II 

114TH CONGRESS 

1ST SESSION S. 810 

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

sustainable growth rate and improve Medicare payments for physicians 

and other professionals, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 19, 2015 

Mr. HATCH introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to repeal 

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

and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘SGR Repeal and Medicare Provider Payment Moderniza6 tion Act of 2015’’. 

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

8 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

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

payment for physicians’ services. 

Sec. 3. Priorities and funding for measure development. 

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

Sec. 5. Empowering beneficiary choices through continued access to information 

on physicians’ services. 

Sec. 6. Expanding availability of Medicare data. 

Sec. 7. Reducing administrative burden and other provisions. 

1 SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE 

2 (SGR) AND IMPROVING MEDICARE PAYMENT 

3 FOR PHYSICIANS’ SERVICES. 

4 (a) STABILIZING FEE UPDATES.— 

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

7 (42 U.S.C. 1395w–4) is amended— 

8 (A) in subsection (d)— 

9 (i) in paragraph (1)(A)— 

10 (I) by inserting ‘‘and ending with 

11 2025’’ after ‘‘beginning with 2001’’; 

12 and 

13 (II) by inserting ‘‘or a subse14 quent paragraph’’ after ‘‘paragraph 

15 (4)’’; and 

16 (ii) in paragraph (4)— 

17 (I) in the heading, by inserting 

18 ‘‘AND ENDING WITH 2014’’ after 

19 ‘‘YEARS BEGINNING WITH 2001’’; and 


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1 (II) in subparagraph (A), by in2 serting ‘‘and ending with 2014’’ after 

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

4 (B) in subsection (f)— 

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

6 ‘‘through 2014’’ after ‘‘of each succeeding 

7 year’’; and 

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

9 preceding subparagraph (A), by inserting 

10 ‘‘and ending with 2014’’ after ‘‘beginning 

11 with 2000’’. 

12 (2) UPDATE OF RATES FOR 2015 AND SUBSE13 QUENT YEARS.—Subsection (d) of section 1848 of 

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

15 amended— 

16 (A) in paragraph (1)(A), by adding at the 

17 end the following: ‘‘There shall be two separate 

18 conversion factors for each year beginning with 

19 2026, one for items and services furnished by 

20 a qualifying APM participant (as defined in 

21 section 1833(z)(2)) (referred to in this sub22 section as the ‘qualifying APM conversion fac23 tor’) and the other for other items and services 

24 (referred to in this subsection as the ‘nonquali25 fying APM conversion factor’), equal to the reVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 spective conversion factor for the previous year 

2 (or, in the case of 2026, equal to the single con3 version factor for 2025) multiplied by the up4 date established under paragraph (20) for such 

5 respective conversion factor for such year.’’; 

6 (B) in paragraph (1)(D), by inserting ‘‘(or, 

7 beginning with 2026, applicable conversion fac8 tor)’’ after ‘‘single conversion factor’’; and 

9 (C) by striking paragraph (16) and insert10 ing the following new paragraphs: 

11 ‘‘(16) UPDATE FOR JANUARY THROUGH JUNE

12 OF 2015.—Subject to paragraphs (7)(B), (8)(B), 

13 (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), 

14 and (15)(B), in lieu of the update to the single con15 version factor established in paragraph (1)(C) that 

16 would otherwise apply for 2015 for the period begin17 ning on January 1, 2015, and ending on June 30, 

18 2015, the update to the single conversion factor 

19 shall be 0.0 percent. 

20 ‘‘(17) UPDATE FOR JULY THROUGH DECEMBER

21 OF 2015.—The update to the single conversion factor 

22 established in paragraph (1)(C) for the period begin23 ning on July 1, 2015, and ending on December 31, 

24 2015, shall be 0.5 percent. 


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1 ‘‘(18) UPDATE FOR 2016 THROUGH 2019.—The 

2 update to the single conversion factor established in 

3 paragraph (1)(C) for 2016 and each subsequent 

4 year through 2019 shall be 0.5 percent. 

5 ‘‘(19) UPDATE FOR 2020 THROUGH 2025.—The 

6 update to the single conversion factor established in 

7 paragraph (1)(C) for 2020 and each subsequent 

8 year through 2025 shall be zero percent. 

9 ‘‘(20) UPDATE FOR 2026 AND SUBSEQUENT

10 YEARS.—For 2026 and each subsequent year, the 

11 update to the qualifying APM conversion factor es12 tablished under paragraph (1)(A) is 1.0 percent, and 

13 the update to the nonqualifying APM conversion fac14 tor established under such paragraph is 0.5 per15 cent.’’. 

16 (3) MEDPAC REPORTS.— 

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

18 1, 2017, the Medicare Payment Advisory Com19 mission shall submit to Congress a report on 

20 the relationship between— 

21 (i) physician and other health profes22 sional utilization and expenditures (and the 

23 rate of increase of such utilization and ex24 penditures) of items and services for which 

25 payment is made under section 1848 of the 


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

2 and 

3 (ii) total utilization and expenditures 

4 (and the rate of increase of such utilization 

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

6 of title XVIII of such Act. 

7 Such report shall include a methodology to de8 scribe such relationship and the impact of 

9 changes in such physician and other health pro10 fessional practice and service ordering patterns 

11 on total utilization and expenditures under 

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

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

14 1, 2021, the Medicare Payment Advisory Com15 mission shall submit to Congress a report on 

16 the relationship described in subparagraph (A), 

17 including the results determined from applying 

18 the methodology included in the report sub19 mitted under such subparagraph. 

20 (C) REPORT ON UPDATE TO PHYSICIANS’ 

21 SERVICES UNDER MEDICARE.—Not later than 

22 July 1, 2019, the Medicare Payment Advisory 

23 Commission shall submit to Congress a report 

24 on— 


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1 (i) the payment update for profes2 sional services applied under the Medicare 

3 program under title XVIII of the Social 

4 Security Act for the period of years 2015 

5 through 2019; 

6 (ii) the effect of such update on the 

7 efficiency, economy, and quality of care 

8 provided under such program; 

9 (iii) the effect of such update on en10 suring a sufficient number of providers to 

11 maintain access to care by Medicare bene12 ficiaries; and 

13 (iv) recommendations for any future 

14 payment updates for professional services 

15 under such program to ensure adequate 

16 access to care is maintained for Medicare 

17 beneficiaries. 

18 (b) CONSOLIDATION OF CERTAIN CURRENT LAW

19 PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN20 CENTIVE PAYMENT SYSTEM.— 

21 (1) EHR MEANINGFUL USE INCENTIVE PRO22 GRAM.— 

23 (A) SUNSETTING SEPARATE MEANINGFUL

24 USE PAYMENT ADJUSTMENTS.—Section 


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1 1848(a)(7)(A) of the Social Security Act (42 

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

3 (i) in clause (i), by striking ‘‘2015 or 

4 any subsequent payment year’’ and insert5 ing ‘‘each of 2015 through 2018’’; 

6 (ii) in clause (ii)(III), by striking 

7 ‘‘each subsequent year’’ and inserting 

8 ‘‘2018’’; and 

9 (iii) in clause (iii)— 

10 (I) in the heading, by striking 

11 ‘‘AND SUBSEQUENT YEARS’’; 

12 (II) by striking ‘‘and each subse13 quent year’’; and 

14 (III) by striking ‘‘, but in no case 

15 shall the applicable percent be less 

16 than 95 percent’’. 

17 (B) CONTINUATION OF MEANINGFUL USE

18 DETERMINATIONS FOR MIPS.—Section 

19 1848(o)(2) of the Social Security Act (42 

20 U.S.C. 1395w–4(o)(2)) is amended— 

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

22 preceding clause (i)— 

23 (I) by striking ‘‘For purposes of 

24 paragraph (1), an’’ and inserting 

25 ‘‘An’’; and 


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1 (II) by inserting ‘‘, or pursuant 

2 to subparagraph (D) for purposes of 

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

5 after ‘‘under such subsection for a 

6 year’’; and 

7 (ii) by adding at the end the following 

8 new subparagraph: 

9 ‘‘(D) CONTINUED APPLICATION FOR PUR10 POSES OF MIPS.—With respect to 2019 and 

11 each subsequent payment year, the Secretary 

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

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

17 a meaningful EHR user under this paragraph 

18 for the performance period under subsection (q) 

19 for such year.’’. 

20 (2) QUALITY REPORTING.— 

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

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

24 4(a)(8)(A)) is amended— 


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1 (i) in clause (i), by striking ‘‘2015 or 

2 any subsequent year’’ and inserting ‘‘each 

3 of 2015 through 2018’’; and 

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

5 each subsequent year’’ and inserting ‘‘, 

6 2017, and 2018’’. 

7 (B) CONTINUATION OF QUALITY MEAS8 URES AND PROCESSES FOR MIPS.—Section 

9 1848 of the Social Security Act (42 U.S.C. 

10 1395w–4) is amended— 

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

12 end the following new paragraph: 

13 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

14 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN15 TEERING TO REPORT.—The Secretary shall, in ac16 cordance with subsection (q)(1)(F), carry out the 

17 provisions of this subsection— 

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

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

20 MIPS eligible professionals (as defined in sub21 section (q)(1)(C)) for the year involved.’’; and 

22 (ii) in subsection (m)— 

23 (I) by redesignating paragraph 

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1 lic Law 111–148 as paragraph (8); 

2 and 

3 (II) by adding at the end the fol4 lowing new paragraph: 

5 ‘‘(9) CONTINUED APPLICATION FOR PURPOSES

6 OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN7 TEERING TO REPORT.—The Secretary shall, in ac8 cordance with subsection (q)(1)(F), carry out the 

9 processes under this subsection— 

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

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

12 MIPS eligible professionals (as defined in sub13 section (q)(1)(C)) for the year involved.’’. 

14 (3) VALUE-BASED PAYMENTS.— 

15 (A) SUNSETTING SEPARATE VALUE-BASED

16 PAYMENTS.—Clause (iii) of section 

17 1848(p)(4)(B) of the Social Security Act (42 

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

19 as follows: 

20 ‘‘(iii) APPLICATION.—The Secretary 

21 shall apply the payment modifier estab22 lished under this subsection for items and 

23 services furnished on or after January 1, 

24 2015, with respect to specific physicians 

25 and groups of physicians the Secretary deVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 termines appropriate, and for services fur2 nished on or after January 1, 2017, with 

3 respect to all physicians and groups of 

4 physicians. Such payment modifier shall 

5 not be applied for items and services fur6 nished on or after January 1, 2019.’’. 

7 (B) CONTINUATION OF VALUE-BASED PAY8 MENT MODIFIER MEASURES FOR MIPS.—Section 

9 1848(p) of the Social Security Act (42 U.S.C. 

10 1395w–4(p)) is amended— 

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

12 end the following new subparagraph: 

13 ‘‘(C) CONTINUED APPLICATION FOR PUR14 POSES OF MIPS.—The Secretary shall, in ac15 cordance with subsection (q)(1)(F), carry out 

16 subparagraph (B) for purposes of subsection 

17 (q).’’; and 

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

19 end the following: ‘‘With respect to 2019 

20 and each subsequent year, the Secretary 

21 shall, in accordance with subsection 

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

23 purposes of subsection (q).’’. 

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


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

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

3 adding at the end the following new subsection: 

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

5 ‘‘(1) ESTABLISHMENT.— 

6 ‘‘(A) IN GENERAL.—Subject to the suc7 ceeding provisions of this subsection, the Sec8 retary shall establish an eligible professional 

9 Merit-based Incentive Payment System (in this 

10 subsection referred to as the ‘MIPS’) under 

11 which the Secretary shall— 

12 ‘‘(i) develop a methodology for assess13 ing the total performance of each MIPS el14 igible professional according to perform15 ance standards under paragraph (3) for a 

16 performance period (as established under 

17 paragraph (4)) for a year; 

18 ‘‘(ii) using such methodology, provide 

19 for a composite performance score in ac20 cordance with paragraph (5) for each such 

21 professional for each performance period; 

22 and 

23 ‘‘(iii) use such composite performance 

24 score of the MIPS eligible professional for 

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1 mine and apply a MIPS adjustment factor 

2 (and, as applicable, an additional MIPS 

3 adjustment factor) under paragraph (6) to 

4 the professional for the year. 

5 Notwithstanding subparagraph (C)(ii), under 

6 the MIPS, the Secretary shall permit any eligi7 ble professional (as defined in subsection 

8 (k)(3)(B)) to report on applicable measures and 

9 activities described in paragraph (2)(B). 

10 ‘‘(B) PROGRAM IMPLEMENTATION.—The 

11 MIPS shall apply to payments for items and 

12 services furnished on or after January 1, 2019. 

13 ‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE14 FINED.— 

15 ‘‘(i) IN GENERAL.—For purposes of 

16 this subsection, subject to clauses (ii) and 

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

18 means— 

19 ‘‘(I) for the first and second 

20 years for which the MIPS applies to 

21 payments (and for the performance 

22 period for such first and second year), 

23 a physician (as defined in section 

24 1861(r)), a physician assistant, nurse 

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1 cialist (as such terms are defined in 

2 section 1861(aa)(5)), a certified reg3 istered nurse anesthetist (as defined 

4 in section 1861(bb)(2)), and a group 

5 that includes such professionals; and 

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

7 the MIPS applies to payments (and 

8 for the performance period for such 

9 third year) and for each succeeding 

10 year (and for the performance period 

11 for each such year), the professionals 

12 described in subclause (I), such other 

13 eligible professionals (as defined in 

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

15 the Secretary, and a group that in16 cludes such professionals. 

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

18 clause (i), the term ‘MIPS eligible profes19 sional’ does not include, with respect to a 

20 year, an eligible professional (as defined in 

21 subsection (k)(3)(B)) who— 

22 ‘‘(I) is a qualifying APM partici23 pant (as defined in section 

24 1833(z)(2)); 


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

2 partial qualifying APM participant (as 

3 defined in clause (iii)) for the most re4 cent period for which data are avail5 able and who, for the performance pe6 riod with respect to such year, does 

7 not report on applicable measures and 

8 activities described in paragraph 

9 (2)(B) that are required to be re10 ported by such a professional under 

11 the MIPS; or 

12 ‘‘(III) for the performance period 

13 with respect to such year, does not ex14 ceed the low-volume threshold meas15 urement selected under clause (iv). 

16 ‘‘(iii) PARTIAL QUALIFYING APM PAR17 TICIPANT.—For purposes of this subpara18 graph, the term ‘partial qualifying APM 

19 participant’ means, with respect to a year, 

20 an eligible professional for whom the Sec21 retary determines the minimum payment 

22 percentage (or percentages), as applicable, 

23 described in paragraph (2) of section 

24 1833(z) for such year have not been satis25 fied, but who would be considered a qualiVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 fying APM participant (as defined in such 

2 paragraph) for such year if— 

3 ‘‘(I) with respect to 2019 and 

4 2020, the reference in subparagraph 

5 (A) of such paragraph to 25 percent 

6 was instead a reference to 20 percent; 

7 ‘‘(II) with respect to 2021 and 

8 2022— 

9 ‘‘(aa) the reference in sub10 paragraph (B)(i) of such para11 graph to 50 percent was instead 

12 a reference to 40 percent; and 

13 ‘‘(bb) the references in sub14 paragraph (B)(ii) of such para15 graph to 50 percent and 25 per16 cent of such paragraph were in17 stead references to 40 percent 

18 and 20 percent, respectively; and 

19 ‘‘(III) with respect to 2023 and 

20 subsequent years— 

21 ‘‘(aa) the reference in sub22 paragraph (C)(i) of such para23 graph to 75 percent was instead 

24 a reference to 50 percent; and 


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1 ‘‘(bb) the references in sub2 paragraph (C)(ii) of such para3 graph to 75 percent and 25 per4 cent of such paragraph were in5 stead references to 50 percent 

6 and 20 percent, respectively. 

7 ‘‘(iv) SELECTION OF LOW-VOLUME

8 THRESHOLD MEASUREMENT.—The Sec9 retary shall select a low-volume threshold 

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

11 which may include one or more or a com12 bination of the following: 

13 ‘‘(I) The minimum number (as 

14 determined by the Secretary) of indi15 viduals enrolled under this part who 

16 are treated by the eligible professional 

17 for the performance period involved. 

18 ‘‘(II) The minimum number (as 

19 determined by the Secretary) of items 

20 and services furnished to individuals 

21 enrolled under this part by such pro22 fessional for such performance period. 

23 ‘‘(III) The minimum amount (as 

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1 sional under this part for such per2 formance period. 

3 ‘‘(v) TREATMENT OF NEW MEDICARE

4 ENROLLED ELIGIBLE PROFESSIONALS.—In 

5 the case of a professional who first be6 comes a Medicare enrolled eligible profes7 sional during the performance period for a 

8 year (and had not previously submitted 

9 claims under this title such as a person, an 

10 entity, or a part of a physician group or 

11 under a different billing number or tax 

12 identifier), such professional shall not be 

13 treated under this subsection as a MIPS 

14 eligible professional until the subsequent 

15 year and performance period for such sub16 sequent year. 

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

18 items and services furnished during a year 

19 by an individual who is not a MIPS eligible 

20 professional (including pursuant to clauses 

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

22 case shall a MIPS adjustment factor (or 

23 additional MIPS adjustment factor) under 

24 paragraph (6) apply to such individual for 

25 such year. 


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1 ‘‘(vii) PARTIAL QUALIFYING APM PAR2 TICIPANT CLARIFICATIONS.— 

3 ‘‘(I) TREATMENT AS MIPS ELIGI4 BLE PROFESSIONAL.—In the case of 

5 an eligible professional who is a par6 tial qualifying APM participant, with 

7 respect to a year, and who, for the 

8 performance period for such year, re9 ports on applicable measures and ac10 tivities described in paragraph (2)(B) 

11 that are required to be reported by 

12 such a professional under the MIPS, 

13 such eligible professional is considered 

14 to be a MIPS eligible professional 

15 with respect to such year. 

16 ‘‘(II) NOT ELIGIBLE FOR QUALI17 FYING APM PARTICIPANT PAY18 MENTS.—In no case shall an eligible 

19 professional who is a partial quali20 fying APM participant, with respect 

21 to a year, be considered a qualifying 

22 APM participant (as defined in para23 graph (2) of section 1833(z)) for such 

24 year or be eligible for the additional 


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1 payment under paragraph (1) of such 

2 section for such year. 

3 ‘‘(D) APPLICATION TO GROUP PRAC4 TICES.— 

5 ‘‘(i) IN GENERAL.—Under the MIPS: 

6 ‘‘(I) QUALITY PERFORMANCE

7 CATEGORY.—The Secretary shall es8 tablish and apply a process that in9 cludes features of the provisions of 

10 subsection (m)(3)(C) for MIPS eligi11 ble professionals in a group practice 

12 with respect to assessing performance 

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

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

16 ‘‘(II) OTHER PERFORMANCE CAT17 EGORIES.—The Secretary may estab18 lish and apply a process that includes 

19 features of the provisions of sub20 section (m)(3)(C) for MIPS eligible 

21 professionals in a group practice with 

22 respect to assessing the performance 

23 of such group with respect to the per24 formance categories described in 


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1 clauses (ii) through (iv) of such para2 graph. 

3 ‘‘(ii) ENSURING COMPREHENSIVENESS

4 OF GROUP PRACTICE ASSESSMENT.—The 

5 process established under clause (i) shall to 

6 the extent practicable reflect the range of 

7 items and services furnished by the MIPS 

8 eligible professionals in the group practice 

9 involved. 

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

11 MIPS, the Secretary shall encourage the use of 

12 qualified clinical data registries pursuant to 

13 subsection (m)(3)(E) in carrying out this sub14 section. 

15 ‘‘(F) APPLICATION OF CERTAIN PROVI16 SIONS.—In applying a provision of subsection 

17 (k), (m), (o), or (p) for purposes of this sub18 section, the Secretary shall— 

19 ‘‘(i) adjust the application of such 

20 provision to ensure the provision is con21 sistent with the provisions of this sub22 section; and 

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

24 extent that the provision is duplicative with 

25 a provision of this subsection. 


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

2 ‘‘(i) RISK FACTORS.—Taking into ac3 count the relevant studies conducted and 

4 recommendations made in reports under 

5 section 2(d) of the Improving Medicare 

6 Post-Acute Care Transformation Act of 

7 2014, and, as appropriate, other informa8 tion, including information collected before 

9 completion of such studies and rec10 ommendations, the Secretary, on an ongo11 ing basis, shall, as the Secretary deter12 mines appropriate and based on an individ13 ual’s health status and other risk factors— 

14 ‘‘(I) assess appropriate adjust15 ments to quality measures, resource 

16 use measures, and other measures 

17 used under the MIPS; and 

18 ‘‘(II) assess and implement ap19 propriate adjustments to payment ad20 justments, composite performance 

21 scores, scores for performance cat22 egories, or scores for measures or ac23 tivities under the MIPS. 

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


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1 ‘‘(A) PERFORMANCE CATEGORIES.—Under 

2 the MIPS, the Secretary shall use the following 

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

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

7 ‘‘(i) Quality. 

8 ‘‘(ii) Resource use. 

9 ‘‘(iii) Clinical practice improvement 

10 activities. 

11 ‘‘(iv) Meaningful use of certified EHR 

12 technology. 

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

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

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

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

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

21 the quality measures included in the final 

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

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

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

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

6 use for such period under subsection 

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

9 and applicable, accounting for the cost of 

10 drugs under part D. 

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

13 category described in subparagraph 

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

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

17 by the Secretary for such period, which 

18 shall include at least the following: 

19 ‘‘(I) The subcategory of expanded 

20 practice access, such as same day ap21 pointments for urgent needs and after 

22 hours access to clinician advice. 

23 ‘‘(II) The subcategory of popu24 lation management, such as moni25 toring health conditions of individuals 


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1 to provide timely health care interven2 tions or participation in a qualified 

3 clinical data registry. 

4 ‘‘(III) The subcategory of care 

5 coordination, such as timely commu6 nication of test results, timely ex7 change of clinical information to pa8 tients and other providers, and use of 

9 remote monitoring or telehealth. 

10 ‘‘(IV) The subcategory of bene11 ficiary engagement, such as the estab12 lishment of care plans for individuals 

13 with complex care needs, beneficiary 

14 self-management assessment and 

15 training, and using shared decision16 making mechanisms. 

17 ‘‘(V) The subcategory of patient 

18 safety and practice assessment, such 

19 as through use of clinical or surgical 

20 checklists and practice assessments 

21 related to maintaining certification. 

22 ‘‘(VI) The subcategory of partici23 pation in an alternative payment 

24 model (as defined in section 

25 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 items and services furnished by 

8 emergency physicians, radiologists, and an9 esthesiologists. 

10 ‘‘(iii) GLOBAL AND POPULATION11 BASED MEASURES.—The Secretary may 

12 use global measures, such as global out13 come measures, and population-based 

14 measures for purposes of the performance 

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

16 ‘‘(iv) APPLICATION OF MEASURES AND

17 ACTIVITIES TO NON-PATIENT-FACING PRO18 FESSIONALS.—In carrying out this para19 graph, with respect to measures and activi20 ties specified in subparagraph (B) for per21 formance categories described in subpara22 graph (A), the Secretary— 

23 ‘‘(I) shall give consideration to 

24 the circumstances of professional 

25 types (or subcategories of those types 


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1 determined by practice characteris2 tics) who typically furnish services 

3 that do not involve face-to-face inter4 action with a patient; and 

5 ‘‘(II) may, to the extent feasible 

6 and appropriate, take into account 

7 such circumstances and apply under 

8 this subsection with respect to MIPS 

9 eligible professionals of such profes10 sional types or subcategories, alter11 native measures or activities that ful12 fill the goals of the applicable per13 formance category. 

14 In carrying out the previous sentence, the 

15 Secretary shall consult with professionals 

16 of such professional types or subcategories. 

17 ‘‘(v) CLINICAL PRACTICE IMPROVE18 MENT ACTIVITIES.— 

19 ‘‘(I) REQUEST FOR INFORMA20 TION.—In initially applying subpara21 graph (B)(iii), the Secretary shall use 

22 a request for information to solicit 

23 recommendations from stakeholders to 

24 identify activities described in such 


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1 subparagraph and specifying criteria 

2 for such activities. 

3 ‘‘(II) CONTRACT AUTHORITY FOR

4 CLINICAL PRACTICE IMPROVEMENT

5 ACTIVITIES PERFORMANCE CAT6 EGORY.—In applying subparagraph 

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

8 with entities to assist the Secretary 

9 in— 

10 ‘‘(aa) identifying activities 

11 described in subparagraph 

12 (B)(iii); 

13 ‘‘(bb) specifying criteria for 

14 such activities; and 

15 ‘‘(cc) determining whether a 

16 MIPS eligible professional meets 

17 such criteria. 

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

20 For purposes of this subsection, the 

21 term ‘clinical practice improvement 

22 activity’ means an activity that rel23 evant eligible professional organiza24 tions and other relevant stakeholders 

25 identify as improving clinical practice 


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1 or care delivery and that the Sec2 retary determines, when effectively ex3 ecuted, is likely to result in improved 

4 outcomes. 

5 ‘‘(D) ANNUAL LIST OF QUALITY MEASURES

6 AVAILABLE FOR MIPS ASSESSMENT.— 

7 ‘‘(i) IN GENERAL.—Under the MIPS, 

8 the Secretary, through notice and comment 

9 rulemaking and subject to the succeeding 

10 clauses of this subparagraph, shall, with 

11 respect to the performance period for a 

12 year, establish an annual final list of qual13 ity measures from which MIPS eligible 

14 professionals may choose for purposes of 

15 assessment under this subsection for such 

16 performance period. Pursuant to the pre17 vious sentence, the Secretary shall— 

18 ‘‘(I) not later than November 1 

19 of the year prior to the first day of 

20 the first performance period under the 

21 MIPS, establish and publish in the 

22 Federal Register a final list of quality 

23 measures; and 

24 ‘‘(II) not later than November 1 

25 of the year prior to the first day of 


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1 each subsequent performance period, 

2 update the final list of quality meas3 ures from the previous year (and pub4 lish such updated final list in the Fed5 eral Register), by— 

6 ‘‘(aa) removing from such 

7 list, as appropriate, quality meas8 ures, which may include the re9 moval of measures that are no 

10 longer meaningful (such as meas11 ures that are topped out); 

12 ‘‘(bb) adding to such list, as 

13 appropriate, new quality meas14 ures; and 

15 ‘‘(cc) determining whether 

16 or not quality measures on such 

17 list that have undergone sub18 stantive changes should be in19 cluded in the updated list. 

20 ‘‘(ii) CALL FOR QUALITY MEAS21 URES.— 

22 ‘‘(I) IN GENERAL.—Eligible pro23 fessional organizations and other rel24 evant stakeholders shall be requested 

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1 ures to be considered for selection 

2 under this subparagraph in the an3 nual list of quality measures published 

4 under clause (i) and to identify and 

5 submit updates to the measures on 

6 such list. For purposes of the previous 

7 sentence, measures may be submitted 

8 regardless of whether such measures 

9 were previously published in a pro10 posed rule or endorsed by an entity 

11 with a contract under section 1890(a). 

12 ‘‘(II) ELIGIBLE PROFESSIONAL

13 ORGANIZATION DEFINED.—In this 

14 subparagraph, the term ‘eligible pro15 fessional organization’ means a pro16 fessional organization as defined by 

17 nationally recognized specialty boards 

18 of certification or equivalent certifi19 cation boards. 

20 ‘‘(iii) REQUIREMENTS.—In selecting 

21 quality measures for inclusion in the an22 nual final list under clause (i), the Sec23 retary shall— 

24 ‘‘(I) provide that, to the extent 

25 practicable, all quality domains (as 


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

2 addressed by such measures; and 

3 ‘‘(II) ensure that such selection 

4 is consistent with the process for se5 lection of measures under subsections 

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

7 ‘‘(iv) PEER REVIEW.—Before includ8 ing a new measure in the final list of 

9 measures published under clause (i) for a 

10 year, the Secretary shall submit for publi11 cation in applicable specialty-appropriate 

12 peer-reviewed journals such measure and 

13 the method for developing and selecting 

14 such measure, including clinical and other 

15 data supporting such measure. 

16 ‘‘(v) MEASURES FOR INCLUSION.— 

17 The final list of quality measures published 

18 under clause (i) shall include, as applica19 ble, measures under subsections (k), (m), 

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

21 from among— 

22 ‘‘(I) measures endorsed by a con23 sensus-based entity; 

24 ‘‘(II) measures developed under 

25 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 or 

24 performance period under the respective 


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1 subsection beginning before the first per2 formance period under 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 2019). Such performance pe19 riod (or periods) shall begin and end prior to the be20 ginning of such year and be as close as possible to 

21 such year. In this subsection, such performance pe22 riod (or periods) for a year shall be referred to as 

23 the performance period for the year. 

24 ‘‘(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 CERTIFICATION.—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, as determined by the Sec15 retary, with respect to a performance pe16 riod 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.—Subject to clause (i), 

9 under the methodology developed under 

10 subparagraph (A), the Secretary may as11 sign a higher scoring weight under sub12 paragraph (F) with respect to the achieve13 ment of a MIPS eligible professional than 

14 with respect to any improvement of such 

15 professional applied under clause (i) with 

16 respect to a measure, activity, or category 

17 described in paragraph (2). 

18 ‘‘(E) WEIGHTS FOR THE PERFORMANCE

19 CATEGORIES.— 

20 ‘‘(i) IN GENERAL.—Under the meth21 odology developed under subparagraph (A), 

22 subject to subparagraph (F)(i) and clause 

23 (ii), the composite performance score shall 

24 be determined as follows: 

25 ‘‘(I) QUALITY.— 


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1 ‘‘(aa) IN GENERAL.—Sub2 ject to item (bb), thirty percent 

3 of such score shall be based on 

4 performance with respect to the 

5 category described in clause (i) of 

6 paragraph (2)(A). In applying 

7 the previous sentence, the Sec8 retary shall, as feasible, encour9 age the application of outcome 

10 measures within such category. 

11 ‘‘(bb) FIRST 2 YEARS.—For 

12 the first and second years for 

13 which the MIPS applies to pay14 ments, the percentage applicable 

15 under item (aa) shall be in16 creased in a manner such that 

17 the total percentage points of the 

18 increase under this item for the 

19 respective year equals the total 

20 number of percentage points by 

21 which the percentage applied 

22 under subclause (II)(bb) for the 

23 respective year is less than 30 

24 percent. 

25 ‘‘(II) RESOURCE USE.— 


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1 ‘‘(aa) IN GENERAL.—Sub2 ject to item (bb), thirty percent 

3 of such score shall be based on 

4 performance with respect to the 

5 category described in clause (ii) 

6 of paragraph (2)(A). 

7 ‘‘(bb) FIRST 2 YEARS.—For 

8 the first year for which the MIPS 

9 applies to payments, not more 

10 than 10 percent of such score 

11 shall be based on performance 

12 with respect to the category de13 scribed in clause (ii) of para14 graph (2)(A). For the second 

15 year for which the MIPS applies 

16 to payments, not more than 15 

17 percent of such score shall be 

18 based on performance with re19 spect to the category described in 

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

21 ‘‘(III) CLINICAL PRACTICE IM22 PROVEMENT ACTIVITIES.—Fifteen 

23 percent of such score shall be based 

24 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 activities (described in 

10 paragraph (2)(B)) 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) with respect to 

24 the performance categories described in 

25 clauses (i) and (ii) of paragraph (2)(A)— 


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1 ‘‘(I) the assessment of perform2 ance provided under such methodology 

3 with respect to such performance cat4 egories that is to be applied to each 

5 such professional in such group for 

6 such performance period shall be with 

7 respect to the combined performance 

8 of all such professionals in such group 

9 for such period; and 

10 ‘‘(II) with respect to the com11 posite performance score provided 

12 under this paragraph for such per13 formance period for each such MIPS 

14 eligible professional in such virtual 

15 group, the components of the com16 posite performance score that assess 

17 performance with respect to such per18 formance categories shall be based on 

19 the assessment of the combined per20 formance under subclause (I) for such 

21 performance categories and perform22 ance period. 

23 ‘‘(ii) ELECTION OF PRACTICES TO BE

24 A VIRTUAL GROUP.—The Secretary shall, 

25 in accordance with the requirements under 


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1 clause (iii), establish and have in place a 

2 process to allow an individual MIPS eligi3 ble professional or a group practice con4 sisting of not more than 10 MIPS eligible 

5 professionals to elect, with respect to a 

6 performance period for a year to be a vir7 tual group under this subparagraph with 

8 at least one other such individual MIPS el9 igible professional or group practice. Such 

10 a virtual group may be based on appro11 priate classifications of providers, such as 

12 by geographic areas or by provider special13 ties defined by nationally recognized spe14 cialty boards of certification or equivalent 

15 certification boards. 

16 ‘‘(iii) REQUIREMENTS.—The require17 ments for the process under clause (ii) 

18 shall— 

19 ‘‘(I) provide that an election 

20 under such clause, with respect to a 

21 performance period, shall be made be22 fore the beginning of such perform23 ance period and may not be changed 

24 during such performance period; 


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1 ‘‘(II) provide that an individual 

2 MIPS eligible professional and a 

3 group practice described in clause (ii) 

4 may elect to be in no more than one 

5 virtual group for a performance period 

6 and that, in the case of such a group 

7 practice that elects to be in such vir8 tual group for such performance pe9 riod, such election applies to all MIPS 

10 eligible professionals in such group 

11 practice; 

12 ‘‘(III) provide that a virtual 

13 group be a combination of tax identi14 fication numbers; 

15 ‘‘(IV) provide for formal written 

16 agreements among MIPS eligible pro17 fessionals electing to be a virtual 

18 group under this subparagraph; and 

19 ‘‘(V) include such other require20 ments as the Secretary determines ap21 propriate. 

22 ‘‘(6) MIPS PAYMENTS.— 

23 ‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak24 ing into account paragraph (1)(G), the Sec25 retary shall specify a MIPS adjustment factor 


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1 for each MIPS eligible professional for a year. 

2 Such MIPS adjustment factor for a MIPS eligi3 ble professional for a year shall be in the form 

4 of a percent and shall be determined— 

5 ‘‘(i) by comparing the composite per6 formance score of the eligible professional 

7 for such year to the performance threshold 

8 established under subparagraph (D)(i) for 

9 such year; 

10 ‘‘(ii) in a manner such that the ad11 justment factors specified under this sub12 paragraph for a year result in differential 

13 payments under this paragraph reflecting 

14 that— 

15 ‘‘(I) MIPS eligible professionals 

16 with composite performance scores for 

17 such year at or above such perform18 ance threshold for such year receive 

19 zero or positive payment adjustment 

20 factors for such year in accordance 

21 with clause (iii), with such profes22 sionals having higher composite per23 formance scores receiving higher ad24 justment factors; and 


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1 ‘‘(II) MIPS eligible professionals 

2 with composite performance scores for 

3 such year below such performance 

4 threshold for such year receive nega5 tive payment adjustment factors for 

6 such year in accordance with clause 

7 (iv), with such professionals having 

8 lower composite performance scores 

9 receiving lower adjustment factors; 

10 ‘‘(iii) in a manner such that MIPS eli11 gible professionals with composite scores 

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

13 subject to clauses (i) and (ii) of subpara14 graph (F), receive a zero or positive ad15 justment factor on a linear sliding scale 

16 such that an adjustment factor of 0 per17 cent is assigned for a score at the perform18 ance threshold and an adjustment factor of 

19 the applicable percent specified in subpara20 graph (B) is assigned for a score of 100; 

21 and 

22 ‘‘(iv) in a manner such that— 

23 ‘‘(I) subject to subclause (II), 

24 MIPS eligible professionals with com25 posite performance scores described in 


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

2 negative payment adjustment factor 

3 on a linear sliding scale such that an 

4 adjustment factor of 0 percent is as5 signed for a score at the performance 

6 threshold and an adjustment factor of 

7 the negative of the applicable percent 

8 specified in subparagraph (B) is as9 signed for a score of 0; and 

10 ‘‘(II) MIPS eligible professionals 

11 with composite performance scores 

12 that are equal to or greater than 0, 

but not greater than 1 13 ⁄4 of the per14 formance threshold specified under 

15 subparagraph (D)(i) for such year, re16 ceive a negative payment adjustment 

17 factor that is equal to the negative of 

18 the applicable percent specified in 

19 subparagraph (B) for such year. 

20 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

21 For purposes of this paragraph, the term ‘ap22 plicable percent’ means— 

23 ‘‘(i) for 2019, 4 percent; 

24 ‘‘(ii) for 2020, 5 percent; 

25 ‘‘(iii) for 2021, 7 percent; and 


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1 ‘‘(iv) for 2022 and subsequent years, 

2 9 percent. 

3 ‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC4 TORS FOR EXCEPTIONAL PERFORMANCE.—For 

5 2019 and each subsequent year through 2024, 

6 in the case of a MIPS eligible professional with 

7 a composite performance score for a year at or 

8 above the additional performance threshold 

9 under subparagraph (D)(ii) for such year, in 

10 addition to the MIPS adjustment factor under 

11 subparagraph (A) for the eligible professional 

12 for such year, subject to subparagraph (F)(iv), 

13 the Secretary shall specify an additional positive 

14 MIPS adjustment factor for such professional 

15 and year. Such additional MIPS adjustment 

16 factors shall be in the form of a percent and de17 termined by the Secretary in a manner such 

18 that professionals having higher composite per19 formance scores above the additional perform20 ance threshold receive higher additional MIPS 

21 adjustment factors. 

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 of the mean or 

14 median under the previous sentence every 

15 3 years. 

16 ‘‘(ii) ADDITIONAL PERFORMANCE

17 THRESHOLD FOR EXCEPTIONAL PERFORM18 ANCE.—In addition to the performance 

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

20 the MIPS, the Secretary shall compute an 

21 additional performance threshold for pur22 poses of determining the additional MIPS 

23 adjustment factors under subparagraph 

24 (C). For each such year, the Secretary 

25 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 determined 

8 under clause (i). 

9 ‘‘(II) The threshold shall be the 

10 score that is equal to the 25th per11 centile of the actual composite per12 formance scores for MIPS eligible 

13 professionals with composite perform14 ance scores at or above the perform15 ance threshold with respect to the 

16 prior period described in clause (i). 

17 ‘‘(iii) SPECIAL RULE FOR INITIAL 2

18 YEARS.—With respect to each of the first 

19 two years to which the MIPS applies, the 

20 Secretary shall, prior to the performance 

21 period for such years, establish a perform22 ance threshold for purposes of determining 

23 MIPS adjustment factors under subpara24 graph (A) and a threshold for purposes of 

25 determining additional MIPS adjustment 


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1 factors under subparagraph (C). Each 

2 such performance threshold shall— 

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

4 such performance periods; and 

5 ‘‘(II) take into account— 

6 ‘‘(aa) data available with re7 spect to performance on meas8 ures and activities that may be 

9 used under the performance cat10 egories under subparagraph 

11 (2)(B); and 

12 ‘‘(bb) other factors deter13 mined appropriate by the Sec14 retary. 

15 ‘‘(E) APPLICATION OF MIPS ADJUSTMENT

16 FACTORS.—In the case of items and services 

17 furnished by a MIPS eligible professional dur18 ing a year (beginning with 2019), the amount 

19 otherwise paid under this part with respect to 

20 such items and services and MIPS eligible pro21 fessional for such year, shall be multiplied by— 

22 ‘‘(i) 1, plus 

23 ‘‘(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) 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) and 

23 the additional adjustment factors 

24 under clause (iv) shall not apply for 

25 such year. 


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

3 clause (i) results in a scaling factor 

4 equal to the maximum scaling factor 

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

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

8 not apply for such year. 

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

11 ‘‘(I) IN GENERAL.—Subject to 

12 subclause (II), in specifying the MIPS 

13 additional adjustment factors under 

14 subparagraph (C) for each applicable 

15 MIPS eligible professional for a year, 

16 the Secretary shall ensure that the es17 timated aggregate increase in pay18 ments under this part resulting from 

19 the application of such additional ad20 justment factors for MIPS eligible 

21 professionals in a year shall be equal 

22 (as estimated by the Secretary) to 

23 $500,000,000 for each year beginning 

24 with 2019 and ending with 2024. 


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1 ‘‘(II) LIMITATION ON ADDI2 TIONAL INCENTIVE PAYMENT ADJUST3 MENTS.—The MIPS additional ad4 justment factor under subparagraph 

5 (C) for a year for an applicable MIPS 

6 eligible professional whose composite 

7 performance score is above the addi8 tional performance threshold under 

9 subparagraph (D)(ii) for such year 

10 shall not exceed 10 percent. The ap11 plication of the previous sentence may 

12 result in an aggregate amount of ad13 ditional incentive payments that are 

14 less than the amount specified in sub15 clause (I). 

16 ‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST17 MENTS.—Under the MIPS, the Secretary shall, not 

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

19 involved, make available to MIPS eligible profes20 sionals the MIPS adjustment factor (and, as appli21 cable, the additional MIPS adjustment factor) under 

22 paragraph (6) applicable to the eligible professional 

23 for items and services furnished by the professional 

24 for such year. The Secretary may include such inforVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00062 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 mation in the confidential feedback under paragraph 

2 (12). 

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

4 MIPS adjustment factors and additional MIPS ad5 justment factors under paragraph (6) shall apply 

6 only with respect to the year involved, and the Sec7 retary shall not take into account such adjustment 

8 factors in making payments to a MIPS eligible pro9 fessional under this part in a subsequent year. 

10 ‘‘(9) PUBLIC REPORTING.— 

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

12 in an easily understandable format, make avail13 able on the Physician Compare Internet website 

14 of the Centers for Medicare & Medicaid Serv15 ices the following: 

16 ‘‘(i) Information regarding the per17 formance of MIPS eligible professionals 

18 under the MIPS, which— 

19 ‘‘(I) shall include the composite 

20 score for each such MIPS eligible pro21 fessional and the performance of each 

22 such MIPS eligible professional with 

23 respect to each performance category; 

24 and 


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1 ‘‘(II) may include the perform2 ance of each such MIPS eligible pro3 fessional with respect to each measure 

4 or activity specified in paragraph 

5 (2)(B). 

6 ‘‘(ii) The names of eligible profes7 sionals in eligible alternative payment mod8 els (as defined in section 1833(z)(3)(D)) 

9 and, to the extent feasible, the names of 

10 such eligible alternative payment models 

11 and performance of such models. 

12 ‘‘(B) DISCLOSURE.—The information 

13 made available under this paragraph shall indi14 cate, where appropriate, that publicized infor15 mation may not be representative of the eligible 

16 professional’s entire patient population, the va17 riety of services furnished by the eligible profes18 sional, or the health conditions of individuals 

19 treated. 

20 ‘‘(C) OPPORTUNITY TO REVIEW AND SUB21 MIT CORRECTIONS.—The Secretary shall pro22 vide for an opportunity for a professional de23 scribed in subparagraph (A) to review, and sub24 mit corrections for, the information to be made 

25 public with respect to the professional under 


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1 such subparagraph prior to such information 

2 being made public. 

3 ‘‘(D) AGGREGATE INFORMATION.—The 

4 Secretary shall periodically post on the Physi5 cian Compare Internet website aggregate infor6 mation on the MIPS, including the range of 

7 composite scores for all MIPS eligible profes8 sionals and the range of the performance of all 

9 MIPS eligible professionals with respect to each 

10 performance category. 

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

12 consult with stakeholders in carrying out the MIPS, 

13 including for the identification of measures and ac14 tivities under paragraph (2)(B) and the methodolo15 gies developed under paragraphs (5)(A) and (6) and 

16 regarding the use of qualified clinical data registries. 

17 Such consultation shall include the use of a request 

18 for information or other mechanisms determined ap19 propriate. 

20 ‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC21 TICES AND PRACTICES IN HEALTH PROFESSIONAL

22 SHORTAGE AREAS.— 

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

24 enter into contracts or agreements with appro25 priate entities (such as quality improvement orVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 ganizations, regional extension centers (as de2 scribed in section 3012(c) of the Public Health 

3 Service Act), or regional health collaboratives) 

4 to offer guidance and assistance to MIPS eligi5 ble professionals in practices of 15 or fewer pro6 fessionals (with priority given to such practices 

7 located in rural areas, health professional short8 age areas (as designated under in section 

9 332(a)(1)(A) of such Act), and medically under10 served areas, and practices with low composite 

11 scores) with respect to— 

12 ‘‘(i) the performance categories de13 scribed in clauses (i) through (iv) of para14 graph (2)(A); or 

15 ‘‘(ii) how to transition to the imple16 mentation of and participation in an alter17 native payment model as described in sec18 tion 1833(z)(3)(C). 

19 ‘‘(B) FUNDING FOR TECHNICAL ASSIST20 ANCE.—For purposes of implementing subpara21 graph (A), the Secretary shall provide for the 

22 transfer from the Federal Supplementary Med23 ical Insurance Trust Fund established under 

24 section 1841 to the Centers for Medicare & 

25 Medicaid Services Program Management AcVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00066 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 count of $20,000,000 for each of fiscal years 

2 2016 through 2020. Amounts transferred under 

3 this subparagraph for a fiscal year shall be 

4 available until expended. 

5 ‘‘(12) FEEDBACK AND INFORMATION TO IM6 PROVE PERFORMANCE.— 

7 ‘‘(A) PERFORMANCE FEEDBACK.— 

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

9 2017, the Secretary— 

10 ‘‘(I) shall make available timely 

11 (such as quarterly) confidential feed12 back to MIPS eligible professionals on 

13 the performance of such professionals 

14 with respect to the performance cat15 egories under clauses (i) and (ii) of 

16 paragraph (2)(A); and 

17 ‘‘(II) may make available con18 fidential feedback to such profes19 sionals on the performance of such 

20 professionals with respect to the per21 formance categories under clauses (iii) 

22 and (iv) of such paragraph. 

23 ‘‘(ii) MECHANISMS.—The Secretary 

24 may use one or more mechanisms to make 

25 feedback available under clause (i), which 


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1 may include use of a web-based portal or 

2 other mechanisms determined appropriate 

3 by the Secretary. With respect to the per4 formance category described in paragraph 

5 (2)(A)(i), feedback under this subpara6 graph shall, to the extent an eligible pro7 fessional chooses to participate in a data 

8 registry for purposes of this subsection (in9 cluding registries under subsections (k) 

10 and (m)), be provided based on perform11 ance on quality measures reported through 

12 the use of such registries. With respect to 

13 any other performance category described 

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

15 encourage provision of feedback through 

16 qualified clinical data registries as de17 scribed in subsection (m)(3)(E)). 

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

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

20 with respect to a MIPS eligible profes21 sional, from periods prior to the current 

22 performance period and may use rolling 

23 periods in order to make illustrative cal24 culations about the performance of such 

25 professional. 


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1 ‘‘(iv) DISCLOSURE EXEMPTION.— 

2 Feedback made available under this sub3 paragraph shall be exempt from disclosure 

4 under section 552 of title 5, United States 

5 Code. 

6 ‘‘(v) RECEIPT OF INFORMATION.— 

7 The Secretary may use the mechanisms es8 tablished under clause (ii) to receive infor9 mation from professionals, such as infor10 mation with respect to this subsection. 

11 ‘‘(B) ADDITIONAL INFORMATION.— 

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

13 2018, the Secretary shall make available to 

14 MIPS eligible professionals information, 

15 with respect to individuals who are pa16 tients of such MIPS eligible professionals, 

17 about items and services for which pay18 ment is made under this title that are fur19 nished to such individuals by other sup20 pliers and providers of services, which may 

21 include information described in clause (ii). 

22 Such information may be made available 

23 under the previous sentence to such MIPS 

24 eligible professionals by mechanisms deter25 mined appropriate by the Secretary, which 


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1 may include use of a web-based portal. 

2 Such information may be made available in 

3 accordance with the same or similar terms 

4 as data are made available to accountable 

5 care organizations participating in the 

6 shared savings program under section 

7 1899. 

8 ‘‘(ii) TYPE OF INFORMATION.—For 

9 purposes of clause (i), the information de10 scribed in this clause, is the following: 

11 ‘‘(I) With respect to selected 

12 items and services (as determined ap13 propriate by the Secretary) for which 

14 payment is made under this title and 

15 that are furnished to individuals, who 

16 are patients of a MIPS eligible profes17 sional, by another supplier or provider 

18 of services during the most recent pe19 riod for which data are available (such 

20 as the most recent three-month pe21 riod), such as the name of such pro22 viders furnishing such items and serv23 ices to such patients during such pe24 riod, the types of such items and servVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 ices so furnished, and the dates such 

2 items and services were so furnished. 

3 ‘‘(II) Historical data, such as 

4 averages and other measures of the 

5 distribution if appropriate, of the 

6 total, and components of, allowed 

7 charges (and other figures as deter8 mined appropriate by the Secretary). 

9 ‘‘(13) REVIEW.— 

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

11 shall establish a process under which a MIPS 

12 eligible professional may seek an informal re13 view of the calculation of the MIPS adjustment 

14 factor (or factors) applicable to such eligible 

15 professional under this subsection for a year. 

16 The results of a review conducted pursuant to 

17 the previous sentence shall not be taken into ac18 count for purposes of paragraph (6) with re19 spect to a year (other than with respect to the 

20 calculation of such eligible professional’s MIPS 

21 adjustment factor for such year or additional 

22 MIPS adjustment factor for such year) after 

23 the factors determined in subparagraph (A) and 

24 subparagraph (C) of such paragraph have been 

25 determined for such year. 


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

2 in subparagraph (A), there shall be no adminis3 trative or judicial review under section 1869, 

4 section 1878, or otherwise of the following: 

5 ‘‘(i) The methodology used to deter6 mine the amount of the MIPS adjustment 

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

8 amount of the additional MIPS adjustment 

9 factor under paragraph (6)(C) and the de10 termination of such amounts. 

11 ‘‘(ii) The establishment of the per12 formance standards under paragraph (3) 

13 and the performance period under para14 graph (4). 

15 ‘‘(iii) The identification of measures 

16 and activities specified under paragraph 

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

18 posted on the Physician Compare Internet 

19 website of the Centers for Medicare & 

20 Medicaid Services under paragraph (9). 

21 ‘‘(iv) The methodology developed 

22 under paragraph (5) that is used to cal23 culate performance scores and the calcula24 tion of such scores, including the weighting 


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1 of measures and activities under such 

2 methodology.’’. 

3 (2) GAO REPORTS.— 

4 (A) EVALUATION OF ELIGIBLE PROFES5 SIONAL MIPS.—Not later than October 1, 2021, 

6 the Comptroller General of the United States 

7 shall submit to Congress a report evaluating the 

8 eligible professional Merit-based Incentive Pay9 ment System under subsection (q) of section 

10 1848 of the Social Security Act (42 U.S.C. 

11 1395w–4), as added by paragraph (1). Such re12 port shall— 

13 (i) examine the distribution of the 

14 composite performance scores and MIPS 

15 adjustment factors (and additional MIPS 

16 adjustment factors) for MIPS eligible pro17 fessionals (as defined in subsection 

18 (q)(1)(c) of such section) under such pro19 gram, and patterns relating to such scores 

20 and adjustment factors, including based on 

21 type of provider, practice size, geographic 

22 location, and patient mix; 

23 (ii) provide recommendations for im24 proving such program; 


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1 (iii) evaluate the impact of technical 

2 assistance funding under section 

3 1848(q)(11) of the Social Security Act, as 

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

5 professionals to improve within such pro6 gram or successfully transition to an alter7 native payment model (as defined in sec8 tion 1833(z)(3) of the Social Security Act, 

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

10 for such evaluation given to practices lo11 cated in rural areas, health professional 

12 shortage areas (as designated in section 

13 332(a)(1)(a) of the Public Health Service 

14 Act), and medically underserved areas; and 

15 (iv) provide recommendations for opti16 mizing the use of such technical assistance 

17 funds. 

18 (B) STUDY TO EXAMINE ALIGNMENT OF

19 QUALITY MEASURES USED IN PUBLIC AND PRI20 VATE PROGRAMS.— 

21 (i) IN GENERAL.—Not later than 18 

22 months after the date of the enactment of 

23 this Act, the Comptroller General of the 

24 United States shall submit to Congress a 

25 report that— 


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1 (I) compares the similarities and 

2 differences in the use of quality meas3 ures under the original Medicare fee4 for-service program under parts A and 

5 B of title XVIII of the Social Security 

6 Act, the Medicare Advantage program 

7 under part C of such title, selected 

8 State Medicaid programs under title 

9 XIX of such Act, and private payer 

10 arrangements; and 

11 (II) makes recommendations on 

12 how to reduce the administrative bur13 den involved in applying such quality 

14 measures. 

15 (ii) REQUIREMENTS.—The report 

16 under clause (i) shall— 

17 (I) consider those measures ap18 plicable to individuals entitled to, or 

19 enrolled for, benefits under such part 

20 A, or enrolled under such part B and 

21 individuals under the age of 65; and 

22 (II) focus on those measures that 

23 comprise the most significant compo24 nent of the quality performance cat25 egory of the eligible professional 


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

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

5 (C) STUDY ON ROLE OF INDEPENDENT

6 RISK MANAGERS.—Not later than January 1, 

7 2017, the Comptroller General of the United 

8 States shall submit to Congress a report exam9 ining whether entities that pool financial risk 

10 for physician practices, such as independent 

11 risk managers, can play a role in supporting 

12 physician practices, particularly small physician 

13 practices, in assuming financial risk for the 

14 treatment of patients. Such report shall exam15 ine barriers that small physician practices cur16 rently face in assuming financial risk for treat17 ing patients, the types of risk management enti18 ties that could assist physician practices in par19 ticipating in two-sided risk payment models, 

20 and how such entities could assist with risk 

21 management and with quality improvement ac22 tivities. Such report shall also include an anal23 ysis of any existing legal barriers to such ar24 rangements. 


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1 (D) STUDY TO EXAMINE RURAL AND

2 HEALTH PROFESSIONAL SHORTAGE AREA AL3 TERNATIVE PAYMENT MODELS.—Not later than 

4 October 1, 2021, the Comptroller General of 

5 the United States shall submit to Congress a 

6 report that examines the transition of profes7 sionals in rural areas, health professional short8 age areas (as designated in section 

9 332(a)(1)(A) of the Public Health Service Act), 

10 or medically underserved areas to an alternative 

11 payment model (as defined in section 

12 1833(z)(3) of the Social Security Act, as added 

13 by subsection (e)). Such report shall make rec14 ommendations for removing administrative bar15 riers to practices, including small practices con16 sisting of 15 or fewer professionals, in rural 

17 areas, health professional shortage areas, and 

18 medically underserved areas to participation in 

19 such models. 

20 (3) FUNDING FOR IMPLEMENTATION.—For 

21 purposes of implementing the provisions of and the 

22 amendments made by this section, the Secretary of 

23 Health and Human Services shall provide for the 

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

25 Medical Insurance Trust Fund established under 


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

2 1395t) to the Centers for Medicare & Medicaid Pro3 gram Management Account for each of the fiscal 

4 years 2015 through 2019. Amounts transferred 

5 under this paragraph shall be available until ex6 pended. 

7 (d) IMPROVING QUALITY REPORTING FOR COM8 POSITE SCORES.— 

9 (1) CHANGES FOR GROUP REPORTING OP10 TION.— 

11 (A) IN GENERAL.—Section 

12 1848(m)(3)(C)(ii) of the Social Security Act 

13 (42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 

14 by inserting ‘‘and, for 2016 and subsequent 

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

16 (B) CLARIFICATION OF QUALIFIED CLIN17 ICAL DATA REGISTRY REPORTING TO GROUP

18 PRACTICES.—Section 1848(m)(3)(D) of the So19 cial Security Act (42 U.S.C. 1395w– 

20 4(m)(3)(D)) is amended by inserting ‘‘and, for 

21 2016 and subsequent years, subparagraph (A) 

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

23 (2) CHANGES FOR MULTIPLE REPORTING PERI24 ODS AND ALTERNATIVE CRITERIA FOR SATISFAC25 TORY REPORTING.—Section 1848(m)(5)(F) of the 


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

2 is amended— 

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

4 and inserting ‘‘through reporting periods occur5 ring in 2015’’; and 

6 (B) by inserting ‘‘and, for reporting peri7 ods occurring in 2016 and subsequent years, 

8 the Secretary may establish’’ after ‘‘shall estab9 lish’’. 

10 (3) PHYSICIAN FEEDBACK PROGRAM REPORTS

11 SUCCEEDED BY REPORTS UNDER MIPS.—Section 

12 1848(n) of the Social Security Act (42 U.S.C. 

13 1395w–4(n)) is amended by adding at the end the 

14 following new paragraph: 

15 ‘‘(11) REPORTS ENDING WITH 2017.—Reports 

16 under the Program shall not be provided after De17 cember 31, 2017. See subsection (q)(12) for reports 

18 under the eligible professionals Merit-based Incentive 

19 Payment System.’’. 

20 (4) COORDINATION WITH SATISFYING MEANING21 FUL EHR USE CLINICAL QUALITY MEASURE REPORT22 ING REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 

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

24 4(o)(2)(A)(iii)) is amended by inserting ‘‘and subVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00079 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara2 graph (B)(ii)’’. 

3 (e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 

4 (1) INCREASING TRANSPARENCY OF PHYSICIAN5 FOCUSED PAYMENT MODELS.—Section 1868 of the 

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

7 by adding at the end the following new subsection: 

8 ‘‘(c) PHYSICIAN-FOCUSED PAYMENT MODELS.— 

9 ‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 

10 ‘‘(A) ESTABLISHMENT.—There is estab11 lished an ad hoc committee to be known as the 

12 ‘Physician-Focused Payment Model Technical 

13 Advisory Committee’ (referred to in this sub14 section as the ‘Committee’). 

15 ‘‘(B) MEMBERSHIP.— 

16 ‘‘(i) NUMBER AND APPOINTMENT.— 

17 The Committee shall be composed of 11 

18 members appointed by the Comptroller 

19 General of the United States. 

20 ‘‘(ii) QUALIFICATIONS.—The member21 ship of the Committee shall include indi22 viduals with national recognition for their 

23 expertise in physician-focused payment 

24 models and related delivery of care. No 

25 more than 5 members of the Committee 


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1 shall be providers of services or suppliers, 

2 or representatives of providers of services 

3 or suppliers. 

4 ‘‘(iii) PROHIBITION ON FEDERAL EM5 PLOYMENT.—A member of the Committee 

6 shall not be an employee of the Federal 

7 Government. 

8 ‘‘(iv) ETHICS DISCLOSURE.—The 

9 Comptroller General shall establish a sys10 tem for public disclosure by members of 

11 the Committee of financial and other po12 tential conflicts of interest relating to such 

13 members. Members of the Committee shall 

14 be treated as employees of Congress for 

15 purposes of applying title I of the Ethics 

16 in Government Act of 1978 (Public Law 

17 95–521). 

18 ‘‘(v) DATE OF INITIAL APPOINT19 MENTS.—The initial appointments of mem20 bers of the Committee shall be made by 

21 not later than 180 days after the date of 

22 enactment of this subsection. 

23 ‘‘(C) TERM; VACANCIES.— 

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

25 the Committee shall be for 3 years except 


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1 that the Comptroller General shall des2 ignate staggered terms for the members 

3 first appointed. 

4 ‘‘(ii) VACANCIES.—Any member ap5 pointed to fill a vacancy occurring before 

6 the expiration of the term for which the 

7 member’s predecessor was appointed shall 

8 be appointed only for the remainder of that 

9 term. A member may serve after the expi10 ration of that member’s term until a suc11 cessor has taken office. A vacancy in the 

12 Committee shall be filled in the manner in 

13 which the original appointment was made. 

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

15 as needed, to provide comments and rec16 ommendations to the Secretary, as described in 

17 paragraph (2)(C), on physician-focused pay18 ment models. 

19 ‘‘(E) COMPENSATION OF MEMBERS.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), a member of the Com22 mittee shall serve without compensation. 

23 ‘‘(ii) TRAVEL EXPENSES.—A member 

24 of the Committee shall be allowed travel 

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1 sistence, at rates authorized for an em2 ployee of an agency under subchapter I of 

3 chapter 57 of title 5, United States Code, 

4 while away from the home or regular place 

5 of business of the member in the perform6 ance of the duties of the Committee. 

7 ‘‘(F) OPERATIONAL AND TECHNICAL SUP8 PORT.— 

9 ‘‘(i) IN GENERAL.—The Assistant 

10 Secretary for Planning and Evaluation 

11 shall provide technical and operational sup12 port for the Committee, which may be by 

13 use of a contractor. The Office of the Ac14 tuary of the Centers for Medicare & Med15 icaid Services shall provide to the Com16 mittee actuarial assistance as needed. 

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

18 provide for the transfer, from the Federal 

19 Supplementary Medical Insurance Trust 

20 Fund under section 1841, such amounts as 

21 are necessary to carry out this paragraph 

22 (not to exceed $5,000,000) for fiscal year 

23 2015 and each subsequent fiscal year. Any 

24 amounts transferred under the preceding 


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1 sentence for a fiscal year shall remain 

2 available until expended. 

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

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

5 App.) shall not apply to the Committee. 

6 ‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION

7 AND REVIEW OF PHYSICIAN-FOCUSED PAYMENT

8 MODELS.— 

9 ‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN10 FOCUSED PAYMENT MODELS.— 

11 ‘‘(i) RULEMAKING.—Not later than 

12 November 1, 2016, the Secretary shall, 

13 through notice and comment rulemaking, 

14 following a request for information, estab15 lish criteria for physician-focused payment 

16 models, including models for specialist phy17 sicians, that could be used by the Com18 mittee for making comments and rec19 ommendations pursuant to paragraph 

20 (1)(D). 

21 ‘‘(ii) MEDPAC SUBMISSION OF COM22 MENTS.—During the comment period for 

23 the proposed rule described in clause (i), 

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1 retary on the proposed criteria under such 

2 clause. 

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

4 update the criteria established under this 

5 subparagraph through rulemaking. 

6 ‘‘(B) STAKEHOLDER SUBMISSION OF PHY7 SICIAN-FOCUSED PAYMENT MODELS.—On an 

8 ongoing basis, individuals and stakeholder enti9 ties may submit to the Committee proposals for 

10 physician-focused payment models that such in11 dividuals and entities believe meet the criteria 

12 described in subparagraph (A). 

13 ‘‘(C) COMMITTEE REVIEW OF MODELS

14 SUBMITTED.—The Committee shall, on a peri15 odic basis, review models submitted under sub16 paragraph (B), prepare comments and rec17 ommendations regarding whether such models 

18 meet the criteria described in subparagraph 

19 (A), and submit such comments and rec20 ommendations to the Secretary. 

21 ‘‘(D) SECRETARY REVIEW AND RE22 SPONSE.—The Secretary shall review the com23 ments and recommendations submitted by the 

24 Committee under subparagraph (C) and post a 

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1 ommendations on the Internet website of the 

2 Centers for Medicare & Medicaid Services. 

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

4 this subsection shall be construed to impact the de5 velopment or testing of models under this title or ti6 tles XI, XIX, or XXI.’’. 

7 (2) INCENTIVE PAYMENTS FOR PARTICIPATION

8 IN ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

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

10 1395l) is amended by adding at the end the fol11 lowing new subsection: 

12 ‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN

13 ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 

14 ‘‘(1) PAYMENT INCENTIVE.— 

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

16 professional services furnished by an eligible 

17 professional during a year that is in the period 

18 beginning with 2019 and ending with 2024 and 

19 for which the professional is a qualifying APM 

20 participant with respect to such year, in addi21 tion to the amount of payment that would oth22 erwise be made for such covered professional 

23 services under this part for such year, there 

24 also shall be paid to such professional an 

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1 gregate payment amounts for such covered pro2 fessional services under this part for the pre3 ceding year. For purposes of the previous sen4 tence, the payment amount for the preceding 

5 year may be an estimation for the full pre6 ceding year based on a period of such preceding 

7 year that is less than the full year. The Sec8 retary shall establish policies to implement this 

9 subparagraph in cases in which payment for 

10 covered professional services furnished by a 

11 qualifying APM participant in an alternative 

12 payment model— 

13 ‘‘(i) is made to an eligible alternative 

14 payment entity rather than directly to the 

15 qualifying APM participant; or 

16 ‘‘(ii) is made on a basis other than a 

17 fee-for-service basis (such as payment on a 

18 capitated basis). 

19 ‘‘(B) FORM OF PAYMENT.—Payments 

20 under this subsection shall be made in a lump 

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

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

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


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1 payment model and for purposes of determining 

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

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

5 additional payment under this subsection or 

6 subsection (m) shall be determined without re7 gard to any additional payment under sub8 section (m) and this subsection, respectively. 

9 The amount of the additional payment under 

10 this subsection or subsection (x) shall be deter11 mined without regard to any additional pay12 ment under subsection (x) and this subsection, 

13 respectively. The amount of the additional pay14 ment under this subsection or subsection (y) 

15 shall be determined without regard to any addi16 tional payment under subsection (y) and this 

17 subsection, respectively. 

18 ‘‘(2) QUALIFYING APM PARTICIPANT.—For pur19 poses of this subsection, the term ‘qualifying APM 

20 participant’ means the following: 

21 ‘‘(A) 2019 AND 2020.—With respect to 

22 2019 and 2020, an eligible professional for 

23 whom the Secretary determines that at least 25 

24 percent of payments under this part for covered 

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1 sional during the most recent period for which 

2 data are available (which may be less than a 

3 year) were attributable to such services fur4 nished under this part through an eligible alter5 native payment entity. 

6 ‘‘(B) 2021 AND 2022.—With respect to 

7 2021 and 2022, an eligible professional de8 scribed in either of the following clauses: 

9 ‘‘(i) MEDICARE PAYMENT THRESHOLD

10 OPTION.—An eligible professional for 

11 whom the Secretary determines that at 

12 least 50 percent of payments under this 

13 part for covered professional services fur14 nished by such professional during the 

15 most recent period for which data are 

16 available (which may be less than a year) 

17 were attributable to such services furnished 

18 under this part through an eligible alter19 native payment entity. 

20 ‘‘(ii) COMBINATION ALL-PAYER AND

21 MEDICARE PAYMENT THRESHOLD OP22 TION.—An eligible professional— 

23 ‘‘(I) for whom the Secretary de24 termines, with respect to items and 

25 services furnished by such professional 


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1 during the most recent period for 

2 which data are available (which may 

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

4 percent of the sum of— 

5 ‘‘(aa) payments described in 

6 clause (i); and 

7 ‘‘(bb) all other payments, re8 gardless of payer (other than 

9 payments made by the Secretary 

10 of Defense or the Secretary of 

11 Veterans Affairs and other than 

12 payments made under title XIX 

13 in a State in which no medical 

14 home or alternative payment 

15 model is available under the 

16 State program under that title), 

17 meet the requirement described in 

18 clause (iii)(I) with respect to pay19 ments described in item (aa) and meet 

20 the requirement described in clause 

21 (iii)(II) with respect to payments de22 scribed in item (bb); 

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1 fessional services furnished by such 

2 professional during the most recent 

3 period for which data are available 

4 (which may be less than a year) were 

5 attributable to such services furnished 

6 under this part through an eligible al7 ternative payment entity; and 

8 ‘‘(III) who provides to the Sec9 retary such information as is nec10 essary for the Secretary to make a de11 termination under subclause (I), with 

12 respect to such professional. 

13 ‘‘(iii) REQUIREMENT.—For purposes 

14 of clause (ii)(I)— 

15 ‘‘(I) the requirement described in 

16 this subclause, with respect to pay17 ments described in item (aa) of such 

18 clause, is that such payments are 

19 made to an eligible alternative pay20 ment entity; and 

21 ‘‘(II) the requirement described 

22 in this subclause, with respect to pay23 ments described in item (bb) of such 

24 clause, is that such payments are 

25 made under arrangements in which— 


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1 ‘‘(aa) quality measures com2 parable to measures under the 

3 performance category described 

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

5 ‘‘(bb) certified EHR tech6 nology is used; and 

7 ‘‘(cc) the eligible profes8 sional participates in an entity 

9 that— 

10 ‘‘(AA) bears more than 

11 nominal financial risk if ac12 tual aggregate expenditures 

13 exceeds expected aggregate 

14 expenditures; or 

15 ‘‘(BB) with respect to 

16 beneficiaries under title 

17 XIX, is a medical home that 

18 meets criteria comparable to 

19 medical homes expanded 

20 under section 1115A(c). 

21 ‘‘(C) BEGINNING IN 2023.—With respect to 

22 2023 and each subsequent year, an eligible pro23 fessional described in either of the following 

24 clauses: 


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1 ‘‘(i) MEDICARE PAYMENT THRESHOLD

2 OPTION.—An eligible professional for 

3 whom the Secretary determines that at 

4 least 75 percent of payments under this 

5 part for covered professional services fur6 nished by such professional during the 

7 most recent period for which data are 

8 available (which may be less than a year) 

9 were attributable to such services furnished 

10 under this part through an eligible alter11 native payment entity. 

12 ‘‘(ii) COMBINATION ALL-PAYER AND

13 MEDICARE PAYMENT THRESHOLD OP14 TION.—An eligible professional— 

15 ‘‘(I) for whom the Secretary de16 termines, with respect to items and 

17 services furnished by such professional 

18 during the most recent period for 

19 which data are available (which may 

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

21 percent of the sum of— 

22 ‘‘(aa) payments described in 

23 clause (i); and 

24 ‘‘(bb) all other payments, re25 gardless of payer (other than 


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1 payments made by the Secretary 

2 of Defense or the Secretary of 

3 Veterans Affairs and other than 

4 payments made under title XIX 

5 in a State in which no medical 

6 home or alternative payment 

7 model is available under the 

8 State program under that title), 

9 meet the requirement described in 

10 clause (iii)(I) with respect to pay11 ments described in item (aa) and meet 

12 the requirement described in clause 

13 (iii)(II) with respect to payments de14 scribed in item (bb); 

15 ‘‘(II) for whom the Secretary de16 termines at least 25 percent of pay17 ments under this part for covered pro18 fessional services furnished by such 

19 professional during the most recent 

20 period for which data are available 

21 (which may be less than a year) were 

22 attributable to such services furnished 

23 under this part through an eligible al24 ternative payment entity; 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 to an eligible alternative pay13 ment entity; 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 arrangements in which— 

19 ‘‘(aa) quality measures com20 parable to measures under the 

21 performance category described 

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

23 ‘‘(bb) certified EHR tech24 nology is used; and 


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1 ‘‘(cc) the eligible profes2 sional participates in an entity 

3 that— 

4 ‘‘(AA) bears more than 

5 nominal financial risk if ac6 tual aggregate expenditures 

7 exceeds expected aggregate 

8 expenditures; or 

9 ‘‘(BB) with respect to 

10 beneficiaries under title 

11 XIX, is a medical home that 

12 meets criteria comparable to 

13 medical homes expanded 

14 under section 1115A(c). 

15 ‘‘(D) USE OF PATIENT APPROACH.—The 

16 Secretary may base the determination of wheth17 er an eligible professional is a qualifying APM 

18 participant under this subsection and the deter19 mination of whether an eligible professional is a 

20 partial qualifying APM participant under sec21 tion 1848(q)(1)(C)(iii) by using counts of pa22 tients in lieu of using payments and using the 

23 same or similar percentage criteria (as specified 

24 in this subsection and such section, respec25 tively), as the Secretary determines appropriate. 


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1 ‘‘(3) ADDITIONAL DEFINITIONS.—In this sub2 section: 

3 ‘‘(A) COVERED PROFESSIONAL SERV4 ICES.—The term ‘covered professional services’ 

5 has the meaning given that term in section 

6 1848(k)(3)(A). 

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

8 ‘eligible professional’ has the meaning given 

9 that term in section 1848(k)(3)(B) and includes 

10 a group that includes such professionals. 

11 ‘‘(C) ALTERNATIVE PAYMENT MODEL

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

13 means, other than for purposes of subpara14 graphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of para15 graph (2), any of the following: 

16 ‘‘(i) A model under section 1115A 

17 (other than a health care innovation 

18 award). 

19 ‘‘(ii) The shared savings program 

20 under section 1899. 

21 ‘‘(iii) A demonstration under section 

22 1866C. 

23 ‘‘(iv) A demonstration required by 

24 Federal law. 


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1 ‘‘(D) ELIGIBLE ALTERNATIVE PAYMENT

2 ENTITY.—The term ‘eligible alternative pay3 ment entity’ means, with respect to a year, an 

4 entity that— 

5 ‘‘(i) participates in an alternative pay6 ment model that— 

7 ‘‘(I) requires participants in such 

8 model to use certified EHR tech9 nology (as defined in subsection 

10 (o)(4)); and 

11 ‘‘(II) provides for payment for 

12 covered professional services based on 

13 quality measures comparable to meas14 ures under the performance category 

15 described in section 1848(q)(2)(B)(i); 

16 and 

17 ‘‘(ii)(I) bears financial risk for mone18 tary losses under such alternative payment 

19 model that are in excess of a nominal 

20 amount; or 

21 ‘‘(II) is a medical home expanded 

22 under section 1115A(c). 

23 ‘‘(4) LIMITATION.—There shall be no adminis24 trative or judicial review under section 1869, 1878, 

25 or otherwise, of the following: 


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1 ‘‘(A) The determination that an eligible 

2 professional is a qualifying APM participant 

3 under paragraph (2) and the determination 

4 that an entity is an eligible alternative payment 

5 entity under paragraph (3)(D). 

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

7 the 5 percent payment incentive under para8 graph (1)(A), including any estimation as part 

9 of such determination.’’. 

10 (3) COORDINATION CONFORMING AMEND11 MENTS.—Section 1833 of the Social Security Act 

12 (42 U.S.C. 1395l) is further amended— 

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

14 end the following new sentence: ‘‘The amount 

15 of the additional payment for a service under 

16 this subsection and subsection (z) shall be de17 termined without regard to any additional pay18 ment for the service under subsection (z) and 

19 this subsection, respectively.’’; and 

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

21 end the following new sentence: ‘‘The amount 

22 of the additional payment for a service under 

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1 ment for the service under subsection (z) and 

2 this subsection, respectively.’’. 

3 (4) ENCOURAGING DEVELOPMENT AND TEST4 ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 

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

6 amended— 

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

8 end the following new clauses: 

9 ‘‘(xxi) Focusing primarily on physi10 cians’ services (as defined in section 

11 1848(j)(3)) furnished by physicians who 

12 are not primary care practitioners. 

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

14 fewer professionals. 

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

16 for small physician practices which may in17 volve two-sided risk and prospective patient 

18 assignment, and which examine risk-ad19 justed decreases in mortality rates, hos20 pital readmissions rates, and other relevant 

21 and appropriate clinical measures. 

22 ‘‘(xxiv) Focusing primarily on title 

23 XIX, working in conjunction with the Cen24 ter for Medicaid and CHIP Services.’’; and 


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

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

3 and inserting ‘‘other public sector payers, pri4 vate sector payers, or Statewide payment mod5 els’’. 

6 (5) CONSTRUCTION REGARDING TELEHEALTH

7 SERVICES.—Nothing in the provisions of, or amend8 ments made by, this Act shall be construed as pre9 cluding an alternative payment model or a qualifying 

10 APM participant (as those terms are defined in sec11 tion 1833(z) of the Social Security Act, as added by 

12 paragraph (1)) from furnishing a telehealth service 

13 for which payment is not made under section 

14 1834(m) of the Social Security Act (42 U.S.C. 

15 1395m(m)). 

16 (6) INTEGRATING MEDICARE ADVANTAGE AL17 TERNATIVE PAYMENT MODELS.—Not later than July 

18 1, 2016, the Secretary of Health and Human Serv19 ices shall submit to Congress a study that examines 

20 the feasibility of integrating alternative payment 

21 models in the Medicare Advantage payment system. 

22 The study shall include the feasibility of including a 

23 value-based modifier and whether such modifier 

24 should be budget neutral. 


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1 (7) STUDY AND REPORT ON FRAUD RELATED

2 TO ALTERNATIVE PAYMENT MODELS UNDER THE

3 MEDICARE PROGRAM.— 

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

5 Human Services, in consultation with the In6 spector General of the Department of Health 

7 and Human Services, shall conduct a study 

8 that— 

9 (i) examines the applicability of the 

10 Federal fraud prevention laws to items and 

11 services furnished under title XVIII of the 

12 Social Security Act for which payment is 

13 made under an alternative payment model 

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

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

16 (ii) identifies aspects of such alter17 native payment models that are vulnerable 

18 to fraudulent activity; and 

19 (iii) examines the implications of waiv20 ers to such laws granted in support of such 

21 alternative payment models, including 

22 under any potential expansion of such 

23 models. 

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

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1 retary shall submit to Congress a report con2 taining the results of the study conducted under 

3 subparagraph (A). Such report shall include 

4 recommendations for actions to be taken to re5 duce the vulnerability of such alternative pay6 ment models to fraudulent activity. Such report 

7 also shall include, as appropriate, recommenda8 tions of the Inspector General for changes in 

9 Federal fraud prevention laws to reduce such 

10 vulnerability. 

11 (f) COLLABORATING WITH THE PHYSICIAN, PRACTI12 TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

13 IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 

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

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

16 at the end the following new subsection: 

17 ‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC18 TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO

19 IMPROVE RESOURCE USE MEASUREMENT.— 

20 ‘‘(1) IN GENERAL.—In order to involve the phy21 sician, practitioner, and other stakeholder commu22 nities in enhancing the infrastructure for resource 

23 use measurement, including for purposes of the 

24 Merit-based Incentive Payment System under sub25 section (q) and alternative payment models under 


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

2 steps described in the succeeding provisions of this 

3 subsection. 

4 ‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA5 TIENT CONDITION GROUPS AND CLASSIFICATION

6 CODES.— 

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

8 similar patients into care episode groups and 

9 patient condition groups, the Secretary shall 

10 undertake the steps described in the succeeding 

11 provisions of this paragraph. 

12 ‘‘(B) PUBLIC AVAILABILITY OF EXISTING

13 EFFORTS TO DESIGN AN EPISODE GROUPER.— 

14 Not later than 180 days after the date of the 

15 enactment of this subsection, the Secretary 

16 shall post on the Internet website of the Cen17 ters for Medicare & Medicaid Services a list of 

18 the episode groups developed pursuant to sub19 section (n)(9)(A) and related descriptive infor20 mation. 

21 ‘‘(C) STAKEHOLDER INPUT.—The Sec22 retary shall accept, through the date that is 

23 120 days after the day the Secretary posts the 

24 list pursuant to subparagraph (B), suggestions 

25 from physician specialty societies, applicable 


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1 practitioner organizations, and other stake2 holders for episode groups in addition to those 

3 posted pursuant to such subparagraph, and 

4 specific clinical criteria and patient characteris5 tics to classify patients into— 

6 ‘‘(i) care episode groups; and 

7 ‘‘(ii) patient condition groups. 

8 ‘‘(D) DEVELOPMENT OF PROPOSED CLAS9 SIFICATION CODES.— 

10 ‘‘(i) IN GENERAL.—Taking into ac11 count the information described in sub12 paragraph (B) and the information re13 ceived under subparagraph (C), the Sec14 retary shall— 

15 ‘‘(I) establish care episode groups 

16 and patient condition groups, which 

17 account for a target of an estimated 

1 18 ⁄2 of expenditures under parts A and 

19 B (with such target increasing over 

20 time as appropriate); and 

21 ‘‘(II) assign codes to such 

22 groups. 

23 ‘‘(ii) CARE EPISODE GROUPS.—In es24 tablishing the care episode groups under 


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1 clause (i), the Secretary shall take into ac2 count— 

3 ‘‘(I) the patient’s clinical prob4 lems at the time items and services 

5 are furnished during an episode of 

6 care, such as the clinical conditions or 

7 diagnoses, whether or not inpatient 

8 hospitalization occurs, and the prin9 cipal procedures or services furnished; 

10 and 

11 ‘‘(II) other factors determined 

12 appropriate by the Secretary. 

13 ‘‘(iii) PATIENT CONDITION GROUPS.— 

14 In establishing the patient condition 

15 groups under clause (i), the Secretary shall 

16 take into account— 

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

18 at the time of a medical visit, such as 

19 the patient’s combination of chronic 

20 conditions, current health status, and 

21 recent significant history (such as 

22 hospitalization and major surgery dur23 ing a previous period, such as 3 

24 months); and 


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1 ‘‘(II) other factors determined 

2 appropriate by the Secretary, such as 

3 eligibility status under this title (in4 cluding eligibility under section 

5 226(a), 226(b), or 226A, and dual eli6 gibility under this title and title XIX). 

7 ‘‘(E) DRAFT CARE EPISODE AND PATIENT

8 CONDITION GROUPS AND CLASSIFICATION

9 CODES.—Not later than 270 days after the end 

10 of the comment period described in subpara11 graph (C), the Secretary shall post on the 

12 Internet website of the Centers for Medicare & 

13 Medicaid Services a draft list of the care epi14 sode and patient condition codes established 

15 under subparagraph (D) (and the criteria and 

16 characteristics assigned to such code). 

17 ‘‘(F) SOLICITATION OF INPUT.—The Sec18 retary shall seek, through the date that is 120 

19 days after the Secretary posts the list pursuant 

20 to subparagraph (E), comments from physician 

21 specialty societies, applicable practitioner orga22 nizations, and other stakeholders, including rep23 resentatives of individuals entitled to benefits 

24 under part A or enrolled under this part, re25 garding the care episode and patient condition 


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1 groups (and codes) posted under subparagraph 

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

3 shall use one or more mechanisms (other than 

4 notice and comment rulemaking) that may in5 clude use of open door forums, town hall meet6 ings, or other appropriate mechanisms. 

7 ‘‘(G) OPERATIONAL LIST OF CARE EPI8 SODE AND PATIENT CONDITION GROUPS AND

9 CODES.—Not later than 270 days after the end 

10 of the comment period described in subpara11 graph (F), taking into account the comments 

12 received under such subparagraph, the Sec13 retary shall post on the Internet website of the 

14 Centers for Medicare & Medicaid Services an 

15 operational list of care episode and patient con16 dition codes (and the criteria and characteris17 tics assigned to such code). 

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

19 than November 1 of each year (beginning with 

20 2018), the Secretary shall, through rulemaking, 

21 make revisions to the operational lists of care 

22 episode and patient condition codes as the Sec23 retary determines may be appropriate. Such re24 visions may be based on experience, new infor25 mation developed pursuant to subsection 


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1 (n)(9)(A), and input from the physician spe2 cialty societies, applicable practitioner organiza3 tions, and other stakeholders, including rep4 resentatives of individuals entitled to benefits 

5 under part A or enrolled under this part. 

6 ‘‘(3) ATTRIBUTION OF PATIENTS TO PHYSI7 CIANS OR PRACTITIONERS.— 

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

9 the attribution of patients and episodes (in 

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

11 applicable practitioners furnishing items and 

12 services, the Secretary shall undertake the steps 

13 described in the succeeding provisions of this 

14 paragraph. 

15 ‘‘(B) DEVELOPMENT OF PATIENT RELA16 TIONSHIP CATEGORIES AND CODES.—The Sec17 retary shall develop patient relationship cat18 egories and codes that define and distinguish 

19 the relationship and responsibility of a physi20 cian or applicable practitioner with a patient at 

21 the time of furnishing an item or service. Such 

22 patient relationship categories shall include dif23 ferent relationships of the physician or applica24 ble practitioner to the patient (and the codes 

25 may reflect combinations of such categories), 


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1 such as a physician or applicable practitioner 

2 who— 

3 ‘‘(i) considers themself to have the 

4 primary responsibility for the general and 

5 ongoing care for the patient over extended 

6 periods of time; 

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

8 physician or practitioner and who furnishes 

9 items and services and coordinates care 

10 furnished by other physicians or practi11 tioners for the patient during an acute epi12 sode; 

13 ‘‘(iii) furnishes items and services to 

14 the patient on a continuing basis during an 

15 acute episode of care, but in a supportive 

16 rather than a lead role; 

17 ‘‘(iv) furnishes items and services to 

18 the patient on an occasional basis, usually 

19 at the request of another physician or 

20 practitioner; or 

21 ‘‘(v) furnishes items and services only 

22 as ordered by another physician or practi23 tioner. 

24 ‘‘(C) DRAFT LIST OF PATIENT RELATION25 SHIP CATEGORIES AND CODES.—Not later than 


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1 one year after the date of the enactment of this 

2 subsection, the Secretary shall post on the 

3 Internet website of the Centers for Medicare & 

4 Medicaid Services a draft list of the patient re5 lationship categories and codes developed under 

6 subparagraph (B). 

7 ‘‘(D) STAKEHOLDER INPUT.—The Sec8 retary shall seek, through the date that is 120 

9 days after the Secretary posts the list pursuant 

10 to subparagraph (C), comments from physician 

11 specialty societies, applicable practitioner orga12 nizations, and other stakeholders, including rep13 resentatives of individuals entitled to benefits 

14 under part A or enrolled under this part, re15 garding the patient relationship categories and 

16 codes posted under subparagraph (C). In seek17 ing such comments, the Secretary shall use one 

18 or more mechanisms (other than notice and 

19 comment rulemaking) that may include open 

20 door forums, town hall meetings, web-based fo21 rums, or other appropriate mechanisms. 

22 ‘‘(E) OPERATIONAL LIST OF PATIENT RE23 LATIONSHIP CATEGORIES AND CODES.—Not 

24 later than 240 days after the end of the com25 ment period described in subparagraph (D), 


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1 taking into account the comments received 

2 under such subparagraph, the Secretary shall 

3 post on the Internet website of the Centers for 

4 Medicare & Medicaid Services an operational 

5 list of patient relationship categories and codes. 

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

7 than November 1 of each year (beginning with 

8 2018), the Secretary shall, through rulemaking, 

9 make revisions to the operational list of patient 

10 relationship categories and codes as the Sec11 retary determines appropriate. Such revisions 

12 may be based on experience, new information 

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

14 input from the physician specialty societies, ap15 plicable practitioner organizations, and other 

16 stakeholders, including representatives of indi17 viduals entitled to benefits under part A or en18 rolled under this part. 

19 ‘‘(4) REPORTING OF INFORMATION FOR RE20 SOURCE USE MEASUREMENT.—Claims submitted for 

21 items and services furnished by a physician or appli22 cable practitioner on or after January 1, 2018, shall, 

23 as determined appropriate by the Secretary, in24 clude— 


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1 ‘‘(A) applicable codes established under 

2 paragraphs (2) and (3); and 

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

4 ordering physician or applicable practitioner (if 

5 different from the billing physician or applicable 

6 practitioner). 

7 ‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL8 YSIS.— 

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

10 the resources used to treat patients (with re11 spect to care episode and patient condition 

12 groups), the Secretary shall, as the Secretary 

13 determines appropriate— 

14 ‘‘(i) use the patient relationship codes 

15 reported on claims pursuant to paragraph 

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

17 part) to one or more physicians and appli18 cable practitioners; 

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

20 condition codes reported on claims pursu21 ant to paragraph (4) as a basis to compare 

22 similar patients and care episodes and pa23 tient condition groups; and 


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1 ‘‘(iii) conduct an analysis of resource 

2 use (with respect to care episodes and pa3 tient condition groups of such patients). 

4 ‘‘(B) ANALYSIS OF PATIENTS OF PHYSI5 CIANS AND PRACTITIONERS.—In conducting the 

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

7 respect to patients attributed to physicians and 

8 applicable practitioners, the Secretary shall, as 

9 feasible— 

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

11 such patients by patient condition codes 

12 during a common period, such as 12 

13 months; and 

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

15 such patients by care episode codes— 

16 ‘‘(I) in the case of episodes with17 out a hospitalization, during periods 

18 of time (such as the number of days) 

19 determined appropriate by the Sec20 retary; and 

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

22 a hospitalization, during periods of 

23 time (such as the number of days) be24 fore, during, and after the hospitaliza25 tion. 


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

2 In measuring such resource use, the Sec3 retary— 

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

5 charges for all services under part A and 

6 this part (and, if the Secretary determines 

7 appropriate, part D) for the analysis of pa8 tient resource use, by care episode codes 

9 and by patient condition codes; and 

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

11 use other measures of allowed charges 

12 (such as subtotals for categories of items 

13 and services) and measures of utilization of 

14 items and services (such as frequency of 

15 specific items and services and the ratio of 

16 specific items and services among attrib17 uted patients or episodes). 

18 ‘‘(D) STAKEHOLDER INPUT.—The Sec19 retary shall seek comments from the physician 

20 specialty societies, applicable practitioner orga21 nizations, and other stakeholders, including rep22 resentatives of individuals entitled to benefits 

23 under part A or enrolled under this part, re24 garding the resource use methodology estab25 lished pursuant to this paragraph. In seeking 


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1 comments the Secretary shall use one or more 

2 mechanisms (other than notice and comment 

3 rulemaking) that may include open door fo4 rums, town hall meetings, web-based forums, or 

5 other appropriate mechanisms. 

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

7 the Secretary contracts with an entity to carry out 

8 any part of the provisions of this subsection, the 

9 Secretary may not contract with an entity or an en10 tity with a subcontract if the entity or subcon11 tracting entity currently makes recommendations to 

12 the Secretary on relative values for services under 

13 the fee schedule for physicians’ services under this 

14 section. 

15 ‘‘(7) LIMITATION.—There shall be no adminis16 trative or judicial review under section 1869, section 

17 1878, or otherwise of— 

18 ‘‘(A) care episode and patient condition 

19 groups and codes established under paragraph 

20 (2); 

21 ‘‘(B) patient relationship categories and 

22 codes established under paragraph (3); and 

23 ‘‘(C) measurement of, and analyses of re24 source use with respect to, care episode and paVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00116 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 tient condition codes and patient relationship 

2 codes pursuant to paragraph (5). 

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

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

5 ‘‘(9) DEFINITIONS.—In this subsection: 

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

7 has the meaning given such term in section 

8 1861(r)(1). 

9 ‘‘(B) APPLICABLE PRACTITIONER.—The 

10 term ‘applicable practitioner’ means— 

11 ‘‘(i) a physician assistant, nurse prac12 titioner, and clinical nurse specialist (as 

13 such terms are defined in section 

14 1861(aa)(5)), and a certified registered 

15 nurse anesthetist (as defined in section 

16 1861(bb)(2)); and 

17 ‘‘(ii) beginning January 1, 2019, such 

18 other eligible professionals (as defined in 

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

20 Secretary. 

21 ‘‘(10) CLARIFICATION.—The provisions of sec22 tions 1890(b)(7) and 1890A shall not apply to this 

23 subsection.’’. 


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1 SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVEL2 OPMENT. 

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

4 1395w–4), as amended by subsections (c) and (f) of sec5 tion 2, is further amended by inserting at the end the fol6 lowing new subsection: 

7 ‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE8 VELOPMENT.— 

9 ‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP10 MENT PRIORITIES AND TIMELINES.— 

11 ‘‘(A) DRAFT MEASURE DEVELOPMENT

12 PLAN.—Not later than January 1, 2016, the 

13 Secretary shall develop, and post on the Inter14 net website of the Centers for Medicare & Med15 icaid Services, a draft plan for the development 

16 of quality measures for application under the 

17 applicable provisions (as defined in paragraph 

18 (5)). Under such plan the Secretary shall— 

19 ‘‘(i) address how measures used by 

20 private payers and integrated delivery sys21 tems could be incorporated under title 

22 XVIII; 

23 ‘‘(ii) describe how coordination, to the 

24 extent possible, will occur across organiza25 tions developing such measures; and 


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1 ‘‘(iii) take into account how clinical 

2 best practices and clinical practice guide3 lines should be used in the development of 

4 quality measures. 

5 ‘‘(B) QUALITY DOMAINS.—For purposes of 

6 this subsection, the term ‘quality domains’ 

7 means at least the following domains: 

8 ‘‘(i) Clinical care. 

9 ‘‘(ii) Safety. 

10 ‘‘(iii) Care coordination. 

11 ‘‘(iv) Patient and caregiver experience. 

12 ‘‘(v) Population health and preven13 tion. 

14 ‘‘(C) CONSIDERATION.—In developing the 

15 draft plan under this paragraph, the Secretary 

16 shall consider— 

17 ‘‘(i) gap analyses conducted by the en18 tity with a contract under section 1890(a) 

19 or other contractors or entities; 

20 ‘‘(ii) whether measures are applicable 

21 across health care settings; 

22 ‘‘(iii) clinical practice improvement ac23 tivities submitted under subsection 

24 (q)(2)(C)(iv) for identifying possible areas 

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1 fying existing gaps with respect to such 

2 measures; and 

3 ‘‘(iv) the quality domains applied 

4 under this subsection. 

5 ‘‘(D) PRIORITIES.—In developing the draft 

6 plan under this paragraph, the Secretary shall 

7 give priority to the following types of measures: 

8 ‘‘(i) Outcome measures, including pa9 tient reported outcome and functional sta10 tus measures. 

11 ‘‘(ii) Patient experience measures. 

12 ‘‘(iii) Care coordination measures. 

13 ‘‘(iv) Measures of appropriate use of 

14 services, including measures of over use. 

15 ‘‘(E) STAKEHOLDER INPUT.—The Sec16 retary shall accept through March 1, 2016, 

17 comments on the draft plan posted under para18 graph (1)(A) from the public, including health 

19 care providers, payers, consumers, and other 

20 stakeholders. 

21 ‘‘(F) FINAL MEASURE DEVELOPMENT

22 PLAN.—Not later than May 1, 2016, taking 

23 into account the comments received under this 

24 subparagraph, the Secretary shall finalize the 

25 plan and post on the Internet website of the 


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1 Centers for Medicare & Medicaid Services an 

2 operational plan for the development of quality 

3 measures for use under the applicable provi4 sions. Such plan shall be updated as appro5 priate. 

6 ‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS

7 FOR QUALITY MEASURE DEVELOPMENT.— 

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

9 enter into contracts or other arrangements with 

10 entities for the purpose of developing, improv11 ing, updating, or expanding in accordance with 

12 the plan under paragraph (1) quality measures 

13 for application under the applicable provisions. 

14 Such entities shall include organizations with 

15 quality measure development expertise. 

16 ‘‘(B) PRIORITIZATION.— 

17 ‘‘(i) IN GENERAL.—In entering into 

18 contracts or other arrangements under 

19 subparagraph (A), the Secretary shall give 

20 priority to the development of the types of 

21 measures described in paragraph (1)(D). 

22 ‘‘(ii) CONSIDERATION.—In selecting 

23 measures for development under this sub24 section, the Secretary shall consider— 


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1 ‘‘(I) whether such measures 

2 would be electronically specified; and 

3 ‘‘(II) clinical practice guidelines 

4 to the extent that such guidelines 

5 exist. 

6 ‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 

7 ‘‘(A) IN GENERAL.—Not later than May 1, 

8 2017, and annually thereafter, the Secretary 

9 shall post on the Internet website of the Cen10 ters for Medicare & Medicaid Services a report 

11 on the progress made in developing quality 

12 measures for application under the applicable 

13 provisions. 

14 ‘‘(B) REQUIREMENTS.—Each report sub15 mitted pursuant to subparagraph (A) shall in16 clude the following: 

17 ‘‘(i) A description of the Secretary’s 

18 efforts to implement this paragraph. 

19 ‘‘(ii) With respect to the measures de20 veloped during the previous year— 

21 ‘‘(I) a description of the total 

22 number of quality measures developed 

23 and the types of such measures, such 

24 as an outcome or patient experience 

25 measure; 


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1 ‘‘(II) the name of each measure 

2 developed; 

3 ‘‘(III) the name of the developer 

4 and steward of each measure; 

5 ‘‘(IV) with respect to each type 

6 of measure, an estimate of the total 

7 amount expended under this title to 

8 develop all measures of such type; and 

9 ‘‘(V) whether the measure would 

10 be electronically specified. 

11 ‘‘(iii) With respect to measures in de12 velopment at the time of the report— 

13 ‘‘(I) the information described in 

14 clause (ii), if available; and 

15 ‘‘(II) a timeline for completion of 

16 the development of such measures. 

17 ‘‘(iv) A description of any updates to 

18 the plan under paragraph (1) (including 

19 newly identified gaps and the status of pre20 viously identified gaps) and the inventory 

21 of measures applicable under the applicable 

22 provisions. 

23 ‘‘(v) Other information the Secretary 

24 determines to be appropriate. 


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1 ‘‘(4) STAKEHOLDER INPUT.—With respect to 

2 paragraph (1), the Secretary shall seek stakeholder 

3 input with respect to— 

4 ‘‘(A) the identification of gaps where no 

5 quality measures exist, particularly with respect 

6 to the types of measures described in paragraph 

7 (1)(D); 

8 ‘‘(B) prioritizing quality measure develop9 ment to address such gaps; and 

10 ‘‘(C) other areas related to quality measure 

11 development determined appropriate by the Sec12 retary. 

13 ‘‘(5) DEFINITION OF APPLICABLE PROVI14 SIONS.—In this subsection, the term ‘applicable pro15 visions’ means the following provisions: 

16 ‘‘(A) Subsection (q)(2)(B)(i). 

17 ‘‘(B) Section 1833(z)(2)(C). 

18 ‘‘(6) FUNDING.—For purposes of carrying out 

19 this subsection, the Secretary shall provide for the 

20 transfer, from the Federal Supplementary Medical 

21 Insurance Trust Fund under section 1841, of 

22 $15,000,000 to the Centers for Medicare & Medicaid 

23 Services Program Management Account for each of 

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1 ferred under this paragraph shall remain available 

2 through the end of fiscal year 2022. 

3 ‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 

4 United States Code, shall not apply to the collection 

5 of information for the development of quality meas6 ures.’’. 

7 SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVID8 UALS WITH CHRONIC CARE NEEDS. 

9 (a) IN GENERAL.—Section 1848(b) of the Social Se10 curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 

11 at the end the following new paragraph: 

12 ‘‘(8) ENCOURAGING CARE MANAGEMENT FOR

13 INDIVIDUALS WITH CHRONIC CARE NEEDS.— 

14 ‘‘(A) IN GENERAL.—In order to encourage 

15 the management of care for individuals with 

16 chronic care needs the Secretary shall, subject 

17 to subparagraph (B), make payment (as the 

18 Secretary determines to be appropriate) under 

19 this section for chronic care management serv20 ices furnished on or after January 1, 2015, by 

21 a physician (as defined in section 1861(r)(1)), 

22 physician assistant or nurse practitioner (as de23 fined in section 1861(aa)(5)(A)), clinical nurse 

24 specialist (as defined in section 


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1 1861(aa)(5)(B)), or certified nurse midwife (as 

2 defined in section 1861(gg)(2)). 

3 ‘‘(B) POLICIES RELATING TO PAYMENT.— 

4 In carrying out this paragraph, with respect to 

5 chronic care management services, the Sec6 retary shall— 

7 ‘‘(i) make payment to only one appli8 cable provider for such services furnished 

9 to an individual during a period; 

10 ‘‘(ii) not make payment under sub11 paragraph (A) if such payment would be 

12 duplicative of payment that is otherwise 

13 made under this title for such services; and 

14 ‘‘(iii) not require that an annual 

15 wellness visit (as defined in section 

16 1861(hhh)) or an initial preventive phys17 ical examination (as defined in section 

18 1861(ww)) be furnished as a condition of 

19 payment for such management services.’’. 

20 (b) EDUCATION AND OUTREACH.— 

21 (1) CAMPAIGN.— 

22 (A) IN GENERAL.—The Secretary of 

23 Health and Human Services (in this subsection 

24 referred to as the ‘‘Secretary’’) shall conduct an 

25 education and outreach campaign to inform 


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1 professionals who furnish items and services 

2 under part B of title XVIII of the Social Secu3 rity Act and individuals enrolled under such 

4 part of the benefits of chronic care management 

5 services described in section 1848(b)(8) of the 

6 Social Security Act, as added by subsection (a), 

7 and encourage such individuals with chronic 

8 care needs to receive such services. 

9 (B) REQUIREMENTS.—Such campaign 

10 shall— 

11 (i) be directed by the Office of Rural 

12 Health Policy of the Department of Health 

13 and Human Services and the Office of Mi14 nority Health of the Centers for Medicare 

15 & Medicaid Services; and 

16 (ii) focus on encouraging participation 

17 by underserved rural populations and ra18 cial and ethnic minority populations. 

19 (2) REPORT.—Not later than December 31, 

20 2017, the Secretary shall submit to Congress a re21 port on the use of chronic care management services 

22 described in such section 1848(b)(8) by individuals 

23 living in rural areas and by racial and ethnic minor24 ity populations. Such report shall— 


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1 (A) identify barriers to receiving chronic 

2 care management services; and 

3 (B) make recommendations for increasing 

4 the appropriate use of chronic care manage5 ment services. 

6 SEC. 5. EMPOWERING BENEFICIARY CHOICES THROUGH 

7 CONTINUED ACCESS TO INFORMATION ON 

8 PHYSICIANS’ SERVICES. 

9 (a) IN GENERAL.—On an annual basis (beginning 

10 with 2015), the Secretary shall make publicly available, 

11 in an easily understandable format, information with re12 spect to physicians and, as appropriate, other eligible pro13 fessionals on items and services furnished to Medicare 

14 beneficiaries under title XVIII of the Social Security Act 

15 (42 U.S.C. 1395 et seq.). 

16 (b) TYPE AND MANNER OF INFORMATION.—The in17 formation made available under this section shall be simi18 lar to the type of information in the Medicare Provider 

19 Utilization and Payment Data: Physician and Other Sup20 plier Public Use File released by the Secretary with re21 spect to 2012 and shall be made available in a manner 

22 similar to the manner in which the information in such 

23 File is made available. 


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1 (c) REQUIREMENTS.—The information made avail2 able under this section shall include, at a minimum, the 

3 following: 

4 (1) Information on the number of services fur5 nished by the physician or other eligible professional 

6 under part B of title XVIII of the Social Security 

7 Act (42 U.S.C. 1395j et seq.), which may include in8 formation on the most frequent services furnished or 

9 groupings of services. 

10 (2) Information on submitted charges and pay11 ments for services under such part. 

12 (3) A unique identifier for the physician or 

13 other eligible professional that is available to the 

14 public, such as a national provider identifier. 

15 (d) SEARCHABILITY.—The information made avail16 able under this section shall be searchable by at least the 

17 following: 

18 (1) The specialty or type of the physician or 

19 other eligible professional. 

20 (2) Characteristics of the services furnished, 

21 such as volume or groupings of services. 

22 (3) The location of the physician or other eligi23 ble professional. 

24 (e) INTEGRATION ON PHYSICIAN COMPARE.—Begin25 ning with 2016, the Secretary shall integrate the informaVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00129 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 tion made available under this section on Physician Com2 pare. 

3 (f) DEFINITIONS.—In this section: 

4 (1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC5 RETARY.—The terms ‘‘eligible professional’’, ‘‘physi6 cian’’, and ‘‘Secretary’’ have the meaning given such 

7 terms in section 10331(i) of Public Law 111–148. 

8 (2) PHYSICIAN COMPARE.—The term ‘‘Physi9 cian Compare’’ means the Physician Compare Inter10 net website of the Centers for Medicare & Medicaid 

11 Services (or a successor website). 

12 SEC. 6. EXPANDING AVAILABILITY OF MEDICARE DATA. 

13 (a) EXPANDING USES OF MEDICARE DATA BY

14 QUALIFIED ENTITIES.— 

15 (1) ADDITIONAL ANALYSES.— 

16 (A) IN GENERAL.—Subject to subpara17 graph (B), to the extent consistent with appli18 cable information, privacy, security, and disclo19 sure laws (including paragraph (3)), notwith20 standing paragraph (4)(B) of section 1874(e) of 

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

22 and the second sentence of paragraph (4)(D) of 

23 such section, beginning July 1, 2016, a quali24 fied entity may use the combined data described 

25 in paragraph (4)(B)(iii) of such section received 


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1 by such entity under such section, and informa2 tion derived from the evaluation described in 

3 such paragraph (4)(D), to conduct additional 

4 non-public analyses (as determined appropriate 

5 by the Secretary) and provide or sell such anal6 yses to authorized users for non-public use (in7 cluding for the purposes of assisting providers 

8 of services and suppliers to develop and partici9 pate in quality and patient care improvement 

10 activities, including developing new models of 

11 care). 

12 (B) LIMITATIONS WITH RESPECT TO ANAL13 YSES.— 

14 (i) EMPLOYERS.—Any analyses pro15 vided or sold under subparagraph (A) to 

16 an employer described in paragraph 

17 (9)(A)(iii) may only be used by such em18 ployer for purposes of providing health in19 surance to employees and retirees of the 

20 employer. 

21 (ii) HEALTH INSURANCE ISSUERS.—A 

22 qualified entity may not provide or sell an 

23 analysis to a health insurance issuer de24 scribed in paragraph (9)(A)(iv) unless the 

25 issuer is providing the qualified entity with 


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1 data under section 1874(e)(4)(B)(iii) of 

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

3 1395kk(e)(4)(B)(iii)). 

4 (2) ACCESS TO CERTAIN DATA.— 

5 (A) ACCESS.—To the extent consistent 

6 with applicable information, privacy, security, 

7 and disclosure laws (including paragraph (3)), 

8 notwithstanding paragraph (4)(B) of section 

9 1874(e) of the Social Security Act (42 U.S.C. 

10 1395kk(e)) and the second sentence of para11 graph (4)(D) of such section, beginning July 1, 

12 2016, a qualified entity may— 

13 (i) provide or sell the combined data 

14 described in paragraph (4)(B)(iii) of such 

15 section to authorized users described in 

16 clauses (i), (ii), and (v) of paragraph 

17 (9)(A) for non-public use, including for the 

18 purposes described in subparagraph (B); 

19 or 

20 (ii) subject to subparagraph (C), pro21 vide Medicare claims data to authorized 

22 users described in clauses (i), (ii), and (v), 

23 of paragraph (9)(A) for non-public use, in24 cluding for the purposes described in sub25 paragraph (B). 


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1 (B) PURPOSES DESCRIBED.—The purposes 

2 described in this subparagraph are assisting 

3 providers of services and suppliers in developing 

4 and participating in quality and patient care 

5 improvement activities, including developing 

6 new models of care. 

7 (C) MEDICARE CLAIMS DATA MUST BE

8 PROVIDED AT NO COST.—A qualified entity may 

9 not charge a fee for providing the data under 

10 subparagraph (A)(ii). 

11 (3) PROTECTION OF INFORMATION.— 

12 (A) IN GENERAL.—Except as provided in 

13 subparagraph (B), an analysis or data that is 

14 provided or sold under paragraph (1) or (2) 

15 shall not contain information that individually 

16 identifies a patient. 

17 (B) INFORMATION ON PATIENTS OF THE

18 PROVIDER OF SERVICES OR SUPPLIER.—To the 

19 extent consistent with applicable information, 

20 privacy, security, and disclosure laws, an anal21 ysis or data that is provided or sold to a pro22 vider of services or supplier under paragraph 

23 (1) or (2) may contain information that individ24 ually identifies a patient of such provider or 

25 supplier, including with respect to items and 


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1 services furnished to the patient by other pro2 viders of services or suppliers. 

3 (C) PROHIBITION ON USING ANALYSES OR

4 DATA FOR MARKETING PURPOSES.—An author5 ized user shall not use an analysis or data pro6 vided or sold under paragraph (1) or (2) for 

7 marketing purposes. 

8 (4) DATA USE AGREEMENT.—A qualified entity 

9 and an authorized user described in clauses (i), (ii), 

10 and (v) of paragraph (9)(A) shall enter into an 

11 agreement regarding the use of any data that the 

12 qualified entity is providing or selling to the author13 ized user under paragraph (2). Such agreement shall 

14 describe the requirements for privacy and security of 

15 the data and, as determined appropriate by the Sec16 retary, any prohibitions on using such data to link 

17 to other individually identifiable sources of informa18 tion. If the authorized user is not a covered entity 

19 under the rules promulgated pursuant to the Health 

20 Insurance Portability and Accountability Act of 

21 1996, the agreement shall identify the relevant regu22 lations, as determined by the Secretary, that the 

23 user shall comply with as if it were acting in the ca24 pacity of such a covered entity. 


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1 (5) NO REDISCLOSURE OF ANALYSES OR

2 DATA.— 

3 (A) IN GENERAL.—Except as provided in 

4 subparagraph (B), an authorized user that is 

5 provided or sold an analysis or data under 

6 paragraph (1) or (2) shall not redisclose or 

7 make public such analysis or data or any anal8 ysis using such data. 

9 (B) PERMITTED REDISCLOSURE.—A pro10 vider of services or supplier that is provided or 

11 sold an analysis or data under paragraph (1) or 

12 (2) may, as determined by the Secretary, redis13 close such analysis or data for the purposes of 

14 performance improvement and care coordination 

15 activities but shall not make public such anal16 ysis or data or any analysis using such data. 

17 (6) OPPORTUNITY FOR PROVIDERS OF SERV18 ICES AND SUPPLIERS TO REVIEW.—Prior to a quali19 fied entity providing or selling an analysis to an au20 thorized user under paragraph (1), to the extent 

21 that such analysis would individually identify a pro22 vider of services or supplier who is not being pro23 vided or sold such analysis, such qualified entity 

24 shall provide such provider or supplier with the op25 portunity to appeal and correct errors in the manner 


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1 described in section 1874(e)(4)(C)(ii) of the Social 

2 Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 

3 (7) ASSESSMENT FOR A BREACH.— 

4 (A) IN GENERAL.—In the case of a breach 

5 of a data use agreement under this section or 

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

7 U.S.C. 1395kk(e)), the Secretary shall impose 

8 an assessment on the qualified entity both in 

9 the case of— 

10 (i) an agreement between the Sec11 retary and a qualified entity; and 

12 (ii) an agreement between a qualified 

13 entity and an authorized user. 

14 (B) ASSESSMENT.—The assessment under 

15 subparagraph (A) shall be an amount up to 

16 $100 for each individual entitled to, or enrolled 

17 for, benefits under part A of title XVIII of the 

18 Social Security Act or enrolled for benefits 

19 under part B of such title— 

20 (i) in the case of an agreement de21 scribed in subparagraph (A)(i), for whom 

22 the Secretary provided data on to the 

23 qualified entity under paragraph (2); and 

24 (ii) in the case of an agreement de25 scribed in subparagraph (A)(ii), for whom 


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1 the qualified entity provided data on to the 

2 authorized user under paragraph (2). 

3 (C) DEPOSIT OF AMOUNTS COLLECTED.— 

4 Any amounts collected pursuant to this para5 graph shall be deposited in Federal Supple6 mentary Medical Insurance Trust Fund under 

7 section 1841 of the Social Security Act (42 

8 U.S.C. 1395t). 

9 (8) ANNUAL REPORTS.—Any qualified entity 

10 that provides or sells an analysis or data under 

11 paragraph (1) or (2) shall annually submit to the 

12 Secretary a report that includes— 

13 (A) a summary of the analyses provided or 

14 sold, including the number of such analyses, the 

15 number of purchasers of such analyses, and the 

16 total amount of fees received for such analyses; 

17 (B) a description of the topics and pur18 poses of such analyses; 

19 (C) information on the entities who re20 ceived the data under paragraph (2), the uses 

21 of the data, and the total amount of fees re22 ceived for providing, selling, or sharing the 

23 data; and 

24 (D) other information determined appro25 priate by the Secretary. 


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1 (9) DEFINITIONS.—In this subsection and sub2 section (b): 

3 (A) AUTHORIZED USER.—The term ‘‘au4 thorized user’’ means the following: 

5 (i) A provider of services. 

6 (ii) A supplier. 

7 (iii) An employer (as defined in sec8 tion 3(5) of the Employee Retirement In9 surance Security Act of 1974). 

10 (iv) A health insurance issuer (as de11 fined in section 2791 of the Public Health 

12 Service Act). 

13 (v) A medical society or hospital asso14 ciation. 

15 (vi) Any entity not described in 

16 clauses (i) through (v) that is approved by 

17 the Secretary (other than an employer or 

18 health insurance issuer not described in 

19 clauses (iii) and (iv), respectively, as deter20 mined by the Secretary). 

21 (B) PROVIDER OF SERVICES.—The term 

22 ‘‘provider of services’’ has the meaning given 

23 such term in section 1861(u) of the Social Se24 curity Act (42 U.S.C. 1395x(u)). 


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1 (C) QUALIFIED ENTITY.—The term ‘‘quali2 fied entity’’ has the meaning given such term in 

3 section 1874(e)(2) of the Social Security Act 

4 (42 U.S.C. 1395kk(e)). 

5 (D) SECRETARY.—The term ‘‘Secretary’’ 

6 means the Secretary of Health and Human 

7 Services. 

8 (E) SUPPLIER.—The term ‘‘supplier’’ has 

9 the meaning given such term in section 1861(d) 

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

11 1395x(d)). 

12 (b) ACCESS TO MEDICARE DATA BY QUALIFIED

13 CLINICAL DATA REGISTRIES TO FACILITATE QUALITY

14 IMPROVEMENT.— 

15 (1) ACCESS.— 

16 (A) IN GENERAL.—To the extent con17 sistent with applicable information, privacy, se18 curity, and disclosure laws, beginning July 1, 

19 2016, the Secretary shall, at the request of a 

20 qualified clinical data registry under section 

21 1848(m)(3)(E) of the Social Security Act (42 

22 U.S.C. 1395w–4(m)(3)(E)), provide the data 

23 described in subparagraph (B) (in a form and 

24 manner determined to be appropriate) to such 

25 qualified clinical data registry for purposes of 


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1 linking such data with clinical outcomes data 

2 and performing risk-adjusted, scientifically valid 

3 analyses and research to support quality im4 provement or patient safety, provided that any 

5 public reporting of such analyses or research 

6 that identifies a provider of services or supplier 

7 shall only be conducted with the opportunity of 

8 such provider or supplier to appeal and correct 

9 errors in the manner described in subsection 

10 (a)(6). 

11 (B) DATA DESCRIBED.—The data de12 scribed in this subparagraph is— 

13 (i) claims data under the Medicare 

14 program under title XVIII of the Social 

15 Security Act; and 

16 (ii) if the Secretary determines appro17 priate, claims data under the Medicaid 

18 program under title XIX of such Act and 

19 the State Children’s Health Insurance Pro20 gram under title XXI of such Act. 

21 (2) FEE.—Data described in paragraph (1)(B) 

22 shall be provided to a qualified clinical data registry 

23 under paragraph (1) at a fee equal to the cost of 

24 providing such data. Any fee collected pursuant to 

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1 ters for Medicare & Medicaid Services Program 

2 Management Account. 

3 (c) EXPANSION OF DATA AVAILABLE TO QUALIFIED

4 ENTITIES.—Section 1874(e) of the Social Security Act 

5 (42 U.S.C. 1395kk(e)) is amended— 

6 (1) in the subsection heading, by striking 

7 ‘‘MEDICARE’’; and 

8 (2) in paragraph (3)— 

9 (A) by inserting after the first sentence the 

10 following new sentence: ‘‘Beginning July 1, 

11 2016, if the Secretary determines appropriate, 

12 the data described in this paragraph may also 

13 include standardized extracts (as determined by 

14 the Secretary) of claims data under titles XIX 

15 and XXI for assistance provided under such ti16 tles for one or more specified geographic areas 

17 and time periods requested by a qualified enti18 ty.’’; and 

19 (B) in the last sentence, by inserting ‘‘or 

20 under titles XIX or XXI’’ before the period at 

21 the end. 

22 (d) REVISION OF PLACEMENT OF FEES.—Section 

23 1874(e)(4)(A) of the Social Security Act (42 U.S.C. 

24 1395kk(e)(4)(A)) is amended, in the second sentence— 


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1 (1) by inserting ‘‘, for periods prior to July 1, 

2 2016,’’ after ‘‘deposited’’; and 

3 (2) by inserting the following before the period 

4 at the end: ‘‘, and, beginning July 1, 2016, into the 

5 Centers for Medicare & Medicaid Services Program 

6 Management Account’’. 

7 SEC. 7. REDUCING ADMINISTRATIVE BURDEN AND OTHER 

8 PROVISIONS. 

9 (a) MEDICARE PHYSICIAN AND PRACTITIONER OPT10 OUT TO PRIVATE CONTRACT.— 

11 (1) INDEFINITE, CONTINUING AUTOMATIC EX12 TENSION OF OPT OUT ELECTION.— 

13 (A) IN GENERAL.—Section 1802(b)(3) of 

14 the Social Security Act (42 U.S.C. 1395a(b)(3)) 

15 is amended— 

16 (i) in subparagraph (B)(ii), by strik17 ing ‘‘during the 2-year period beginning on 

18 the date the affidavit is signed’’ and insert19 ing ‘‘during the applicable 2-year period 

20 (as defined in subparagraph (D))’’; 

21 (ii) in subparagraph (C), by striking 

22 ‘‘during the 2-year period described in sub23 paragraph (B)(ii)’’ and inserting ‘‘during 

24 the applicable 2-year period’’; and 


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1 (iii) by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(D) APPLICABLE 2-YEAR PERIODS FOR

4 EFFECTIVENESS OF AFFIDAVITS.—In this sub5 section, the term ‘applicable 2-year period’ 

6 means, with respect to an affidavit of a physi7 cian or practitioner under subparagraph (B), 

8 the 2-year period beginning on the date the af9 fidavit is signed and includes each subsequent 

10 2-year period unless the physician or practi11 tioner involved provides notice to the Secretary 

12 (in a form and manner specified by the Sec13 retary), not later than 30 days before the end 

14 of the previous 2-year period, that the physician 

15 or practitioner does not want to extend the ap16 plication of the affidavit for such subsequent 2- 

17 year period.’’. 

18 (B) EFFECTIVE DATE.—The amendments 

19 made by subparagraph (A) shall apply to affi20 davits entered into on or after the date that is 

21 60 days after the date of the enactment of this 

22 Act. 

23 (2) PUBLIC AVAILABILITY OF INFORMATION ON

24 OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 


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1 1802(b) of the Social Security Act (42 U.S.C. 

2 1395a(b)) is amended— 

3 (A) in paragraph (5), by adding at the end 

4 the following new subparagraph: 

5 ‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 

6 The term ‘opt-out physician or practitioner’ means 

7 a physician or practitioner who has in effect an affi8 davit under paragraph (3)(B).’’; 

9 (B) by redesignating paragraph (5) as 

10 paragraph (6); and 

11 (C) by inserting after paragraph (4) the 

12 following new paragraph: 

13 ‘‘(5) POSTING OF INFORMATION ON OPT-OUT

14 PHYSICIANS AND PRACTITIONERS.— 

15 ‘‘(A) IN GENERAL.—Beginning not later 

16 than February 1, 2016, the Secretary shall 

17 make publicly available through an appropriate 

18 publicly accessible website of the Department of 

19 Health and Human Services information on the 

20 number and characteristics of opt-out physi21 cians and practitioners and shall update such 

22 information on such website not less often than 

23 annually. 

24 ‘‘(B) INFORMATION TO BE INCLUDED.— 

25 The information to be made available under 


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1 subparagraph (A) shall include at least the fol2 lowing with respect to opt-out physicians and 

3 practitioners: 

4 ‘‘(i) Their number. 

5 ‘‘(ii) Their physician or professional 

6 specialty or other designation. 

7 ‘‘(iii) Their geographic distribution. 

8 ‘‘(iv) The timing of their becoming 

9 opt-out physicians and practitioners, rel10 ative, to the extent feasible, to when they 

11 first enrolled in the program under this 

12 title and with respect to applicable 2-year 

13 periods. 

14 ‘‘(v) The proportion of such physi15 cians and practitioners who billed for 

16 emergency or urgent care services.’’. 

17 (b) GAINSHARING STUDY AND REPORT.—Not later 

18 than 6 months after the date of the enactment of this Act, 

19 the Secretary of Health and Human Services, in consulta20 tion with the Inspector General of the Department of 

21 Health and Human Services, shall submit to Congress a 

22 report with legislative recommendations to amend existing 

23 fraud and abuse laws, through exceptions, safe harbors, 

24 or other narrowly targeted provisions, to permit 

25 gainsharing or similar arrangements between physicians 


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1 and hospitals that improve care while reducing waste and 

2 increasing efficiency. The report shall— 

3 (1) consider whether such provisions should 

4 apply to ownership interests, compensation arrange5 ments, or other relationships; 

6 (2) describe how the recommendations address 

7 accountability, transparency, and quality, including 

8 how best to limit inducements to stint on care, dis9 charge patients prematurely, or otherwise reduce or 

10 limit medically necessary care; and 

11 (3) consider whether a portion of any savings 

12 generated by such arrangements should accrue to 

13 the Medicare program under title XVIII of the So14 cial Security Act. 

15 (c) PROMOTING INTEROPERABILITY OF ELECTRONIC

16 HEALTH RECORD SYSTEMS.— 

17 (1) RECOMMENDATIONS FOR ACHIEVING WIDE18 SPREAD EHR INTEROPERABILITY.— 

19 (A) OBJECTIVE.—As a consequence of a 

20 significant Federal investment in the implemen21 tation of health information technology through 

22 the Medicare and Medicaid EHR incentive pro23 grams, Congress declares it a national objective 

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1 mation through interoperable certified EHR 

2 technology nationwide by December 31, 2018. 

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, 2016, 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, 2018, then the Sec8 retary shall submit to Congress a report, by not 

9 later than December 31, 2019, 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 USE 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 action (such as to dis5 able functionality) to limit or restrict the com6 patibility or interoperability of the certified 

7 EHR technology’’. 

8 (B) FOR MEANINGFUL USE EHR HOS9 PITALS.—Section 1886(n)(3)(A)(ii) of the So10 cial Security Act (42 U.S.C. 

11 1395ww(n)(3)(A)(ii)) is amended by inserting 

12 before the period at the end the following: ‘‘, 

13 and the hospital demonstrates (through a proc14 ess specified by the Secretary, such as the use 

15 of an attestation) that the hospital has not 

16 knowingly and willfully taken action (such as to 

17 disable functionality) to limit or restrict the 

18 compatibility or interoperability of the certified 

19 EHR technology’’. 

20 (C) EFFECTIVE DATE.—The amendments 

21 made by this subsection shall apply to meaning22 ful EHR users as of the date that is one year 

23 after the date of the enactment of this Act. 


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1 (3) STUDY AND REPORT ON THE FEASIBILITY

2 OF ESTABLISHING A MECHANISM TO COMPARE CER3 TIFIED EHR TECHNOLOGY PRODUCTS.— 

4 (A) STUDY.—The Secretary shall conduct 

5 a study to examine the feasibility of estab6 lishing one or more mechanisms to assist pro7 viders in comparing and selecting certified 

8 EHR technology products. Such mechanisms 

9 may include— 

10 (i) a website with aggregated results 

11 of surveys of meaningful EHR users on 

12 the functionality of certified EHR tech13 nology products to enable such users to di14 rectly compare the functionality and other 

15 features of such products; and 

16 (ii) information from vendors of cer17 tified products that is made publicly avail18 able in a standardized format. 

19 The aggregated results of the surveys described 

20 in clause (i) may be made available through 

21 contracts with physicians, hospitals, or other or22 ganizations that maintain such comparative in23 formation described in such clause. 

24 (B) REPORT.—Not later than 1 year after 

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1 retary shall submit to Congress a report on 

2 mechanisms that would assist providers in com3 paring and selecting certified EHR technology 

4 products. The report shall include information 

5 on the benefits of, and resources needed to de6 velop and maintain, such mechanisms. 

7 (4) DEFINITIONS.—In this subsection: 

8 (A) The term ‘‘certified EHR technology’’ 

9 has the meaning given such term in section 

10 1848(o)(4) of the Social Security Act (42 

11 U.S.C. 1395w–4(o)(4)). 

12 (B) The term ‘‘meaningful EHR user’’ has 

13 the meaning given such term under the Medi14 care EHR incentive programs. 

15 (C) The term ‘‘Medicare and Medicaid 

16 EHR incentive programs’’ means— 

17 (i) in the case of the Medicare pro18 gram under title XVIII of the Social Secu19 rity Act, the incentive programs under sec20 tion 1814(l)(3), section 1848(o), sub21 sections (l) and (m) of section 1853, and 

22 section 1886(n) of the Social Security Act 

23 (42 U.S.C. 1395f(l)(3), 1395w–4(o), 

24 1395w–23, 1395ww(n)); and 


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1 (ii) in the case of the Medicaid pro2 gram under title XIX of such Act, the in3 centive program under subsections 

4 (a)(3)(F) and (t) of section 1903 of such 

5 Act (42 U.S.C. 1396b). 

6 (D) The term ‘‘Secretary’’ means the Sec7 retary of Health and Human Services. 

8 (d) GAO STUDIES AND REPORTS ON THE USE OF

9 TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE10 MOTE PATIENT MONITORING SERVICES.— 

11 (1) STUDY ON TELEHEALTH SERVICES.—The 

12 Comptroller General of the United States shall con13 duct a study on the following: 

14 (A) How the definition of telehealth across 

15 various Federal programs and Federal efforts 

16 can inform the use of telehealth in the Medicare 

17 program under title XVIII of the Social Secu18 rity Act (42 U.S.C. 1395 et seq.). 

19 (B) Issues that can facilitate or inhibit the 

20 use of telehealth under the Medicare program 

21 under such title, including oversight and profes22 sional licensure, changing technology, privacy 

23 and security, infrastructure requirements, and 

24 varying needs across urban and rural areas. 


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1 (C) Potential implications of greater use of 

2 telehealth with respect to payment and delivery 

3 system transformations under the Medicare 

4 program under such title XVIII and the Med5 icaid program under title XIX of such Act (42 

6 U.S.C. 1396 et seq.). 

7 (D) How the Centers for Medicare & Med8 icaid Services monitors payments made under 

9 the Medicare program under such title XVIII to 

10 providers for telehealth services. 

11 (2) STUDY ON REMOTE PATIENT MONITORING

12 SERVICES.— 

13 (A) IN GENERAL.—The Comptroller Gen14 eral of the United States shall conduct a 

15 study— 

16 (i) of the dissemination of remote pa17 tient monitoring technology in the private 

18 health insurance market; 

19 (ii) of the financial incentives in the 

20 private health insurance market relating to 

21 adoption of such technology; 

22 (iii) of the barriers to adoption of 

23 such services under the Medicare program 

24 under title XVIII of the Social Security 

25 Act; 


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1 (iv) that evaluates the patients, condi2 tions, and clinical circumstances that could 

3 most benefit from remote patient moni4 toring services; and 

5 (v) that evaluates the challenges re6 lated to establishing appropriate valuation 

7 for remote patient monitoring services 

8 under the Medicare physician fee schedule 

9 under section 1848 of the Social Security 

10 Act (42 U.S.C. 1395w–4) in order to accu11 rately reflect the resources involved in fur12 nishing such services. 

13 (B) DEFINITIONS.—For purposes of this 

14 paragraph: 

15 (i) REMOTE PATIENT MONITORING

16 SERVICES.—The term ‘‘remote patient 

17 monitoring services’’ means services fur18 nished through remote patient monitoring 

19 technology. 

20 (ii) REMOTE PATIENT MONITORING

21 TECHNOLOGY.—The term ‘‘remote patient 

22 monitoring technology’’ means a coordi23 nated system that uses one or more home24 based or mobile monitoring devices that 

25 automatically transmit vital sign data or 


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1 information on activities of daily living and 

2 may include responses to assessment ques3 tions collected on the devices wirelessly or 

4 through a telecommunications connection 

5 to a server that complies with the Federal 

6 regulations (concerning the privacy of indi7 vidually identifiable health information) 

8 promulgated under section 264(c) of the 

9 Health Insurance Portability and Account10 ability Act of 1996, as part of an estab11 lished plan of care for that patient that in12 cludes the review and interpretation of that 

13 data by a health care professional. 

14 (3) REPORTS.—Not later than 24 months after 

15 the date of the enactment of this Act, the Comp16 troller General shall submit to Congress— 

17 (A) a report containing the results of the 

18 study conducted under paragraph (1); and 

19 (B) a report containing the results of the 

20 study conducted under paragraph (2). 

21 A report required under this paragraph shall be sub22 mitted together with recommendations for such leg23 islation and administrative action as the Comptroller 

24 General determines appropriate. The Comptroller 

25 General may submit one report containing the reVerDate Sep 11 2014 00:25 Mar 20, 2015 Jkt 049200 PO 00000 Frm 00155 Fmt 6652 Sfmt 6201 E:\BILLS\S810.IS S810

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1 sults described in subparagraphs (A) and (B) and 

2 the recommendations described in the previous sen3 tence. 

4 (e) RULE OF CONSTRUCTION REGARDING HEALTH

5 CARE PROVIDERS.— 

6 (1) IN GENERAL.—Subject to paragraph (3), 

7 the development, recognition, or implementation of 

8 any guideline or other standard under any Federal 

9 health care provision shall not be construed to estab10 lish the standard of care or duty of care owed by a 

11 health care provider to a patient in any medical mal12 practice or medical product liability action or claim. 

13 (2) DEFINITIONS.—For purposes of this sub14 section: 

15 (A) FEDERAL HEALTH CARE PROVISION.— 

16 The term ‘‘Federal health care provision’’ 

17 means any provision of the Patient Protection 

18 and Affordable Care Act (Public Law 111– 

19 148), title I or subtitle B of title II of the 

20 Health Care and Education Reconciliation Act 

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

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

23 1395 et seq., 42 U.S.C. 1396 et seq.). 

24 (B) HEALTH CARE PROVIDER.—The term 

25 ‘‘health care provider’’ means any individual, 


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1 group practice, corporation of health care pro2 fessionals, or hospital— 

3 (i) licensed, registered, or certified 

4 under Federal or State laws or regulations 

5 to provide health care services; or 

6 (ii) required to be so licensed, reg7 istered, or certified but that is exempted 

8 by other statute or regulation. 

9 (C) MEDICAL MALPRACTICE OR MEDICAL

10 PRODUCT LIABILITY ACTION OR CLAIM.—The 

11 term ‘‘medical malpractice or medical product 

12 liability action or claim’’ means a medical mal13 practice action or claim (as defined in section 

14 431(7) of the Health Care Quality Improve15 ment Act of 1986 (42 U.S.C. 11151(7))) and 

16 includes a liability action or claim relating to a 

17 health care provider’s prescription or provision 

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

19 terms are defined in section 201 of the Federal 

20 Food, Drug, and Cosmetic Act (21 U.S.C. 321) 

21 or section 351 of the Public Health Service Act 

22 (42 U.S.C. 262)). 

23 (D) STATE.—The term ‘‘State’’ includes 

24 the District of Columbia, Puerto Rico, and any 


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1 other commonwealth, possession, or territory of 

2 the United States. 

3 (3) NO PREEMPTION.—Nothing in paragraph 

4 (1) or any provision of the Patient Protection and 

5 Affordable Care Act (Public Law 111–148), title I 

6 or subtitle B of title II of the Health Care and Edu7 cation Reconciliation Act of 2010 (Public Law 111– 

8 152), or title XVIII or XIX of the Social Security 

9 Act (42 U.S.C. 1395 et seq., 42 U.S.C. 1396 et 

10 seq.) shall be construed to preempt any State or 

11 common law governing medical professional or med12 ical product liability actions or claims. 

Æ 


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