—There is estab21 lished an ad hoc committee to be known as the 

22 ‘Payment Model Technical Advisory Committee’ 

23 (referred to in this subsection as the ‘Com24 mittee’). 

25 ‘‘(B) MEMBERSHIP.— 


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1 ‘‘(i) NUMBER AND APPOINTMENT.— 

2 The Committee shall be composed of 11 

3 members appointed by the Comptroller 

4 General of the United States. 

5 ‘‘(ii) QUALIFICATIONS.—The member6 ship of the Committee shall include indi7 viduals with national recognition for their 

8 expertise in payment models and related 

9 delivery of care. No more than 5 members 

10 of the Committee shall be providers of 

11 services or suppliers, or representatives of 

12 providers of services or suppliers. 

13 ‘‘(iii) PROHIBITION ON FEDERAL EM14 PLOYMENT.—A member of the Committee 

15 shall not be an employee of the Federal 

16 Government. 

17 ‘‘(iv) ETHICS DISCLOSURE.—The 

18 Comptroller General shall establish a sys19 tem for public disclosure by members of 

20 the Committee of financial and other po21 tential conflicts of interest relating to such 

22 members. Members of the Committee shall 

23 be treated as employees of Congress for 

24 purposes of applying title I of the Ethics 


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1 in Government Act of 1978 (Public Law 

2 95–521). 

3 ‘‘(v) DATE OF INITIAL APPOINT4 MENTS.—The initial appointments of mem5 bers of the Committee shall be made by 

6 not later than 180 days after the date of 

7 enactment of this subsection. 

8 ‘‘(C) TERM; VACANCIES.— 

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

10 the Committee shall be for 3 years except 

11 that the Comptroller General shall des12 ignate staggered terms for the members 

13 first appointed. 

14 ‘‘(ii) VACANCIES.—Any member ap15 pointed to fill a vacancy occurring before 

16 the expiration of the term for which the 

17 member’s predecessor was appointed shall 

18 be appointed only for the remainder of that 

19 term. A member may serve after the expi20 ration of that member’s term until a suc21 cessor has taken office. A vacancy in the 

22 Committee shall be filled in the manner in 

23 which the original appointment was made. 

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

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1 ommendations to the Secretary, as described in 

2 paragraph (2)(C), on physician-focused pay3 ment models. 

4 ‘‘(E) COMPENSATION OF MEMBERS.— 

5 ‘‘(i) IN GENERAL.—Except as pro6 vided in clause (ii), a member of the Com7 mittee shall serve without compensation. 

8 ‘‘(ii) TRAVEL EXPENSES.—A member 

9 of the Committee shall be allowed travel 

10 expenses, including per diem in lieu of sub11 sistence, at rates authorized for an em12 ployee of an agency under subchapter I of 

13 chapter 57 of title 5, United States Code, 

14 while away from the home or regular place 

15 of business of the member in the perform16 ance of the duties of the Committee. 

17 ‘‘(F) OPERATIONAL AND TECHNICAL SUP18 PORT.— 

19 ‘‘(i) IN GENERAL.—The Assistant 

20 Secretary for Planning and Evaluation 

21 shall provide technical and operational sup22 port for the Committee, which may be by 

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1 icaid Services shall provide to the Com2 mittee actuarial assistance as needed. 

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

4 provide for the transfer, from the Federal 

5 Supplementary Medical Insurance Trust 

6 Fund under section 1841, such amounts as 

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

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

9 and each subsequent fiscal year. Any 

10 amounts transferred under the preceding 

11 sentence for a fiscal year shall remain 

12 available until expended. 

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

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

15 App.) shall not apply to the Committee. 

16 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

17 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

18 MODELS.— 

19 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN20 FOCUSED PAYMENT MODELS.— 

21 ‘‘(i) RULEMAKING.—Not later than 

22 November 1, 2015, the Secretary shall, 

23 through notice and comment rulemaking, 

24 following a request for information, estab25 lish criteria for physician-focused payment 


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1 models, including models for specialist phy2 sicians, that could be used by the Com3 mittee for making comments and rec4 ommendations pursuant to paragraph 

5 (1)(D). 

6 ‘‘(ii) MEDPAC SUBMISSION OF COM7 MENTS.—During the comment period for 

8 the proposed rule described in clause (i), 

9 the Medicare Payment Advisory Commis10 sion may submit comments to the Sec11 retary on the proposed criteria under such 

12 clause. 

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

14 update the criteria established under this 

15 subparagraph through rulemaking. 

16 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY17 SICIAN FOCUSED PAYMENT MODELS.—On an 

18 ongoing basis, individuals and stakeholder enti19 ties may submit to the Committee proposals for 

20 physician-focused payment models that such in21 dividuals and entities believe meet the criteria 

22 described in subparagraph (A). 

23 ‘‘(C) TAC REVIEW OF MODELS SUB24 MITTED.—The Committee shall, on a periodic 

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1 graph (B), prepare comments and recommenda2 tions regarding whether such models meet the 

3 criteria described in subparagraph (A), and 

4 submit such comments and recommendations to 

5 the Secretary. 

6 ‘‘(D) SECRETARY REVIEW AND RE7 SPONSE.—The Secretary shall review the com8 ments and recommendations submitted by the 

9 Committee under subparagraph (C) and post a 

10 detailed response to such comments and rec11 ommendations on the Internet Website of the 

12 Centers for Medicare & Medicaid Services. 

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

14 this subsection shall be construed to impact the de15 velopment or testing of models under this title or ti16 tles XI, XIX, or XXI.’’. 

17 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

18 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

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

20 1395l) is amended by adding at the end the fol21 lowing new subsection: 

22 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

23 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

24 ‘‘(1) PAYMENT INCENTIVE.— 


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

2 professional services furnished by an eligible 

3 professional during a year that is in the period 

4 beginning with 2018 and ending with 2023 and 

5 for which the professional is a qualifying APM 

6 participant, in addition to the amount of pay7 ment that would otherwise be made for such 

8 covered professional services under this part for 

9 such year, there also shall be paid to such pro10 fessional an amount equal to 5 percent of the 

11 payment amount for the covered professional 

12 services under this part for the preceding year. 

13 For purposes of the previous sentence, the pay14 ment amount for the preceding year may be an 

15 estimation for the full preceding year based on 

16 a period of such preceding year that is less than 

17 the full year. The Secretary shall establish poli18 cies to implement this subparagraph in cases 

19 where payment for covered professional services 

20 furnished by a qualifying APM participant in 

21 an alternative payment model is made to an en22 tity participating in the alternative payment 

23 model rather than directly to the qualifying 

24 APM participant. 


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1 ‘‘(B) FORM OF PAYMENT.—Payments 

2 under this subsection shall be made in a lump 

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

4 ‘‘(C) TREATMENT OF PAYMENT INCEN5 TIVE.—Payments under this subsection shall 

6 not be taken into account for purposes of deter7 mining actual expenditures under an alternative 

8 payment model and for purposes of determining 

9 or rebasing any benchmarks used under the al10 ternative payment model. 

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

12 additional payment for an item or service under 

13 this subsection or subsection (m) shall be deter14 mined without regard to any additional pay15 ment for the item or service under subsection 

16 (m) and this subsection, respectively. The 

17 amount of the additional payment for an item 

18 or service under this subsection or subsection 

19 (x) shall be determined without regard to any 

20 additional payment for the item or service 

21 under subsection (x) and this subsection, re22 spectively. The amount of the additional pay23 ment for an item or service under this sub24 section or subsection (y) shall be determined 

25 without regard to any additional payment for 


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1 the item or service under subsection (y) and 

2 this subsection, respectively. 

3 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur4 poses of this subsection, the term ‘qualifying APM 

5 participant’ means the following: 

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

7 2018 and 2019, an eligible professional for 

8 whom the Secretary determines that at least 25 

9 percent of payments under this part for covered 

10 professional services furnished by such profes11 sional during the most recent period for which 

12 data are available (which may be less than a 

13 year) were attributable to such services fur14 nished under this part through an entity that 

15 participates in an eligible alternative payment 

16 model with respect to such services. 

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

18 2020 and 2021, an eligible professional de19 scribed in either of the following clauses: 

20 ‘‘(i) MEDICARE REVENUE THRESHOLD

21 OPTION.—An eligible professional for 

22 whom the Secretary determines that at 

23 least 50 percent of payments under this 

24 part for covered professional services fur25 nished by such professional during the 


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1 most recent period for which data are 

2 available (which may be less than a year) 

3 were attributable to such services furnished 

4 under this part through an entity that par5 ticipates in an eligible alternative payment 

6 model with respect to such services. 

7 ‘‘(ii) COMBINATION ALL-PAYER AND

8 MEDICARE REVENUE THRESHOLD OP9 TION.—An eligible professional— 

10 ‘‘(I) for whom the Secretary de11 termines, with respect to items and 

12 services furnished by such professional 

13 during the most recent period for 

14 which data are available (which may 

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

16 percent of the sum of— 

17 ‘‘(aa) payments described in 

18 clause (i); and 

19 ‘‘(bb) all other payments, re20 gardless of payer (other than 

21 payments made by the Secretary 

22 of Defense or the Secretary of 

23 Veterans Affairs under chapter 

24 55 of title 10, United States 

25 Code, or title 38, United States 


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1 Code, or any other provision of 

2 law, and other than payments 

3 made under title XIX in a State 

4 in which no medical home or al5 ternative payment model is avail6 able under the State program 

7 under that title), 

8 meet the requirement described in 

9 clause (iii)(I) with respect to pay10 ments described in item (aa) and meet 

11 the requirement described in clause 

12 (iii)(II) with respect to payments de13 scribed in item (bb); 

14 ‘‘(II) for whom the Secretary de15 termines at least 25 percent of pay16 ments under this part for covered pro17 fessional services furnished by such 

18 professional during the most recent 

19 period for which data are available 

20 (which may be less than a year) were 

21 attributable to such services furnished 

22 under this part through an entity that 

23 participates in an eligible alternative 

24 payment model with respect to such 

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

12 2022 and each subsequent year, an eligible pro13 fessional described in either of the following 

14 clauses: 

15 ‘‘(i) MEDICARE REVENUE THRESHOLD

16 OPTION.—An eligible professional for 

17 whom the Secretary determines that at 

18 least 75 percent of payments under this 

19 part for covered professional services fur20 nished by such professional during the 

21 most recent period for which data are 

22 available (which may be less than a year) 

23 were attributable to such services furnished 

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1 ticipates in an eligible alternative payment 

2 model with respect to such services. 

3 ‘‘(ii) COMBINATION ALL-PAYER AND

4 MEDICARE REVENUE THRESHOLD OP5 TION.—An eligible professional— 

6 ‘‘(I) for whom the Secretary de7 termines, with respect to items and 

8 services furnished by such professional 

9 during the most recent period for 

10 which data are available (which may 

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

12 percent of the sum of— 

13 ‘‘(aa) payments described in 

14 clause (i); and 

15 ‘‘(bb) all other payments, re16 gardless of payer (other than 

17 payments made by the Secretary 

18 of Defense or the Secretary of 

19 Veterans Affairs under chapter 

20 55 of title 10, United States 

21 Code, or title 38, United States 

22 Code, or any other provision of 

23 law, and other than payments 

24 made under title XIX in a State 

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1 ternative payment model is avail2 able under the State program 

3 under that title), 

4 meet the requirement described in 

5 clause (iii)(I) with respect to pay6 ments described in item (aa) and meet 

7 the requirement described in clause 

8 (iii)(II) with respect to payments de9 scribed in item (bb); 

10 ‘‘(II) for whom the Secretary de11 termines at least 25 percent of pay12 ments under this part for covered pro13 fessional services furnished by such 

14 professional during the most recent 

15 period for which data are available 

16 (which may be less than a year) were 

17 attributable to such services furnished 

18 under this part through an entity that 

19 participates in an eligible alternative 

20 payment model with respect to such 

21 services; and 

22 ‘‘(III) who provides to the Sec23 retary such information as is nec24 essary for the Secretary to make a deVerDate Mar 15 2010 23:32 Feb 07, 2014 Jkt 039200 PO 00000 Frm 00093 Fmt 6652 Sfmt 6201 E:\BILLS\H4015.IH H4015

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1 termination under subclause (I), with 

2 respect to such professional. 

3 ‘‘(iii) REQUIREMENT.—For purposes 

4 of clause (ii)(I)— 

5 ‘‘(I) the requirement described in 

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

8 clause, is that such payments are 

9 made under an eligible alternative 

10 payment model; and 

11 ‘‘(II) the requirement described 

12 in this subclause, with respect to pay13 ments described in item (bb) of such 

14 clause, is that such payments are 

15 made under an arrangement in 

16 which— 

17 ‘‘(aa) quality measures com18 parable to measures under the 

19 performance category described 

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

21 ‘‘(bb) certified EHR tech22 nology is used; and 

23 ‘‘(cc) the eligible profes24 sional (AA) bears more than 

25 nominal financial risk if actual 


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1 aggregate expenditures exceeds 

2 expected aggregate expenditures; 

3 or (BB) is a medical home (with 

4 respect to beneficiaries under 

5 title XIX) that meets criteria 

6 comparable to medical homes ex7 panded under section 1115A(c). 

8 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub9 section: 

10 ‘‘(A) COVERED PROFESSIONAL SERV11 ICES.—The term ‘covered professional services’ 

12 has the meaning given that term in section 

13 1848(k)(3)(A). 

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

15 ‘eligible professional’ has the meaning given 

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

17 ‘‘(C) ALTERNATIVE PAYMENT MODEL

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

19 means any of the following: 

20 ‘‘(i) A model under section 1115A 

21 (other than a health care innovation 

22 award). 

23 ‘‘(ii) The shared savings program 

24 under section 1899. 


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1 ‘‘(iii) A demonstration under section 

2 1866C. 

3 ‘‘(iv) A demonstration required by 

4 Federal law. 

5 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

6 MODEL (APM).— 

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

8 alternative payment model’ means, with re9 spect to a year, an alternative payment 

10 model— 

11 ‘‘(I) that requires use of certified 

12 EHR technology (as defined in sub13 section (o)(4)); 

14 ‘‘(II) that provides for payment 

15 for covered professional services based 

16 on quality measures comparable to 

17 measures under the performance cat18 egory described in section 

19 1848(q)(2)(B)(i); and 

20 ‘‘(III) that satisfies the require21 ment described in clause (ii). 

22 ‘‘(ii) ADDITIONAL REQUIREMENT.— 

23 For purposes of clause (i)(III), the require24 ment described in this clause, with respect 

25 to a year and an alternative payment 


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1 model, is that the alternative payment 

2 model— 

3 ‘‘(I) is one in which one or more 

4 entities bear financial risk for mone5 tary losses under such model that are 

6 in excess of a nominal amount; or 

7 ‘‘(II) is a medical home expanded 

8 under section 1115A(c). 

9 ‘‘(4) LIMITATION.—There shall be no adminis10 trative or judicial review under section 1869, 1878, 

11 or otherwise, of the following: 

12 ‘‘(A) The determination that an eligible 

13 professional is a qualifying APM participant 

14 under paragraph (2) and the determination 

15 that an alternative payment model is an eligible 

16 alternative payment model under paragraph 

17 (3)(D). 

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

19 the 5 percent payment incentive under para20 graph (1)(A), including any estimation as part 

21 of such determination.’’. 

22 (3) COORDINATION CONFORMING AMEND23 MENTS.—Section 1833 of the Social Security Act 

24 (42 U.S.C. 1395l) is further amended— 


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

2 end the following new sentence: ‘‘The amount 

3 of the additional payment for a service under 

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

7 this subsection, respectively.’’; and 

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

9 end the following new sentence: ‘‘The amount 

10 of the additional payment for a service under 

11 this subsection and subsection (z) shall be de12 termined without regard to any additional pay13 ment for the service under subsection (z) and 

14 this subsection, respectively.’’. 

15 (4) ENCOURAGING DEVELOPMENT AND TEST16 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

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

18 amended— 

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

20 end the following new clauses: 

21 ‘‘(xxi) Focusing primarily on physi22 cians’ services (as defined in section 

23 1848(j)(3)) furnished by physicians who 

24 are not primary care practitioners. 


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

2 fewer professionals. 

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

4 for small physician practices which may in5 volve two-sided risk and prospective patient 

6 assignment, and which examine risk-ad7 justed decreases in mortality rates, hos8 pital readmissions rates, and other relevant 

9 and appropriate clinical measures. 

10 ‘‘(xxiv) Focusing primarily on title 

11 XIX, working in conjunction with the Cen12 ter for Medicaid and CHIP Services.’’; and 

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

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

15 and inserting ‘‘other public sector payers, pri16 vate sector payers, or Statewide payment mod17 els’’. 

18 (5) CONSTRUCTION REGARDING TELEHEALTH

19 SERVICES.—Nothing in the provisions of, or amend20 ments made by, this Act shall be construed as pre21 cluding an alternative payment model or a qualifying 

22 APM participant (as those terms are defined in sec23 tion 1833(z) of the Social Security Act, as added by 

24 paragraph (1)) from furnishing a telehealth service 

25 for which payment is not made under section 


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1 1834(m) of the Social Security Act (42 U.S.C. 

2 1395m(m)). 

3 (6) INTEGRATING MEDICARE ADVANTAGE AL4 TERNATIVE PAYMENT MODELS.—Not later than July 

5 1, 2015, the Secretary of Health and Human Serv6 ices shall submit to Congress a study that examines 

7 the feasibility of integrating alternative payment 

8 models in the Medicare Advantage payment system. 

9 The study shall include the feasibility of including a 

10 value-based modifier and whether such modifier 

11 should be budget neutral. 

12 (7) STUDY AND REPORT ON FRAUD RELATED

13 TO ALTERNATIVE PAYMENT MODELS UNDER THE

14 MEDICARE PROGRAM.— 

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

16 Human Services, in consultation with the In17 spector General of the Department of Health 

18 and Human Services, shall conduct a study 

19 that— 

20 (i) examines the applicability of the 

21 Federal fraud prevention laws to items and 

22 services furnished under title XVIII of the 

23 Social Security Act for which payment is 

24 made under an alternative payment model 


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

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

3 (ii) identifies aspects of such alter4 native payment models that are vulnerable 

5 to fraudulent activity; and 

6 (iii) examines the implications of waiv7 ers to such laws granted in support of such 

8 alternative payment models, including 

9 under any potential expansion of such 

10 models. 

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

12 the date of the enactment of this Act, the Sec13 retary shall submit to Congress a report con14 taining the results of the study conducted under 

15 subparagraph (A). Such report shall include 

16 recommendations for actions to be taken to re17 duce the vulnerability of such alternative pay18 ment models to fraudulent activity. Such report 

19 also shall include, as appropriate, recommenda20 tions of the Inspector General for changes in 

21 Federal fraud prevention laws to reduce such 

22 vulnerability. 

23 (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 

24 Internet website of the Centers for Medicare & 

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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. 

Æ 


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