ties in conducting activities under this 
paragraph, including the development of 
performance benchmarks based on provider 
participation and progress toward integra-
tion. 
‘‘(iv) PRIORITY.—The grants and in-
centive payments under this subparagraph 
shall be directed to target assistance to 
solo and small specialty practices as well as 
community health centers and similar pro-
viders of primary care services.’’. 
(g) CONTINUING INCENTIVES FOR PROVIDING HIGH- 
QUALITY, HIGH-VALUE CARE.— 
(1) 
FEE
SCHEDULE
ADJUSTMENTS.—Sub-
section (d) of section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4), as amended by subsections 
(b), (c)(3), and (f), is amended by adding at the end 
the following: 
‘‘(18) UPDATES FOR 2020 THROUGH 2023.— 
‘‘(A) IN GENERAL.—Except as provided in 
this paragraph, the update to each of the con-
version factors— 
‘‘(i) for 2020 shall be minus 2 per-
cent; 
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‘‘(ii) for 2021 shall be minus 3 per-
cent; 
‘‘(iii) for 2022 shall be minus 4 per-
cent; and 
‘‘(iv) for 2023 shall be minus 5 per-
cent. 
‘‘(B) TREATMENT
OF
SERVICES
PAID 
USING ALTERNATIVE PAYMENT AND DELIVERY 
MODELS.—In the case of physicians’ services 
for which payment is covered under an alter-
native payment and delivery model, such as 
those implemented under section 1115A, sub-
paragraph (A) does not apply. 
‘‘(C) GENERAL
EXEMPTION.—The Sec-
retary shall, by regulation, exempt a provider 
from the application of the negative payment 
update specified in subparagraph (A) for a year 
if the Secretary determines that— 
‘‘(i) the provider— 
‘‘(I) is a meaningful EHR user 
(as 
determined 
under 
subsection 
(o)(2) with respect to the year); and 
‘‘(II) meets the qualifications 
under subparagraph (B) of subsection 
(m)(7) (relating to additional incen-
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tive payments) for an additional in-
centive payment under subparagraph 
(A) of such subsection (which includes 
satisfactory participation in the qual-
ity reporting system and participation 
in an approved Maintenance of Cer-
tification program); 
‘‘(ii) the payment modifier for the 
provider under subsection (p), which is 
based upon the performance of the pro-
vider on measures of quality of care fur-
nished compared to cost and which is ex-
pressed as a percentage of payment, is 
within the top 25 percent of such payment 
modifiers for providers within the same fee 
schedule area, as determined by the Sec-
retary; or 
‘‘(iii) in the case of outpatient therapy 
services, the provider of such services ad-
heres to a comprehensive list of cost, qual-
ity, and outcome measures as dem-
onstrated by— 
‘‘(I) participation in a certified 
registry; 
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‘‘(II) if applicable, participation 
in the physician quality reporting sys-
tem under subsection (k); 
‘‘(III) use of an approved patient 
assessment tool; 
‘‘(IV) current certification as a 
physical therapist clinical specialist by 
the American Physical Therapy Asso-
ciation (APTA), an occupational ther-
apist by the American Occupational 
Therapy Association, or as an audiol-
ogist or a speech-language pathologist 
by the American Speech-Language- 
Hearing Association; or 
‘‘(V) compliance with comparable 
functional measures reporting require-
ments as recognized by the Secretary. 
‘‘(D) CASE-BY-CASE
HARDSHIP
EXEMP-
TION.—The Secretary may, on a case-by-case 
basis, exempt a provider from the application of 
the negative payment update specified in sub-
paragraph (A) for a year if the Secretary deter-
mines, subject to annual renewal, that because 
of limitations in the nature of a medical prac-
tice, limitations in the number of Medicare 
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beneficiaries that may be served by the pro-
vider, or other special circumstances, imposing 
a financial disincentive under such subpara-
graph for failure to adopt an alternative pay-
ment and delivery model referred to in subpara-
graph (B) would result in a significant hardship 
to the provider. 
‘‘(19) UPDATES BEGINNING WITH 2024.— 
‘‘(A) IN GENERAL.—The update to both of 
the conversion factors for each year beginning 
with 2024 shall be 0 percent. 
‘‘(B) TREATMENT
OF
SERVICES
PAID 
USING ALTERNATIVE PAYMENT AND DELIVERY 
MODELS.—In the case of physicians’ services 
for which payment is covered under an alter-
native payment and delivery model, such as 
those implemented under section 1115A, sub-
paragraph (A) does not apply.’’. 
(2) 
CONSIDERATIONS
IN
PROMULGATING 
GROWTH RATES FOR ALTERNATIVE PAYMENT AND 
DELIVERY MODELS.— 
(A) IN
GENERAL.—In determining the 
growth rates to be recognized beginning with 
2020 for alternative payment and delivery mod-
els under the Medicare program that cover phy-
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sicians’ services, such as those implemented 
under section 1115A of the Social Security Act, 
the Secretary of Health and Human Services 
shall consider (among other factors) the fol-
lowing: 
(i) Ensuring access to primary care 
and specialty services, including participa-
tion of primary care practitioners and spe-
cialists and newly graduating practitioners. 
(ii) Restraining spending growth. 
(iii) Ensuring access to services for 
vulnerable populations. 
(B) LIMITATIONS.—In no case shall the 
growth factor determined under this paragraph 
for a year— 
(i) be less than 1 percent; or 
(ii) be greater than the percentage in-
crease in the MEI (as defined in section 
1842(i)(3) of the Social Security Act, 42 
U.S.C. 1395u(i)(3)) for such year. 
(C) APPLICATION OF CONGRESSIONAL RE-
VIEW ACT.—Chapter 8 of title 5, United States 
Code, applies with respect to the promulgation 
of a growth factor under this paragraph for a 
year. 
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(h) IMPACT REPORT.—Not later than January 1, 
2023, the Secretary of Health and Human Services shall 
submit to Congress a report on the impact on spending 
and on access to services under title XVIII of the Social 
Security Act, including under part A of such title, result-
ing from changes to Medicare delivery and payment sys-
tems, including under the amendments made by this sec-
tion. 
Æ 
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