I 
114TH CONGRESS 
1ST SESSION H. R. 1470 
To amend title XVIII of the Social Security Act to repeal the Medicare 
sustainable growth rate and improve Medicare payments for physicians 
and other professionals, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 19, 2015 
Mr. BURGESS (for himself, Mr. UPTON, Mr. LEVIN, Mr. RYAN of Wisconsin, 
Mr. PALLONE, Mr. PITTS, Mr. GENE GREEN of Texas, Mr. BRADY of 
Texas, Mr. MCDERMOTT, and Mr. BOUSTANY) introduced the following 
bill; which was referred to the Committee on Energy and Commerce, and 
in addition to the Committees on Ways and Means and the Judiciary, 
for a period to be subsequently determined by the Speaker, in each case 
for consideration of such provisions as fall within the jurisdiction of the 
committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to repeal 
the Medicare sustainable growth rate and improve Medi-
care payments for physicians and other professionals, 
and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘SGR Repeal and Medicare Provider Payment Moderniza-
tion Act of 2015’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Repealing the sustainable growth rate (SGR) and improving Medicare 
payment for physicians’ services. 
Sec. 3. Priorities and funding for measure development. 
Sec. 4. Encouraging care management for individuals with chronic care needs. 
Sec. 5. 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. 
SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE 
(SGR) AND IMPROVING MEDICARE PAYMENT 
FOR PHYSICIANS’ SERVICES. 
(a) STABILIZING FEE UPDATES.— 
(1) REPEAL
OF
SGR
PAYMENT
METHOD-
OLOGY.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4) is amended— 
(A) in subsection (d)— 
(i) in paragraph (1)(A)— 
(I) by inserting ‘‘and ending with 
2025’’ after ‘‘beginning with 2001’’; 
and 
(II) by inserting ‘‘or a subse-
quent paragraph’’ after ‘‘paragraph 
(4)’’; and 
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established in paragraph (1)(C) for the period begin-
ning on July 1, 2015, and ending on December 31, 
2015, shall be 0.5 percent. 
‘‘(18) UPDATE FOR 2016 THROUGH 2019.—The 
update to the single conversion factor established in 
paragraph (1)(C) for 2016 and each subsequent 
year through 2019 shall be 0.5 percent. 
‘‘(19) UPDATE FOR 2020 THROUGH 2025.—The 
update to the single conversion factor established in 
paragraph (1)(C) for 2020 and each subsequent 
year through 2025 shall be zero percent. 
‘‘(20) UPDATE
FOR
2026
AND
SUBSEQUENT 
YEARS.—For 2026 and each subsequent year, the 
update to the qualifying APM conversion factor es-
tablished under paragraph (1)(A) is 1.0 percent, and 
the update to the nonqualifying APM conversion fac-
tor established under such paragraph is 0.5 per-
cent.’’. 
(3) MEDPAC REPORTS.— 
(A) INITIAL REPORT.—Not later than July 
1, 2017, the Medicare Payment Advisory Com-
mission shall submit to Congress a report on 
the relationship between— 
(i) physician and other health profes-
sional utilization and expenditures (and the 
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rate of increase of such utilization and ex-
penditures) of items and services for which 
payment is made under section 1848 of the 
Social Security Act (42 U.S.C. 1395w–4); 
and 
(ii) total utilization and expenditures 
(and the rate of increase of such utilization 
and expenditures) under parts A, B, and D 
of title XVIII of such Act. 
Such report shall include a methodology to de-
scribe such relationship and the impact of 
changes in such physician and other health pro-
fessional practice and service ordering patterns 
on total utilization and expenditures under 
parts A, B, and D of such title. 
(B) FINAL REPORT.—Not later than July 
1, 2021, the Medicare Payment Advisory Com-
mission shall submit to Congress a report on 
the relationship described in subparagraph (A), 
including the results determined from applying 
the methodology included in the report sub-
mitted under such subparagraph. 
(C) REPORT ON UPDATE TO PHYSICIANS’ 
SERVICES UNDER MEDICARE.—Not later than 
July 1, 2019, the Medicare Payment Advisory 
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Commission shall submit to Congress a report 
on— 
(i) the payment update for profes-
sional services applied under the Medicare 
program under title XVIII of the Social 
Security Act for the period of years 2015 
through 2019; 
(ii) the effect of such update on the 
efficiency, economy, and quality of care 
provided under such program; 
(iii) the effect of such update on en-
suring a sufficient number of providers to 
maintain access to care by Medicare bene-
ficiaries; and 
(iv) recommendations for any future 
payment updates for professional services 
under such program to ensure adequate 
access to care is maintained for Medicare 
beneficiaries. 
(b) CONSOLIDATION
OF CERTAIN CURRENT LAW 
PERFORMANCE PROGRAMS WITH NEW MERIT-BASED IN-
CENTIVE PAYMENT SYSTEM.— 
(1) EHR MEANINGFUL USE INCENTIVE PRO-
GRAM.— 
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(A) SUNSETTING SEPARATE MEANINGFUL 
USE
PAYMENT
ADJUSTMENTS.—Section 
1848(a)(7)(A) of the Social Security Act (42 
U.S.C. 1395w–4(a)(7)(A)) is amended— 
(i) in clause (i), by striking ‘‘2015 or 
any subsequent payment year’’ and insert-
ing ‘‘each of 2015 through 2018’’; 
(ii) in clause (ii)(III), by striking 
‘‘each subsequent year’’ and inserting 
‘‘2018’’; and 
(iii) in clause (iii)— 
(I) in the heading, by striking 
‘‘AND SUBSEQUENT YEARS’’; 
(II) by striking ‘‘and each subse-
quent year’’; and 
(III) by striking ‘‘, but in no case 
shall the applicable percent be less 
than 95 percent’’. 
(B) CONTINUATION OF MEANINGFUL USE 
DETERMINATIONS
FOR
MIPS.—Section 
1848(o)(2) of the Social Security Act (42 
U.S.C. 1395w–4(o)(2)) is amended— 
(i) in subparagraph (A), in the matter 
preceding clause (i)— 
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(I) by striking ‘‘For purposes of 
paragraph (1), an’’ and inserting 
‘‘An’’; and 
(II) by inserting ‘‘, or pursuant 
to subparagraph (D) for purposes of 
subsection (q), for a performance pe-
riod under such subsection for a year’’ 
after ‘‘under such subsection for a 
year’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(D) CONTINUED APPLICATION FOR PUR-
POSES
OF
MIPS.—With respect to 2019 and 
each subsequent payment year, the Secretary 
shall, for purposes of subsection (q) and in ac-
cordance with paragraph (1)(F) of such sub-
section, determine whether an eligible profes-
sional who is a MIPS eligible professional (as 
defined in subsection (q)(1)(C)) for such year is 
a meaningful EHR user under this paragraph 
for the performance period under subsection (q) 
for such year.’’. 
(2) QUALITY REPORTING.— 
(A) SUNSETTING SEPARATE QUALITY RE-
PORTING
INCENTIVES.—Section 1848(a)(8)(A) 
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of the Social Security Act (42 U.S.C. 1395w– 
4(a)(8)(A)) is amended— 
(i) in clause (i), by striking ‘‘2015 or 
any subsequent year’’ and inserting ‘‘each 
of 2015 through 2018’’; and 
(ii) in clause (ii)(II), by striking ‘‘and 
each subsequent year’’ and inserting ‘‘, 
2017, and 2018’’. 
(B) CONTINUATION
OF
QUALITY
MEAS-
URES
AND
PROCESSES
FOR
MIPS.—Section 
1848 of the Social Security Act (42 U.S.C. 
1395w–4) is amended— 
(i) in subsection (k), by adding at the 
end the following new paragraph: 
‘‘(9) CONTINUED APPLICATION FOR PURPOSES 
OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN-
TEERING TO REPORT.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out the 
provisions of this subsection— 
‘‘(A) for purposes of subsection (q); and 
‘‘(B) for eligible professionals who are not 
MIPS eligible professionals (as defined in sub-
section (q)(1)(C)) for the year involved.’’; and 
(ii) in subsection (m)— 
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(I) by redesignating paragraph 
(7) added by section 10327(a) of Pub-
lic Law 111–148 as paragraph (8); 
and 
(II) by adding at the end the fol-
lowing new paragraph: 
‘‘(9) CONTINUED APPLICATION FOR PURPOSES 
OF MIPS AND FOR CERTAIN PROFESSIONALS VOLUN-
TEERING TO REPORT.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out the 
processes under this subsection— 
‘‘(A) for purposes of subsection (q); and 
‘‘(B) for eligible professionals who are not 
MIPS eligible professionals (as defined in sub-
section (q)(1)(C)) for the year involved.’’. 
(3) VALUE-BASED PAYMENTS.— 
(A) SUNSETTING SEPARATE VALUE-BASED 
PAYMENTS.—Clause 
(iii) 
of 
section 
1848(p)(4)(B) of the Social Security Act (42 
U.S.C. 1395w–4(p)(4)(B)) is amended to read 
as follows: 
‘‘(iii) APPLICATION.—The Secretary 
shall apply the payment modifier estab-
lished under this subsection for items and 
services furnished on or after January 1, 
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2015, with respect to specific physicians 
and groups of physicians the Secretary de-
termines appropriate, and for services fur-
nished on or after January 1, 2017, with 
respect to all physicians and groups of 
physicians. Such payment modifier shall 
not be applied for items and services fur-
nished on or after January 1, 2019.’’. 
(B) CONTINUATION OF VALUE-BASED PAY-
MENT MODIFIER MEASURES FOR MIPS.—Section 
1848(p) of the Social Security Act (42 U.S.C. 
1395w–4(p)) is amended— 
(i) in paragraph (2), by adding at the 
end the following new subparagraph: 
‘‘(C) CONTINUED APPLICATION FOR PUR-
POSES OF MIPS.—The Secretary shall, in ac-
cordance with subsection (q)(1)(F), carry out 
subparagraph (B) for purposes of subsection 
(q).’’; and 
(ii) in paragraph (3), by adding at the 
end the following: ‘‘With respect to 2019 
and each subsequent year, the Secretary 
shall, 
in 
accordance 
with 
subsection 
(q)(1)(F), carry out this paragraph for 
purposes of subsection (q).’’. 
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(c) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 
(1) IN GENERAL.—Section 1848 of the Social 
Security Act (42 U.S.C. 1395w–4) is amended by 
adding at the end the following new subsection: 
‘‘(q) MERIT-BASED INCENTIVE PAYMENT SYSTEM.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, the Sec-
retary shall establish an eligible professional 
Merit-based Incentive Payment System (in this 
subsection referred to as the ‘MIPS’) under 
which the Secretary shall— 
‘‘(i) develop a methodology for assess-
ing the total performance of each MIPS el-
igible professional according to perform-
ance standards under paragraph (3) for a 
performance period (as established under 
paragraph (4)) for a year; 
‘‘(ii) using such methodology, provide 
for a composite performance score in ac-
cordance with paragraph (5) for each such 
professional for each performance period; 
and 
‘‘(iii) use such composite performance 
score of the MIPS eligible professional for 
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a performance period for a year to deter-
mine and apply a MIPS adjustment factor 
(and, as applicable, an additional MIPS 
adjustment factor) under paragraph (6) to 
the professional for the year. 
Notwithstanding subparagraph (C)(ii), under 
the MIPS, the Secretary shall permit any eligi-
ble professional (as defined in subsection 
(k)(3)(B)) to report on applicable measures and 
activities described in paragraph (2)(B). 
‘‘(B) PROGRAM
IMPLEMENTATION.—The 
MIPS shall apply to payments for items and 
services furnished on or after January 1, 2019. 
‘‘(C) MIPS ELIGIBLE PROFESSIONAL DE-
FINED.— 
‘‘(i) IN
GENERAL.—For purposes of 
this subsection, subject to clauses (ii) and 
(iv), the term ‘MIPS eligible professional’ 
means— 
‘‘(I) for the first and second 
years for which the MIPS applies to 
payments (and for the performance 
period for such first and second year), 
a physician (as defined in section 
1861(r)), a physician assistant, nurse 
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practitioner, and clinical nurse spe-
cialist (as such terms are defined in 
section 1861(aa)(5)), a certified reg-
istered nurse anesthetist (as defined 
in section 1861(bb)(2)), and a group 
that includes such professionals; and 
‘‘(II) for the third year for which 
the MIPS applies to payments (and 
for the performance period for such 
third year) and for each succeeding 
year (and for the performance period 
for each such year), the professionals 
described in subclause (I), such other 
eligible professionals (as defined in 
subsection (k)(3)(B)) as specified by 
the Secretary, and a group that in-
cludes such professionals. 
‘‘(ii) EXCLUSIONS.—For purposes of 
clause (i), the term ‘MIPS eligible profes-
sional’ does not include, with respect to a 
year, an eligible professional (as defined in 
subsection (k)(3)(B)) who— 
‘‘(I) is a qualifying APM partici-
pant 
(as 
defined 
in 
section 
1833(z)(2)); 
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‘‘(II) subject to clause (vii), is a 
partial qualifying APM participant (as 
defined in clause (iii)) for the most re-
cent period for which data are avail-
able and who, for the performance pe-
riod with respect to such year, does 
not report on applicable measures and 
activities 
described 
in 
paragraph 
(2)(B) that are required to be re-
ported by such a professional under 
the MIPS; or 
‘‘(III) for the performance period 
with respect to such year, does not ex-
ceed the low-volume threshold meas-
urement selected under clause (iv). 
‘‘(iii) PARTIAL QUALIFYING APM PAR-
TICIPANT.—For purposes of this subpara-
graph, the term ‘partial qualifying APM 
participant’ means, with respect to a year, 
an eligible professional for whom the Sec-
retary determines the minimum payment 
percentage (or percentages), as applicable, 
described in paragraph (2) of section 
1833(z) for such year have not been satis-
fied, but who would be considered a quali-
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fying APM participant (as defined in such 
paragraph) for such year if— 
‘‘(I) with respect to 2019 and 
2020, the reference in subparagraph 
(A) of such paragraph to 25 percent 
was instead a reference to 20 percent; 
‘‘(II) with respect to 2021 and 
2022— 
‘‘(aa) the reference in sub-
paragraph (B)(i) of such para-
graph to 50 percent was instead 
a reference to 40 percent; and 
‘‘(bb) the references in sub-
paragraph (B)(ii) of such para-
graph to 50 percent and 25 per-
cent of such paragraph were in-
stead references to 40 percent 
and 20 percent, respectively; and 
‘‘(III) with respect to 2023 and 
subsequent years— 
‘‘(aa) the reference in sub-
paragraph (C)(i) of such para-
graph to 75 percent was instead 
a reference to 50 percent; and 
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‘‘(bb) the references in sub-
paragraph (C)(ii) of such para-
graph to 75 percent and 25 per-
cent of such paragraph were in-
stead references to 50 percent 
and 20 percent, respectively. 
‘‘(iv) SELECTION
OF
LOW-VOLUME 
THRESHOLD
MEASUREMENT.—The Sec-
retary shall select a low-volume threshold 
to apply for purposes of clause (ii)(III), 
which may include one or more or a com-
bination of the following: 
‘‘(I) The minimum number (as 
determined by the Secretary) of indi-
viduals enrolled under this part who 
are treated by the eligible professional 
for the performance period involved. 
‘‘(II) The minimum number (as 
determined by the Secretary) of items 
and services furnished to individuals 
enrolled under this part by such pro-
fessional for such performance period. 
‘‘(III) The minimum amount (as 
determined by the Secretary) of al-
lowed charges billed by such profes-
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sional under this part for such per-
formance period. 
‘‘(v) TREATMENT OF NEW MEDICARE 
ENROLLED ELIGIBLE PROFESSIONALS.—In 
the case of a professional who first be-
comes a Medicare enrolled eligible profes-
sional during the performance period for a 
year (and had not previously submitted 
claims under this title such as a person, an 
entity, or a part of a physician group or 
under a different billing number or tax 
identifier), such professional shall not be 
treated under this subsection as a MIPS 
eligible professional until the subsequent 
year and performance period for such sub-
sequent year. 
‘‘(vi) CLARIFICATION.—In the case of 
items and services furnished during a year 
by an individual who is not a MIPS eligible 
professional (including pursuant to clauses 
(ii) and (v)) with respect to a year, in no 
case shall a MIPS adjustment factor (or 
additional MIPS adjustment factor) under 
paragraph (6) apply to such individual for 
such year. 
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‘‘(vii) PARTIAL QUALIFYING APM PAR-
TICIPANT CLARIFICATIONS.— 
‘‘(I) TREATMENT AS MIPS ELIGI-
BLE PROFESSIONAL.—In the case of 
an eligible professional who is a par-
tial qualifying APM participant, with 
respect to a year, and who, for the 
performance period for such year, re-
ports on applicable measures and ac-
tivities described in paragraph (2)(B) 
that are required to be reported by 
such a professional under the MIPS, 
such eligible professional is considered 
to be a MIPS eligible professional 
with respect to such year. 
‘‘(II) NOT ELIGIBLE FOR QUALI-
FYING
APM
PARTICIPANT
PAY-
MENTS.—In no case shall an eligible 
professional who is a partial quali-
fying APM participant, with respect 
to a year, be considered a qualifying 
APM participant (as defined in para-
graph (2) of section 1833(z)) for such 
year or be eligible for the additional 
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payment under paragraph (1) of such 
section for such year. 
‘‘(D) APPLICATION
TO
GROUP
PRAC-
TICES.— 
‘‘(i) IN GENERAL.—Under the MIPS: 
‘‘(I) 
QUALITY
PERFORMANCE 
CATEGORY.—The Secretary shall es-
tablish and apply a process that in-
cludes features of the provisions of 
subsection (m)(3)(C) for MIPS eligi-
ble professionals in a group practice 
with respect to assessing performance 
of such group with respect to the per-
formance category described in clause 
(i) of paragraph (2)(A). 
‘‘(II) OTHER PERFORMANCE CAT-
EGORIES.—The Secretary may estab-
lish and apply a process that includes 
features of the provisions of sub-
section (m)(3)(C) for MIPS eligible 
professionals in a group practice with 
respect to assessing the performance 
of such group with respect to the per-
formance 
categories 
described 
in 
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clauses (ii) through (iv) of such para-
graph. 
‘‘(ii) ENSURING COMPREHENSIVENESS 
OF
GROUP
PRACTICE
ASSESSMENT.—The 
process established under clause (i) shall to 
the extent practicable reflect the range of 
items and services furnished by the MIPS 
eligible professionals in the group practice 
involved. 
‘‘(E) USE
OF
REGISTRIES.—Under the 
MIPS, the Secretary shall encourage the use of 
qualified clinical data registries pursuant to 
subsection (m)(3)(E) in carrying out this sub-
section. 
‘‘(F) APPLICATION
OF
CERTAIN
PROVI-
SIONS.—In applying a provision of subsection 
(k), (m), (o), or (p) for purposes of this sub-
section, the Secretary shall— 
‘‘(i) adjust the application of such 
provision to ensure the provision is con-
sistent with the provisions of this sub-
section; and 
‘‘(ii) not apply such provision to the 
extent that the provision is duplicative with 
a provision of this subsection. 
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‘‘(G) ACCOUNTING FOR RISK FACTORS.— 
‘‘(i) RISK FACTORS.—Taking into ac-
count the relevant studies conducted and 
recommendations made in reports under 
section 2(d) of the Improving Medicare 
Post-Acute Care Transformation Act of 
2014, and, as appropriate, other informa-
tion, including information collected before 
completion of such studies and rec-
ommendations, the Secretary, on an ongo-
ing basis, shall, as the Secretary deter-
mines appropriate and based on an individ-
ual’s health status and other risk factors— 
‘‘(I) assess appropriate adjust-
ments to quality measures, resource 
use measures, and other measures 
used under the MIPS; and 
‘‘(II) assess and implement ap-
propriate adjustments to payment ad-
justments, 
composite 
performance 
scores, scores for performance cat-
egories, or scores for measures or ac-
tivities under the MIPS. 
‘‘(2) MEASURES AND ACTIVITIES UNDER PER-
FORMANCE CATEGORIES.— 
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‘‘(A) PERFORMANCE CATEGORIES.—Under 
the MIPS, the Secretary shall use the following 
performance categories (each of which is re-
ferred to in this subsection as a performance 
category) in determining the composite per-
formance score under paragraph (5): 
‘‘(i) Quality. 
‘‘(ii) Resource use. 
‘‘(iii) Clinical practice improvement 
activities. 
‘‘(iv) Meaningful use of certified EHR 
technology. 
‘‘(B) MEASURES
AND
ACTIVITIES
SPECI-
FIED FOR EACH CATEGORY.—For purposes of 
paragraph (3)(A) and subject to subparagraph 
(C), measures and activities specified for a per-
formance period (as established under para-
graph (4)) for a year are as follows: 
‘‘(i) QUALITY.—For the performance 
category described in subparagraph (A)(i), 
the quality measures included in the final 
measures list published under subpara-
graph (D)(i) for such year and the list of 
quality measures described in subpara-
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graph (D)(vi) used by qualified clinical 
data registries under subsection (m)(3)(E). 
‘‘(ii) RESOURCE USE.—For the per-
formance category described in subpara-
graph (A)(ii), the measurement of resource 
use for such period under subsection 
(p)(3), using the methodology under sub-
section (r) as appropriate, and, as feasible 
and applicable, accounting for the cost of 
drugs under part D. 
‘‘(iii) CLINICAL
PRACTICE
IMPROVE-
MENT
ACTIVITIES.—For the performance 
category 
described 
in 
subparagraph 
(A)(iii), clinical practice improvement ac-
tivities 
(as 
defined 
in 
subparagraph 
(C)(v)(III)) under subcategories specified 
by the Secretary for such period, which 
shall include at least the following: 
‘‘(I) The subcategory of expanded 
practice access, such as same day ap-
pointments for urgent needs and after 
hours access to clinician advice. 
‘‘(II) The subcategory of popu-
lation management, such as moni-
toring health conditions of individuals 
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to provide timely health care interven-
tions or participation in a qualified 
clinical data registry. 
‘‘(III) The subcategory of care 
coordination, such as timely commu-
nication of test results, timely ex-
change of clinical information to pa-
tients and other providers, and use of 
remote monitoring or telehealth. 
‘‘(IV) The subcategory of bene-
ficiary engagement, such as the estab-
lishment of care plans for individuals 
with complex care needs, beneficiary 
self-management 
assessment 
and 
training, and using shared decision- 
making mechanisms. 
‘‘(V) The subcategory of patient 
safety and practice assessment, such 
as through use of clinical or surgical 
checklists and practice assessments 
related to maintaining certification. 
‘‘(VI) The subcategory of partici-
pation in an alternative payment 
model 
(as 
defined 
in 
section 
1833(z)(3)(C)). 
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In establishing activities under this clause, 
the Secretary shall give consideration to 
the circumstances of small practices (con-
sisting of 15 or fewer professionals) and 
practices located in rural areas and in 
health professional shortage areas (as des-
ignated under section 332(a)(1)(A) of the 
Public Health Service Act). 
‘‘(iv) MEANINGFUL
EHR
USE.—For 
the performance category described in sub-
paragraph (A)(iv), the requirements estab-
lished for such period under subsection 
(o)(2) for determining whether an eligible 
professional is a meaningful EHR user. 
‘‘(C) ADDITIONAL PROVISIONS.— 
‘‘(i) EMPHASIZING
OUTCOME
MEAS-
URES UNDER THE QUALITY PERFORMANCE 
CATEGORY.—In 
applying 
subparagraph 
(B)(i), the Secretary shall, as feasible, em-
phasize the application of outcome meas-
ures. 
‘‘(ii) APPLICATION
OF
ADDITIONAL 
SYSTEM
MEASURES.—The Secretary may 
use measures used for a payment system 
other than for physicians, such as meas-
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ures for inpatient hospitals, for purposes of 
the performance categories described in 
clauses (i) and (ii) of subparagraph (A). 
For purposes of the previous sentence, the 
Secretary may not use measures for hos-
pital outpatient departments, except in the 
case of items and services furnished by 
emergency physicians, radiologists, and an-
esthesiologists. 
‘‘(iii) 
GLOBAL
AND
POPULATION- 
BASED
MEASURES.—The Secretary may 
use global measures, such as global out-
come 
measures, 
and 
population-based 
measures for purposes of the performance 
category described in subparagraph (A)(i). 
‘‘(iv) APPLICATION OF MEASURES AND 
ACTIVITIES TO NON-PATIENT-FACING PRO-
FESSIONALS.—In carrying out this para-
graph, with respect to measures and activi-
ties specified in subparagraph (B) for per-
formance categories described in subpara-
graph (A), the Secretary— 
‘‘(I) shall give consideration to 
the 
circumstances 
of 
professional 
types (or subcategories of those types 
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determined by practice characteris-
tics) who typically furnish services 
that do not involve face-to-face inter-
action with a patient; and 
‘‘(II) may, to the extent feasible 
and appropriate, take into account 
such circumstances and apply under 
this subsection with respect to MIPS 
eligible professionals of such profes-
sional types or subcategories, alter-
native measures or activities that ful-
fill the goals of the applicable per-
formance category. 
In carrying out the previous sentence, the 
Secretary shall consult with professionals 
of such professional types or subcategories. 
‘‘(v) CLINICAL
PRACTICE
IMPROVE-
MENT ACTIVITIES.— 
‘‘(I) REQUEST
FOR
INFORMA-
TION.—In initially applying subpara-
graph (B)(iii), the Secretary shall use 
a request for information to solicit 
recommendations from stakeholders to 
identify activities described in such 
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subparagraph and specifying criteria 
for such activities. 
‘‘(II) CONTRACT AUTHORITY FOR 
CLINICAL
PRACTICE
IMPROVEMENT 
ACTIVITIES
PERFORMANCE
CAT-
EGORY.—In applying subparagraph 
(B)(iii), the Secretary may contract 
with entities to assist the Secretary 
in— 
‘‘(aa) identifying activities 
described 
in 
subparagraph 
(B)(iii); 
‘‘(bb) specifying criteria for 
such activities; and 
‘‘(cc) determining whether a 
MIPS eligible professional meets 
such criteria. 
‘‘(III) CLINICAL
PRACTICE
IM-
PROVEMENT
ACTIVITIES
DEFINED.— 
For purposes of this subsection, the 
term ‘clinical practice improvement 
activity’ means an activity that rel-
evant eligible professional organiza-
tions and other relevant stakeholders 
identify as improving clinical practice 
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or care delivery and that the Sec-
retary determines, when effectively ex-
ecuted, is likely to result in improved 
outcomes. 
‘‘(D) ANNUAL LIST OF QUALITY MEASURES 
AVAILABLE FOR MIPS ASSESSMENT.— 
‘‘(i) IN GENERAL.—Under the MIPS, 
the Secretary, through notice and comment 
rulemaking and subject to the succeeding 
clauses of this subparagraph, shall, with 
respect to the performance period for a 
year, establish an annual final list of qual-
ity measures from which MIPS eligible 
professionals may choose for purposes of 
assessment under this subsection for such 
performance period. Pursuant to the pre-
vious sentence, the Secretary shall— 
‘‘(I) not later than November 1 
of the year prior to the first day of 
the first performance period under the 
MIPS, establish and publish in the 
Federal Register a final list of quality 
measures; and 
‘‘(II) not later than November 1 
of the year prior to the first day of 
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each subsequent performance period, 
update the final list of quality meas-
ures from the previous year (and pub-
lish such updated final list in the Fed-
eral Register), by— 
‘‘(aa) removing from such 
list, as appropriate, quality meas-
ures, which may include the re-
moval of measures that are no 
longer meaningful (such as meas-
ures that are topped out); 
‘‘(bb) adding to such list, as 
appropriate, new quality meas-
ures; and 
‘‘(cc) determining whether 
or not quality measures on such 
list that have undergone sub-
stantive changes should be in-
cluded in the updated list. 
‘‘(ii) 
CALL
FOR
QUALITY
MEAS-
URES.— 
‘‘(I) IN GENERAL.—Eligible pro-
fessional organizations and other rel-
evant stakeholders shall be requested 
to identify and submit quality meas-
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ures to be considered for selection 
under this subparagraph in the an-
nual list of quality measures published 
under clause (i) and to identify and 
submit updates to the measures on 
such list. For purposes of the previous 
sentence, measures may be submitted 
regardless of whether such measures 
were previously published in a pro-
posed rule or endorsed by an entity 
with a contract under section 1890(a). 
‘‘(II) ELIGIBLE
PROFESSIONAL 
ORGANIZATION
DEFINED.—In 
this 
subparagraph, the term ‘eligible pro-
fessional organization’ means a pro-
fessional organization as defined by 
nationally recognized specialty boards 
of certification or equivalent certifi-
cation boards. 
‘‘(iii) REQUIREMENTS.—In selecting 
quality measures for inclusion in the an-
nual final list under clause (i), the Sec-
retary shall— 
‘‘(I) provide that, to the extent 
practicable, all quality domains (as 
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defined in subsection (s)(1)(B)) are 
addressed by such measures; and 
‘‘(II) ensure that such selection 
is consistent with the process for se-
lection of measures under subsections 
(k), (m), and (p)(2). 
‘‘(iv) PEER REVIEW.—Before includ-
ing a new measure in the final list of 
measures published under clause (i) for a 
year, the Secretary shall submit for publi-
cation in applicable specialty-appropriate 
peer-reviewed journals such measure and 
the method for developing and selecting 
such measure, including clinical and other 
data supporting such measure. 
‘‘(v) MEASURES
FOR
INCLUSION.— 
The final list of quality measures published 
under clause (i) shall include, as applica-
ble, measures under subsections (k), (m), 
and (p)(2), including quality measures 
from among— 
‘‘(I) measures endorsed by a con-
sensus-based entity; 
‘‘(II) measures developed under 
subsection (s); and 
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‘‘(III) measures submitted under 
clause (ii)(I). 
Any measure selected for inclusion in such 
list that is not endorsed by a consensus- 
based entity shall have a focus that is evi-
dence-based. 
‘‘(vi) EXCEPTION
FOR
QUALIFIED 
CLINICAL
DATA
REGISTRY
MEASURES.— 
Measures used by a qualified clinical data 
registry under subsection (m)(3)(E) shall 
not be subject to the requirements under 
clauses (i), (iv), and (v). The Secretary 
shall publish the list of measures used by 
such qualified clinical data registries on 
the Internet website of the Centers for 
Medicare & Medicaid Services. 
‘‘(vii) 
EXCEPTION
FOR
EXISTING 
QUALITY
MEASURES.—Any quality meas-
ure specified by the Secretary under sub-
section (k) or (m), including under sub-
section (m)(3)(E), and any measure of 
quality of care established under sub-
section (p)(2) for the reporting period or 
performance period under the respective 
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subsection beginning before the first per-
formance period under the MIPS— 
‘‘(I) shall not be subject to the 
requirements under clause (i) (except 
under items (aa) and (cc) of subclause 
(II) of such clause) or to the require-
ment under clause (iv); and 
‘‘(II) shall be included in the 
final list of quality measures pub-
lished under clause (i) unless removed 
under clause (i)(II)(aa). 
‘‘(viii) CONSULTATION
WITH
REL-
EVANT ELIGIBLE PROFESSIONAL ORGANI-
ZATIONS
AND
OTHER
RELEVANT
STAKE-
HOLDERS.—Relevant eligible professional 
organizations and other relevant stake-
holders, including State and national med-
ical societies, shall be consulted in carrying 
out this subparagraph. 
‘‘(ix) OPTIONAL
APPLICATION.—The 
process under section 1890A is not re-
quired to apply to the selection of meas-
ures under this subparagraph. 
‘‘(3) PERFORMANCE STANDARDS.— 
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‘‘(A) ESTABLISHMENT.—Under the MIPS, 
the Secretary shall establish performance stand-
ards with respect to measures and activities 
specified under paragraph (2)(B) for a perform-
ance period (as established under paragraph 
(4)) for a year. 
‘‘(B) CONSIDERATIONS IN ESTABLISHING 
STANDARDS.—In establishing such performance 
standards with respect to measures and activi-
ties specified under paragraph (2)(B), the Sec-
retary shall consider the following: 
‘‘(i) Historical performance standards. 
‘‘(ii) Improvement. 
‘‘(iii) The opportunity for continued 
improvement. 
‘‘(4) PERFORMANCE
PERIOD.—The Secretary 
shall establish a performance period (or periods) for 
a year (beginning with 2019). Such performance pe-
riod (or periods) shall begin and end prior to the be-
ginning of such year and be as close as possible to 
such year. In this subsection, such performance pe-
riod (or periods) for a year shall be referred to as 
the performance period for the year. 
‘‘(5) COMPOSITE PERFORMANCE SCORE.— 
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‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph and taking 
into account, as available and applicable, para-
graph (1)(G), the Secretary shall develop a 
methodology for assessing the total performance 
of each MIPS eligible professional according to 
performance standards under paragraph (3) 
with respect to applicable measures and activi-
ties specified in paragraph (2)(B) with respect 
to each performance category applicable to such 
professional for a performance period (as estab-
lished under paragraph (4)) for a year. Using 
such methodology, the Secretary shall provide 
for a composite assessment (using a scoring 
scale of 0 to 100) for each such professional for 
the performance period for such year. In this 
subsection such a composite assessment for 
such a professional with respect to a perform-
ance period shall be referred to as the ‘com-
posite performance score’ for such professional 
for such performance period. 
‘‘(B) INCENTIVE
TO
REPORT; ENCOUR-
AGING USE OF CERTIFIED EHR TECHNOLOGY 
FOR REPORTING QUALITY MEASURES.— 
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‘‘(i) INCENTIVE TO REPORT.—Under 
the methodology established under sub-
paragraph (A), the Secretary shall provide 
that in the case of a MIPS eligible profes-
sional who fails to report on an applicable 
measure or activity that is required to be 
reported by the professional, the profes-
sional shall be treated as achieving the 
lowest potential score applicable to such 
measure or activity. 
‘‘(ii) ENCOURAGING
USE
OF
CER-
TIFIED EHR TECHNOLOGY AND QUALIFIED 
CLINICAL DATA REGISTRIES FOR REPORT-
ING
QUALITY
MEASURES.—Under 
the 
methodology established under subpara-
graph (A), the Secretary shall— 
‘‘(I) encourage MIPS eligible 
professionals to report on applicable 
measures with respect to the perform-
ance category described in paragraph 
(2)(A)(i) through the use of certified 
EHR technology and qualified clinical 
data registries; and 
‘‘(II) with respect to a perform-
ance period, with respect to a year, 
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for which a MIPS eligible professional 
reports such measures through the 
use of such EHR technology, treat 
such professional as satisfying the 
clinical quality measures reporting re-
quirement described in subsection 
(o)(2)(A)(iii) for such year. 
‘‘(C) CLINICAL
PRACTICE
IMPROVEMENT 
ACTIVITIES PERFORMANCE SCORE.— 
‘‘(i) RULE
FOR
CERTIFICATION.—A 
MIPS eligible professional who is in a 
practice that is certified as a patient-cen-
tered medical home or comparable spe-
cialty practice, as determined by the Sec-
retary, with respect to a performance pe-
riod shall be given the highest potential 
score for the performance category de-
scribed in paragraph (2)(A)(iii) for such 
period. 
‘‘(ii) APM PARTICIPATION.—Partici-
pation by a MIPS eligible professional in 
an alternative payment model (as defined 
in section 1833(z)(3)(C)) with respect to a 
performance period shall earn such eligible 
professional a minimum score of one-half 
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of the highest potential score for the per-
formance category described in paragraph 
(2)(A)(iii) for such performance period. 
‘‘(iii) SUBCATEGORIES.—A MIPS eli-
gible professional shall not be required to 
perform activities in each subcategory 
under paragraph (2)(B)(iii) or participate 
in an alternative payment model in order 
to achieve the highest potential score for 
the performance category described in 
paragraph (2)(A)(iii). 
‘‘(D) 
ACHIEVEMENT
AND
IMPROVE-
MENT.— 
‘‘(i) TAKING INTO ACCOUNT IMPROVE-
MENT.—Beginning with the second year to 
which the MIPS applies, in addition to the 
achievement of a MIPS eligible profes-
sional, if data sufficient to measure im-
provement is available, the methodology 
developed under subparagraph (A)— 
‘‘(I) in the case of the perform-
ance score for the performance cat-
egory described in clauses (i) and (ii) 
of paragraph (2)(A), shall take into 
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account the improvement of the pro-
fessional; and 
‘‘(II) in the case of performance 
scores for other performance cat-
egories, may take into account the im-
provement of the professional. 
‘‘(ii) ASSIGNING HIGHER WEIGHT FOR 
ACHIEVEMENT.—Subject 
to 
clause 
(i), 
under the methodology developed under 
subparagraph (A), the Secretary may as-
sign a higher scoring weight under sub-
paragraph (F) with respect to the achieve-
ment of a MIPS eligible professional than 
with respect to any improvement of such 
professional applied under clause (i) with 
respect to a measure, activity, or category 
described in paragraph (2). 
‘‘(E) WEIGHTS
FOR
THE
PERFORMANCE 
CATEGORIES.— 
‘‘(i) IN GENERAL.—Under the meth-
odology developed under subparagraph (A), 
subject to subparagraph (F)(i) and clause 
(ii), the composite performance score shall 
be determined as follows: 
‘‘(I) QUALITY.— 
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‘‘(aa) IN
GENERAL.—Sub-
ject to item (bb), thirty percent 
of such score shall be based on 
performance with respect to the 
category described in clause (i) of 
paragraph (2)(A). In applying 
the previous sentence, the Sec-
retary shall, as feasible, encour-
age the application of outcome 
measures within such category. 
‘‘(bb) FIRST 2 YEARS.—For 
the first and second years for 
which the MIPS applies to pay-
ments, the percentage applicable 
under item (aa) shall be in-
creased in a manner such that 
the total percentage points of the 
increase under this item for the 
respective year equals the total 
number of percentage points by 
which the percentage applied 
under subclause (II)(bb) for the 
respective year is less than 30 
percent. 
‘‘(II) RESOURCE USE.— 
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‘‘(aa) IN
GENERAL.—Sub-
ject to item (bb), thirty percent 
of such score shall be based on 
performance with respect to the 
category described in clause (ii) 
of paragraph (2)(A). 
‘‘(bb) FIRST 2 YEARS.—For 
the first year for which the MIPS 
applies to payments, not more 
than 10 percent of such score 
shall be based on performance 
with respect to the category de-
scribed in clause (ii) of para-
graph (2)(A). For the second 
year for which the MIPS applies 
to payments, not more than 15 
percent of such score shall be 
based on performance with re-
spect to the category described in 
clause (ii) of paragraph (2)(A). 
‘‘(III) CLINICAL
PRACTICE
IM-
PROVEMENT
ACTIVITIES.—Fifteen 
percent of such score shall be based 
on performance with respect to the 
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category described in clause (iii) of 
paragraph (2)(A). 
‘‘(IV) MEANINGFUL USE OF CER-
TIFIED
EHR
TECHNOLOGY.—Twenty- 
five percent of such score shall be 
based on performance with respect to 
the category described in clause (iv) of 
paragraph (2)(A). 
‘‘(ii) AUTHORITY
TO
ADJUST
PER-
CENTAGES IN CASE OF HIGH EHR MEAN-
INGFUL USE ADOPTION.—In any year in 
which the Secretary estimates that the pro-
portion of eligible professionals (as defined 
in subsection (o)(5)) who are meaningful 
EHR users (as determined under sub-
section (o)(2)) is 75 percent or greater, the 
Secretary may reduce the percent applica-
ble under clause (i)(IV), but not below 15 
percent. If the Secretary makes such re-
duction for a year, subject to subclauses 
(I)(bb) and (II)(bb) of clause (i), the per-
centages applicable under one or more of 
subclauses (I), (II), and (III) of clause (i) 
for such year shall be increased in a man-
ner such that the total percentage points 
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of the increase under this clause for such 
year equals the total number of percentage 
points reduced under the preceding sen-
tence for such year. 
‘‘(F) 
CERTAIN
FLEXIBILITY
FOR 
WEIGHTING PERFORMANCE CATEGORIES, MEAS-
URES, AND
ACTIVITIES.—Under the method-
ology under subparagraph (A), if there are not 
sufficient measures and activities (described in 
paragraph (2)(B)) applicable and available to 
each type of eligible professional involved, the 
Secretary shall assign different scoring weights 
(including a weight of 0)— 
‘‘(i) which may vary from the scoring 
weights specified in subparagraph (E), for 
each performance category based on the 
extent to which the category is applicable 
to the type of eligible professional involved; 
and 
‘‘(ii) for each measure and activity 
specified under paragraph (2)(B) with re-
spect to each such category based on the 
extent to which the measure or activity is 
applicable and available to the type of eli-
gible professional involved. 
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‘‘(G) RESOURCE
USE.—Analysis of the 
performance category described in paragraph 
(2)(A)(ii) shall include results from the method-
ology described in subsection (r)(5), as appro-
priate. 
‘‘(H) INCLUSION
OF
QUALITY
MEASURE 
DATA FROM OTHER PAYERS.—In applying sub-
sections (k), (m), and (p) with respect to meas-
ures described in paragraph (2)(B)(i), analysis 
of the performance category described in para-
graph (2)(A)(i) may include data submitted by 
MIPS eligible professionals with respect to 
items and services furnished to individuals who 
are not individuals entitled to benefits under 
part A or enrolled under part B. 
‘‘(I) USE OF VOLUNTARY VIRTUAL GROUPS 
FOR CERTAIN ASSESSMENT PURPOSES.— 
‘‘(i) IN
GENERAL.—In the case of 
MIPS eligible professionals electing to be a 
virtual group under clause (ii) with respect 
to a performance period for a year, for 
purposes of applying the methodology 
under subparagraph (A) with respect to 
the performance categories described in 
clauses (i) and (ii) of paragraph (2)(A)— 
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‘‘(I) the assessment of perform-
ance provided under such methodology 
with respect to such performance cat-
egories that is to be applied to each 
such professional in such group for 
such performance period shall be with 
respect to the combined performance 
of all such professionals in such group 
for such period; and 
‘‘(II) with respect to the com-
posite performance score provided 
under this paragraph for such per-
formance period for each such MIPS 
eligible professional in such virtual 
group, the components of the com-
posite performance score that assess 
performance with respect to such per-
formance categories shall be based on 
the assessment of the combined per-
formance under subclause (I) for such 
performance categories and perform-
ance period. 
‘‘(ii) ELECTION OF PRACTICES TO BE 
A VIRTUAL GROUP.—The Secretary shall, 
in accordance with the requirements under 
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clause (iii), establish and have in place a 
process to allow an individual MIPS eligi-
ble professional or a group practice con-
sisting of not more than 10 MIPS eligible 
professionals to elect, with respect to a 
performance period for a year to be a vir-
tual group under this subparagraph with 
at least one other such individual MIPS el-
igible professional or group practice. Such 
a virtual group may be based on appro-
priate classifications of providers, such as 
by geographic areas or by provider special-
ties defined by nationally recognized spe-
cialty boards of certification or equivalent 
certification boards. 
‘‘(iii) REQUIREMENTS.—The require-
ments for the process under clause (ii) 
shall— 
‘‘(I) provide that an election 
under such clause, with respect to a 
performance period, shall be made be-
fore the beginning of such perform-
ance period and may not be changed 
during such performance period; 
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‘‘(II) provide that an individual 
MIPS eligible professional and a 
group practice described in clause (ii) 
may elect to be in no more than one 
virtual group for a performance period 
and that, in the case of such a group 
practice that elects to be in such vir-
tual group for such performance pe-
riod, such election applies to all MIPS 
eligible professionals in such group 
practice; 
‘‘(III) provide that a virtual 
group be a combination of tax identi-
fication numbers; 
‘‘(IV) provide for formal written 
agreements among MIPS eligible pro-
fessionals electing to be a virtual 
group under this subparagraph; and 
‘‘(V) include such other require-
ments as the Secretary determines ap-
propriate. 
‘‘(6) MIPS PAYMENTS.— 
‘‘(A) MIPS ADJUSTMENT FACTOR.—Tak-
ing into account paragraph (1)(G), the Sec-
retary shall specify a MIPS adjustment factor 
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for each MIPS eligible professional for a year. 
Such MIPS adjustment factor for a MIPS eligi-
ble professional for a year shall be in the form 
of a percent and shall be determined— 
‘‘(i) by comparing the composite per-
formance score of the eligible professional 
for such year to the performance threshold 
established under subparagraph (D)(i) for 
such year; 
‘‘(ii) in a manner such that the ad-
justment factors specified under this sub-
paragraph for a year result in differential 
payments under this paragraph reflecting 
that— 
‘‘(I) MIPS eligible professionals 
with composite performance scores for 
such year at or above such perform-
ance threshold for such year receive 
zero or positive payment adjustment 
factors for such year in accordance 
with clause (iii), with such profes-
sionals having higher composite per-
formance scores receiving higher ad-
justment factors; and 
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‘‘(II) MIPS eligible professionals 
with composite performance scores for 
such year below such performance 
threshold for such year receive nega-
tive payment adjustment factors for 
such year in accordance with clause 
(iv), with such professionals having 
lower composite performance scores 
receiving lower adjustment factors; 
‘‘(iii) in a manner such that MIPS eli-
gible professionals with composite scores 
described in clause (ii)(I) for such year, 
subject to clauses (i) and (ii) of subpara-
graph (F), receive a zero or positive ad-
justment factor on a linear sliding scale 
such that an adjustment factor of 0 per-
cent is assigned for a score at the perform-
ance threshold and an adjustment factor of 
the applicable percent specified in subpara-
graph (B) is assigned for a score of 100; 
and 
‘‘(iv) in a manner such that— 
‘‘(I) subject to subclause (II), 
MIPS eligible professionals with com-
posite performance scores described in 
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‘‘(iv) for 2022 and subsequent years, 
9 percent. 
‘‘(C) ADDITIONAL MIPS ADJUSTMENT FAC-
TORS FOR EXCEPTIONAL PERFORMANCE.—For 
2019 and each subsequent year through 2024, 
in the case of a MIPS eligible professional with 
a composite performance score for a year at or 
above the additional performance threshold 
under subparagraph (D)(ii) for such year, in 
addition to the MIPS adjustment factor under 
subparagraph (A) for the eligible professional 
for such year, subject to subparagraph (F)(iv), 
the Secretary shall specify an additional positive 
MIPS adjustment factor for such professional 
and year. Such additional MIPS adjustment 
factors shall be in the form of a percent and de-
termined by the Secretary in a manner such 
that professionals having higher composite per-
formance scores above the additional perform-
ance threshold receive higher additional MIPS 
adjustment factors. 
‘‘(D) ESTABLISHMENT OF PERFORMANCE 
THRESHOLDS.— 
‘‘(i) PERFORMANCE
THRESHOLD.— 
For each year of the MIPS, the Secretary 
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shall compute a performance threshold 
with respect to which the composite per-
formance score of MIPS eligible profes-
sionals shall be compared for purposes of 
determining adjustment factors under sub-
paragraph (A) that are positive, negative, 
and zero. Such performance threshold for 
a year shall be the mean or median (as se-
lected by the Secretary) of the composite 
performance scores for all MIPS eligible 
professionals with respect to a prior period 
specified by the Secretary. The Secretary 
may reassess the selection of the mean or 
median under the previous sentence every 
3 years. 
‘‘(ii) 
ADDITIONAL
PERFORMANCE 
THRESHOLD FOR EXCEPTIONAL PERFORM-
ANCE.—In addition to the performance 
threshold under clause (i), for each year of 
the MIPS, the Secretary shall compute an 
additional performance threshold for pur-
poses of determining the additional MIPS 
adjustment factors under subparagraph 
(C). For each such year, the Secretary 
shall apply either of the following methods 
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for computing such additional performance 
threshold for such a year: 
‘‘(I) The threshold shall be the 
score that is equal to the 25th per-
centile of the range of possible com-
posite performance scores above the 
performance 
threshold 
determined 
under clause (i). 
‘‘(II) The threshold shall be the 
score that is equal to the 25th per-
centile of the actual composite per-
formance scores for MIPS eligible 
professionals with composite perform-
ance scores at or above the perform-
ance threshold with respect to the 
prior period described in clause (i). 
‘‘(iii) SPECIAL RULE FOR INITIAL 2 
YEARS.—With respect to each of the first 
two years to which the MIPS applies, the 
Secretary shall, prior to the performance 
period for such years, establish a perform-
ance threshold for purposes of determining 
MIPS adjustment factors under subpara-
graph (A) and a threshold for purposes of 
determining additional MIPS adjustment 
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factors under subparagraph (C). Each 
such performance threshold shall— 
‘‘(I) be based on a period prior to 
such performance periods; and 
‘‘(II) take into account— 
‘‘(aa) data available with re-
spect to performance on meas-
ures and activities that may be 
used under the performance cat-
egories 
under 
subparagraph 
(2)(B); and 
‘‘(bb) other factors deter-
mined appropriate by the Sec-
retary. 
‘‘(E) APPLICATION OF MIPS ADJUSTMENT 
FACTORS.—In the case of items and services 
furnished by a MIPS eligible professional dur-
ing a year (beginning with 2019), the amount 
otherwise paid under this part with respect to 
such items and services and MIPS eligible pro-
fessional for such year, shall be multiplied by— 
‘‘(i) 1, plus 
‘‘(ii) the sum of— 
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‘‘(I) the MIPS adjustment factor 
determined under subparagraph (A) 
divided by 100, and 
‘‘(II) as applicable, the additional 
MIPS adjustment factor determined 
under subparagraph (C) divided by 
100. 
‘‘(F) AGGREGATE
APPLICATION
OF
MIPS 
ADJUSTMENT FACTORS.— 
‘‘(i) APPLICATION OF SCALING FAC-
TOR.— 
‘‘(I) IN GENERAL.—With respect 
to positive MIPS adjustment factors 
under subparagraph (A)(ii)(I) for eli-
gible professionals whose composite 
performance score is above the per-
formance threshold under subpara-
graph (D)(i) for such year, subject to 
subclause (II), the Secretary shall in-
crease or decrease such adjustment 
factors by a scaling factor in order to 
ensure that the budget neutrality re-
quirement of clause (ii) is met. 
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‘‘(II) SCALING FACTOR LIMIT.— 
In no case may be the scaling factor 
applied under this clause exceed 3.0. 
‘‘(ii) BUDGET NEUTRALITY REQUIRE-
MENT.— 
‘‘(I) IN
GENERAL.—Subject to 
clause (iii), the Secretary shall ensure 
that the estimated amount described 
in subclause (II) for a year is equal to 
the estimated amount described in 
subclause (III) for such year. 
‘‘(II) AGGREGATE INCREASES.— 
The amount described in this sub-
clause is the estimated increase in the 
aggregate allowed charges resulting 
from the application of positive MIPS 
adjustment factors under subpara-
graph (A) (after application of the 
scaling factor described in clause (i)) 
to MIPS eligible professionals whose 
composite performance score for a 
year is above the performance thresh-
old under subparagraph (D)(i) for 
such year. 
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‘‘(III) 
AGGREGATE
DE-
CREASES.—The amount described in 
this subclause is the estimated de-
crease 
in 
the 
aggregate 
allowed 
charges resulting from the application 
of negative MIPS adjustment factors 
under subparagraph (A) to MIPS eli-
gible professionals whose composite 
performance score for a year is below 
the performance threshold under sub-
paragraph (D)(i) for such year. 
‘‘(iii) EXCEPTIONS.— 
‘‘(I) In the case that all MIPS el-
igible professionals receive composite 
performance scores for a year that are 
below 
the 
performance 
threshold 
under subparagraph (D)(i) for such 
year, the negative MIPS adjustment 
factors under subparagraph (A) shall 
apply with respect to such MIPS eligi-
ble professionals and the budget neu-
trality requirement of clause (ii) and 
the 
additional 
adjustment 
factors 
under clause (iv) shall not apply for 
such year. 
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‘‘(II) In the case that, with re-
spect to a year, the application of 
clause (i) results in a scaling factor 
equal to the maximum scaling factor 
specified in clause (i)(II), such scaling 
factor shall apply and the budget neu-
trality requirement of clause (ii) shall 
not apply for such year. 
‘‘(iv) ADDITIONAL
INCENTIVE
PAY-
MENT ADJUSTMENTS.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), in specifying the MIPS 
additional adjustment factors under 
subparagraph (C) for each applicable 
MIPS eligible professional for a year, 
the Secretary shall ensure that the es-
timated aggregate increase in pay-
ments under this part resulting from 
the application of such additional ad-
justment factors for MIPS eligible 
professionals in a year shall be equal 
(as estimated by the Secretary) to 
$500,000,000 for each year beginning 
with 2019 and ending with 2024. 
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‘‘(II) 
LIMITATION
ON
ADDI-
TIONAL INCENTIVE PAYMENT ADJUST-
MENTS.—The MIPS additional ad-
justment factor under subparagraph 
(C) for a year for an applicable MIPS 
eligible professional whose composite 
performance score is above the addi-
tional performance threshold under 
subparagraph (D)(ii) for such year 
shall not exceed 10 percent. The ap-
plication of the previous sentence may 
result in an aggregate amount of ad-
ditional incentive payments that are 
less than the amount specified in sub-
clause (I). 
‘‘(7) ANNOUNCEMENT OF RESULT OF ADJUST-
MENTS.—Under the MIPS, the Secretary shall, not 
later than 30 days prior to January 1 of the year 
involved, make available to MIPS eligible profes-
sionals the MIPS adjustment factor (and, as appli-
cable, the additional MIPS adjustment factor) under 
paragraph (6) applicable to the eligible professional 
for items and services furnished by the professional 
for such year. The Secretary may include such infor-
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mation in the confidential feedback under paragraph 
(12). 
‘‘(8) NO EFFECT IN SUBSEQUENT YEARS.—The 
MIPS adjustment factors and additional MIPS ad-
justment factors under paragraph (6) shall apply 
only with respect to the year involved, and the Sec-
retary shall not take into account such adjustment 
factors in making payments to a MIPS eligible pro-
fessional under this part in a subsequent year. 
‘‘(9) PUBLIC REPORTING.— 
‘‘(A) IN GENERAL.—The Secretary shall, 
in an easily understandable format, make avail-
able on the Physician Compare Internet website 
of the Centers for Medicare & Medicaid Serv-
ices the following: 
‘‘(i) Information regarding the per-
formance of MIPS eligible professionals 
under the MIPS, which— 
‘‘(I) shall include the composite 
score for each such MIPS eligible pro-
fessional and the performance of each 
such MIPS eligible professional with 
respect to each performance category; 
and 
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‘‘(II) may include the perform-
ance of each such MIPS eligible pro-
fessional with respect to each measure 
or activity specified in paragraph 
(2)(B). 
‘‘(ii) The names of eligible profes-
sionals in eligible alternative payment mod-
els (as defined in section 1833(z)(3)(D)) 
and, to the extent feasible, the names of 
such eligible alternative payment models 
and performance of such models. 
‘‘(B) 
DISCLOSURE.—The 
information 
made available under this paragraph shall indi-
cate, where appropriate, that publicized infor-
mation may not be representative of the eligible 
professional’s entire patient population, the va-
riety of services furnished by the eligible profes-
sional, or the health conditions of individuals 
treated. 
‘‘(C) OPPORTUNITY TO REVIEW AND SUB-
MIT
CORRECTIONS.—The Secretary shall pro-
vide for an opportunity for a professional de-
scribed in subparagraph (A) to review, and sub-
mit corrections for, the information to be made 
public with respect to the professional under 
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such subparagraph prior to such information 
being made public. 
‘‘(D) 
AGGREGATE
INFORMATION.—The 
Secretary shall periodically post on the Physi-
cian Compare Internet website aggregate infor-
mation on the MIPS, including the range of 
composite scores for all MIPS eligible profes-
sionals and the range of the performance of all 
MIPS eligible professionals with respect to each 
performance category. 
‘‘(10) CONSULTATION.—The Secretary shall 
consult with stakeholders in carrying out the MIPS, 
including for the identification of measures and ac-
tivities under paragraph (2)(B) and the methodolo-
gies developed under paragraphs (5)(A) and (6) and 
regarding the use of qualified clinical data registries. 
Such consultation shall include the use of a request 
for information or other mechanisms determined ap-
propriate. 
‘‘(11) TECHNICAL ASSISTANCE TO SMALL PRAC-
TICES AND PRACTICES IN HEALTH PROFESSIONAL 
SHORTAGE AREAS.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enter into contracts or agreements with appro-
priate entities (such as quality improvement or-
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ganizations, regional extension centers (as de-
scribed in section 3012(c) of the Public Health 
Service Act), or regional health collaboratives) 
to offer guidance and assistance to MIPS eligi-
ble professionals in practices of 15 or fewer pro-
fessionals (with priority given to such practices 
located in rural areas, health professional short-
age areas (as designated under in section 
332(a)(1)(A) of such Act), and medically under-
served areas, and practices with low composite 
scores) with respect to— 
‘‘(i) the performance categories de-
scribed in clauses (i) through (iv) of para-
graph (2)(A); or 
‘‘(ii) how to transition to the imple-
mentation of and participation in an alter-
native payment model as described in sec-
tion 1833(z)(3)(C). 
‘‘(B) FUNDING
FOR
TECHNICAL
ASSIST-
ANCE.—For purposes of implementing subpara-
graph (A), the Secretary shall provide for the 
transfer from the Federal Supplementary Med-
ical Insurance Trust Fund established under 
section 1841 to the Centers for Medicare & 
Medicaid Services Program Management Ac-
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count of $20,000,000 for each of fiscal years 
2016 through 2020. Amounts transferred under 
this subparagraph for a fiscal year shall be 
available until expended. 
‘‘(12) FEEDBACK
AND
INFORMATION
TO
IM-
PROVE PERFORMANCE.— 
‘‘(A) PERFORMANCE FEEDBACK.— 
‘‘(i) IN GENERAL.—Beginning July 1, 
2017, the Secretary— 
‘‘(I) shall make available timely 
(such as quarterly) confidential feed-
back to MIPS eligible professionals on 
the performance of such professionals 
with respect to the performance cat-
egories under clauses (i) and (ii) of 
paragraph (2)(A); and 
‘‘(II) may make available con-
fidential feedback to such profes-
sionals on the performance of such 
professionals with respect to the per-
formance categories under clauses (iii) 
and (iv) of such paragraph. 
‘‘(ii) MECHANISMS.—The Secretary 
may use one or more mechanisms to make 
feedback available under clause (i), which 
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may include use of a web-based portal or 
other mechanisms determined appropriate 
by the Secretary. With respect to the per-
formance category described in paragraph 
(2)(A)(i), feedback under this subpara-
graph shall, to the extent an eligible pro-
fessional chooses to participate in a data 
registry for purposes of this subsection (in-
cluding registries under subsections (k) 
and (m)), be provided based on perform-
ance on quality measures reported through 
the use of such registries. With respect to 
any other performance category described 
in paragraph (2)(A), the Secretary shall 
encourage provision of feedback through 
qualified clinical data registries as de-
scribed in subsection (m)(3)(E)). 
‘‘(iii) USE OF DATA.—For purposes of 
clause (i), the Secretary may use data, 
with respect to a MIPS eligible profes-
sional, from periods prior to the current 
performance period and may use rolling 
periods in order to make illustrative cal-
culations about the performance of such 
professional. 
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‘‘(iv) 
DISCLOSURE
EXEMPTION.— 
Feedback made available under this sub-
paragraph shall be exempt from disclosure 
under section 552 of title 5, United States 
Code. 
‘‘(v) RECEIPT
OF
INFORMATION.— 
The Secretary may use the mechanisms es-
tablished under clause (ii) to receive infor-
mation from professionals, such as infor-
mation with respect to this subsection. 
‘‘(B) ADDITIONAL INFORMATION.— 
‘‘(i) IN GENERAL.—Beginning July 1, 
2018, the Secretary shall make available to 
MIPS eligible professionals information, 
with respect to individuals who are pa-
tients of such MIPS eligible professionals, 
about items and services for which pay-
ment is made under this title that are fur-
nished to such individuals by other sup-
pliers and providers of services, which may 
include information described in clause (ii). 
Such information may be made available 
under the previous sentence to such MIPS 
eligible professionals by mechanisms deter-
mined appropriate by the Secretary, which 
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may include use of a web-based portal. 
Such information may be made available in 
accordance with the same or similar terms 
as data are made available to accountable 
care organizations participating in the 
shared savings program under section 
1899. 
‘‘(ii) TYPE
OF
INFORMATION.—For 
purposes of clause (i), the information de-
scribed in this clause, is the following: 
‘‘(I) With respect to selected 
items and services (as determined ap-
propriate by the Secretary) for which 
payment is made under this title and 
that are furnished to individuals, who 
are patients of a MIPS eligible profes-
sional, by another supplier or provider 
of services during the most recent pe-
riod for which data are available (such 
as the most recent three-month pe-
riod), such as the name of such pro-
viders furnishing such items and serv-
ices to such patients during such pe-
riod, the types of such items and serv-
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ices so furnished, and the dates such 
items and services were so furnished. 
‘‘(II) Historical data, such as 
averages and other measures of the 
distribution if appropriate, of the 
total, and components of, allowed 
charges (and other figures as deter-
mined appropriate by the Secretary). 
‘‘(13) REVIEW.— 
‘‘(A) TARGETED REVIEW.—The Secretary 
shall establish a process under which a MIPS 
eligible professional may seek an informal re-
view of the calculation of the MIPS adjustment 
factor (or factors) applicable to such eligible 
professional under this subsection for a year. 
The results of a review conducted pursuant to 
the previous sentence shall not be taken into ac-
count for purposes of paragraph (6) with re-
spect to a year (other than with respect to the 
calculation of such eligible professional’s MIPS 
adjustment factor for such year or additional 
MIPS adjustment factor for such year) after 
the factors determined in subparagraph (A) and 
subparagraph (C) of such paragraph have been 
determined for such year. 
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‘‘(B) LIMITATION.—Except as provided for 
in subparagraph (A), there shall be no adminis-
trative or judicial review under section 1869, 
section 1878, or otherwise of the following: 
‘‘(i) The methodology used to deter-
mine the amount of the MIPS adjustment 
factor under paragraph (6)(A) and the 
amount of the additional MIPS adjustment 
factor under paragraph (6)(C) and the de-
termination of such amounts. 
‘‘(ii) The establishment of the per-
formance standards under paragraph (3) 
and the performance period under para-
graph (4). 
‘‘(iii) The identification of measures 
and activities specified under paragraph 
(2)(B) and information made public or 
posted on the Physician Compare Internet 
website of the Centers for Medicare & 
Medicaid Services under paragraph (9). 
‘‘(iv) 
The 
methodology 
developed 
under paragraph (5) that is used to cal-
culate performance scores and the calcula-
tion of such scores, including the weighting 
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of measures and activities under such 
methodology.’’. 
(2) GAO REPORTS.— 
(A) EVALUATION
OF
ELIGIBLE
PROFES-
SIONAL MIPS.—Not later than October 1, 2021, 
the Comptroller General of the United States 
shall submit to Congress a report evaluating the 
eligible professional Merit-based Incentive Pay-
ment System under subsection (q) of section 
1848 of the Social Security Act (42 U.S.C. 
1395w–4), as added by paragraph (1). Such re-
port shall— 
(i) examine the distribution of the 
composite performance scores and MIPS 
adjustment factors (and additional MIPS 
adjustment factors) for MIPS eligible pro-
fessionals 
(as 
defined 
in 
subsection 
(q)(1)(c) of such section) under such pro-
gram, and patterns relating to such scores 
and adjustment factors, including based on 
type of provider, practice size, geographic 
location, and patient mix; 
(ii) provide recommendations for im-
proving such program; 
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(iii) evaluate the impact of technical 
assistance 
funding 
under 
section 
1848(q)(11) of the Social Security Act, as 
added by paragraph (1), on the ability of 
professionals to improve within such pro-
gram or successfully transition to an alter-
native payment model (as defined in sec-
tion 1833(z)(3) of the Social Security Act, 
as added by subsection (e)), with priority 
for such evaluation given to practices lo-
cated in rural areas, health professional 
shortage areas (as designated in section 
332(a)(1)(a) of the Public Health Service 
Act), and medically underserved areas; and 
(iv) provide recommendations for opti-
mizing the use of such technical assistance 
funds. 
(B) STUDY TO EXAMINE ALIGNMENT OF 
QUALITY MEASURES USED IN PUBLIC AND PRI-
VATE PROGRAMS.— 
(i) IN GENERAL.—Not later than 18 
months after the date of the enactment of 
this Act, the Comptroller General of the 
United States shall submit to Congress a 
report that— 
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(I) compares the similarities and 
differences in the use of quality meas-
ures under the original Medicare fee- 
for-service program under parts A and 
B of title XVIII of the Social Security 
Act, the Medicare Advantage program 
under part C of such title, selected 
State Medicaid programs under title 
XIX of such Act, and private payer 
arrangements; and 
(II) makes recommendations on 
how to reduce the administrative bur-
den involved in applying such quality 
measures. 
(ii) 
REQUIREMENTS.—The 
report 
under clause (i) shall— 
(I) consider those measures ap-
plicable to individuals entitled to, or 
enrolled for, benefits under such part 
A, or enrolled under such part B and 
individuals under the age of 65; and 
(II) focus on those measures that 
comprise the most significant compo-
nent of the quality performance cat-
egory of the eligible professional 
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MIPS incentive program under sub-
section (q) of section 1848 of the So-
cial Security Act (42 U.S.C. 1395w– 
4), as added by paragraph (1). 
(C) STUDY
ON
ROLE
OF
INDEPENDENT 
RISK MANAGERS.—Not later than January 1, 
2017, the Comptroller General of the United 
States shall submit to Congress a report exam-
ining whether entities that pool financial risk 
for physician practices, such as independent 
risk managers, can play a role in supporting 
physician practices, particularly small physician 
practices, in assuming financial risk for the 
treatment of patients. Such report shall exam-
ine barriers that small physician practices cur-
rently face in assuming financial risk for treat-
ing patients, the types of risk management enti-
ties that could assist physician practices in par-
ticipating in two-sided risk payment models, 
and how such entities could assist with risk 
management and with quality improvement ac-
tivities. Such report shall also include an anal-
ysis of any existing legal barriers to such ar-
rangements. 
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(D) STUDY
TO
EXAMINE
RURAL
AND 
HEALTH
PROFESSIONAL
SHORTAGE
AREA
AL-
TERNATIVE PAYMENT MODELS.—Not later than 
October 1, 2021, the Comptroller General of 
the United States shall submit to Congress a 
report that examines the transition of profes-
sionals in rural areas, health professional short-
age 
areas 
(as 
designated 
in 
section 
332(a)(1)(A) of the Public Health Service Act), 
or medically underserved areas to an alternative 
payment 
model 
(as 
defined 
in 
section 
1833(z)(3) of the Social Security Act, as added 
by subsection (e)). Such report shall make rec-
ommendations for removing administrative bar-
riers to practices, including small practices con-
sisting of 15 or fewer professionals, in rural 
areas, health professional shortage areas, and 
medically underserved areas to participation in 
such models. 
(3) FUNDING
FOR
IMPLEMENTATION.—For 
purposes of implementing the provisions of and the 
amendments made by this section, the Secretary of 
Health and Human Services shall provide for the 
transfer of $80,000,000 from the Supplementary 
Medical Insurance Trust Fund established under 
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section 1841 of the Social Security Act (42 U.S.C. 
1395t) to the Centers for Medicare & Medicaid Pro-
gram Management Account for each of the fiscal 
years 2015 through 2019. Amounts transferred 
under this paragraph shall be available until ex-
pended. 
(d) IMPROVING QUALITY REPORTING
FOR COM-
POSITE SCORES.— 
(1) CHANGES
FOR
GROUP
REPORTING
OP-
TION.— 
(A) 
IN
GENERAL.—Section 
1848(m)(3)(C)(ii) of the Social Security Act 
(42 U.S.C. 1395w–4(m)(3)(C)(ii)) is amended 
by inserting ‘‘and, for 2016 and subsequent 
years, may provide’’ after ‘‘shall provide’’. 
(B) CLARIFICATION OF QUALIFIED CLIN-
ICAL
DATA
REGISTRY
REPORTING
TO
GROUP 
PRACTICES.—Section 1848(m)(3)(D) of the So-
cial 
Security 
Act 
(42 
U.S.C. 
1395w– 
4(m)(3)(D)) is amended by inserting ‘‘and, for 
2016 and subsequent years, subparagraph (A) 
or (C)’’ after ‘‘subparagraph (A)’’. 
(2) CHANGES FOR MULTIPLE REPORTING PERI-
ODS
AND
ALTERNATIVE
CRITERIA
FOR
SATISFAC-
TORY
REPORTING.—Section 1848(m)(5)(F) of the 
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Social Security Act (42 U.S.C. 1395w–4(m)(5)(F)) 
is amended— 
(A) by striking ‘‘and subsequent years’’ 
and inserting ‘‘through reporting periods occur-
ring in 2015’’; and 
(B) by inserting ‘‘and, for reporting peri-
ods occurring in 2016 and subsequent years, 
the Secretary may establish’’ after ‘‘shall estab-
lish’’. 
(3) PHYSICIAN FEEDBACK PROGRAM REPORTS 
SUCCEEDED
BY
REPORTS
UNDER
MIPS.—Section 
1848(n) of the Social Security Act (42 U.S.C. 
1395w–4(n)) is amended by adding at the end the 
following new paragraph: 
‘‘(11) REPORTS ENDING WITH 2017.—Reports 
under the Program shall not be provided after De-
cember 31, 2017. See subsection (q)(12) for reports 
under the eligible professionals Merit-based Incentive 
Payment System.’’. 
(4) COORDINATION WITH SATISFYING MEANING-
FUL EHR USE CLINICAL QUALITY MEASURE REPORT-
ING
REQUIREMENT.—Section 1848(o)(2)(A)(iii) of 
the Social Security Act (42 U.S.C. 1395w– 
4(o)(2)(A)(iii)) is amended by inserting ‘‘and sub-
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section (q)(5)(B)(ii)(II)’’ after ‘‘Subject to subpara-
graph (B)(ii)’’. 
(e) PROMOTING ALTERNATIVE PAYMENT MODELS.— 
(1) INCREASING TRANSPARENCY OF PHYSICIAN- 
FOCUSED PAYMENT MODELS.—Section 1868 of the 
Social Security Act (42 U.S.C. 1395ee) is amended 
by adding at the end the following new subsection: 
‘‘(c) PHYSICIAN-FOCUSED PAYMENT MODELS.— 
‘‘(1) TECHNICAL ADVISORY COMMITTEE.— 
‘‘(A) ESTABLISHMENT.—There is estab-
lished an ad hoc committee to be known as the 
‘Physician-Focused Payment Model Technical 
Advisory Committee’ (referred to in this sub-
section as the ‘Committee’). 
‘‘(B) MEMBERSHIP.— 
‘‘(i) NUMBER
AND
APPOINTMENT.— 
The Committee shall be composed of 11 
members appointed by the Comptroller 
General of the United States. 
‘‘(ii) QUALIFICATIONS.—The member-
ship of the Committee shall include indi-
viduals with national recognition for their 
expertise in physician-focused payment 
models and related delivery of care. No 
more than 5 members of the Committee 
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shall be providers of services or suppliers, 
or representatives of providers of services 
or suppliers. 
‘‘(iii) PROHIBITION ON FEDERAL EM-
PLOYMENT.—A member of the Committee 
shall not be an employee of the Federal 
Government. 
‘‘(iv) 
ETHICS
DISCLOSURE.—The 
Comptroller General shall establish a sys-
tem for public disclosure by members of 
the Committee of financial and other po-
tential conflicts of interest relating to such 
members. Members of the Committee shall 
be treated as employees of Congress for 
purposes of applying title I of the Ethics 
in Government Act of 1978 (Public Law 
95–521). 
‘‘(v) DATE
OF
INITIAL
APPOINT-
MENTS.—The initial appointments of mem-
bers of the Committee shall be made by 
not later than 180 days after the date of 
enactment of this subsection. 
‘‘(C) TERM; VACANCIES.— 
‘‘(i) TERM.—The terms of members of 
the Committee shall be for 3 years except 
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that the Comptroller General shall des-
ignate staggered terms for the members 
first appointed. 
‘‘(ii) VACANCIES.—Any member ap-
pointed to fill a vacancy occurring before 
the expiration of the term for which the 
member’s predecessor was appointed shall 
be appointed only for the remainder of that 
term. A member may serve after the expi-
ration of that member’s term until a suc-
cessor has taken office. A vacancy in the 
Committee shall be filled in the manner in 
which the original appointment was made. 
‘‘(D) DUTIES.—The Committee shall meet, 
as needed, to provide comments and rec-
ommendations to the Secretary, as described in 
paragraph (2)(C), on physician-focused pay-
ment models. 
‘‘(E) COMPENSATION OF MEMBERS.— 
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), a member of the Com-
mittee shall serve without compensation. 
‘‘(ii) TRAVEL EXPENSES.—A member 
of the Committee shall be allowed travel 
expenses, including per diem in lieu of sub-
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sistence, at rates authorized for an em-
ployee of an agency under subchapter I of 
chapter 57 of title 5, United States Code, 
while away from the home or regular place 
of business of the member in the perform-
ance of the duties of the Committee. 
‘‘(F) OPERATIONAL AND TECHNICAL SUP-
PORT.— 
‘‘(i) IN
GENERAL.—The Assistant 
Secretary for Planning and Evaluation 
shall provide technical and operational sup-
port for the Committee, which may be by 
use of a contractor. The Office of the Ac-
tuary of the Centers for Medicare & Med-
icaid Services shall provide to the Com-
mittee actuarial assistance as needed. 
‘‘(ii) FUNDING.—The Secretary shall 
provide for the transfer, from the Federal 
Supplementary Medical Insurance Trust 
Fund under section 1841, such amounts as 
are necessary to carry out this paragraph 
(not to exceed $5,000,000) for fiscal year 
2015 and each subsequent fiscal year. Any 
amounts transferred under the preceding 
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sentence for a fiscal year shall remain 
available until expended. 
‘‘(G) APPLICATION.—Section 14 of the 
Federal Advisory Committee Act (5 U.S.C. 
App.) shall not apply to the Committee. 
‘‘(2) CRITERIA AND PROCESS FOR SUBMISSION 
AND
REVIEW
OF
PHYSICIAN-FOCUSED
PAYMENT 
MODELS.— 
‘‘(A) CRITERIA FOR ASSESSING PHYSICIAN- 
FOCUSED PAYMENT MODELS.— 
‘‘(i) RULEMAKING.—Not later than 
November 1, 2016, the Secretary shall, 
through notice and comment rulemaking, 
following a request for information, estab-
lish criteria for physician-focused payment 
models, including models for specialist phy-
sicians, that could be used by the Com-
mittee for making comments and rec-
ommendations 
pursuant 
to 
paragraph 
(1)(D). 
‘‘(ii) MEDPAC SUBMISSION OF COM-
MENTS.—During the comment period for 
the proposed rule described in clause (i), 
the Medicare Payment Advisory Commis-
sion may submit comments to the Sec-
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retary on the proposed criteria under such 
clause. 
‘‘(iii) UPDATING.—The Secretary may 
update the criteria established under this 
subparagraph through rulemaking. 
‘‘(B) STAKEHOLDER SUBMISSION OF PHY-
SICIAN-FOCUSED
PAYMENT
MODELS.—On an 
ongoing basis, individuals and stakeholder enti-
ties may submit to the Committee proposals for 
physician-focused payment models that such in-
dividuals and entities believe meet the criteria 
described in subparagraph (A). 
‘‘(C) COMMITTEE
REVIEW
OF
MODELS 
SUBMITTED.—The Committee shall, on a peri-
odic basis, review models submitted under sub-
paragraph (B), prepare comments and rec-
ommendations regarding whether such models 
meet the criteria described in subparagraph 
(A), and submit such comments and rec-
ommendations to the Secretary. 
‘‘(D) 
SECRETARY
REVIEW
AND
RE-
SPONSE.—The Secretary shall review the com-
ments and recommendations submitted by the 
Committee under subparagraph (C) and post a 
detailed response to such comments and rec-
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ommendations on the Internet website of the 
Centers for Medicare & Medicaid Services. 
‘‘(3) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed to impact the de-
velopment or testing of models under this title or ti-
tles XI, XIX, or XXI.’’. 
(2) INCENTIVE PAYMENTS FOR PARTICIPATION 
IN
ELIGIBLE
ALTERNATIVE
PAYMENT
MODELS.— 
Section 1833 of the Social Security Act (42 U.S.C. 
1395l) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(z) INCENTIVE PAYMENTS FOR PARTICIPATION IN 
ELIGIBLE ALTERNATIVE PAYMENT MODELS.— 
‘‘(1) PAYMENT INCENTIVE.— 
‘‘(A) IN GENERAL.—In the case of covered 
professional services furnished by an eligible 
professional during a year that is in the period 
beginning with 2019 and ending with 2024 and 
for which the professional is a qualifying APM 
participant with respect to such year, in addi-
tion to the amount of payment that would oth-
erwise be made for such covered professional 
services under this part for such year, there 
also shall be paid to such professional an 
amount equal to 5 percent of the estimated ag-
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gregate payment amounts for such covered pro-
fessional services under this part for the pre-
ceding year. For purposes of the previous sen-
tence, the payment amount for the preceding 
year may be an estimation for the full pre-
ceding year based on a period of such preceding 
year that is less than the full year. The Sec-
retary shall establish policies to implement this 
subparagraph in cases in which payment for 
covered professional services furnished by a 
qualifying APM participant in an alternative 
payment model— 
‘‘(i) is made to an eligible alternative 
payment entity rather than directly to the 
qualifying APM participant; or 
‘‘(ii) is made on a basis other than a 
fee-for-service basis (such as payment on a 
capitated basis). 
‘‘(B) 
FORM
OF
PAYMENT.—Payments 
under this subsection shall be made in a lump 
sum, on an annual basis, as soon as practicable. 
‘‘(C) TREATMENT
OF
PAYMENT
INCEN-
TIVE.—Payments under this subsection shall 
not be taken into account for purposes of deter-
mining actual expenditures under an alternative 
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payment model and for purposes of determining 
or rebasing any benchmarks used under the al-
ternative payment model. 
‘‘(D) COORDINATION.—The amount of the 
additional payment under this subsection or 
subsection (m) shall be determined without re-
gard to any additional payment under sub-
section (m) and this subsection, respectively. 
The amount of the additional payment under 
this subsection or subsection (x) shall be deter-
mined without regard to any additional pay-
ment under subsection (x) and this subsection, 
respectively. The amount of the additional pay-
ment under this subsection or subsection (y) 
shall be determined without regard to any addi-
tional payment under subsection (y) and this 
subsection, respectively. 
‘‘(2) QUALIFYING APM PARTICIPANT.—For pur-
poses of this subsection, the term ‘qualifying APM 
participant’ means the following: 
‘‘(A) 2019 AND
2020.—With respect to 
2019 and 2020, an eligible professional for 
whom the Secretary determines that at least 25 
percent of payments under this part for covered 
professional services furnished by such profes-
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during the most recent period for 
which data are available (which may 
be less than a year), that at least 50 
percent of the sum of— 
‘‘(aa) payments described in 
clause (i); and 
‘‘(bb) all other payments, re-
gardless of payer (other than 
payments made by the Secretary 
of Defense or the Secretary of 
Veterans Affairs and other than 
payments made under title XIX 
in a State in which no medical 
home or alternative payment 
model is available under the 
State program under that title), 
meet the requirement described in 
clause (iii)(I) with respect to pay-
ments described in item (aa) and meet 
the requirement described in clause 
(iii)(II) with respect to payments de-
scribed in item (bb); 
‘‘(II) for whom the Secretary de-
termines at least 25 percent of pay-
ments under this part for covered pro-
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fessional services furnished by such 
professional during the most recent 
period for which data are available 
(which may be less than a year) were 
attributable to such services furnished 
under this part through an eligible al-
ternative payment entity; and 
‘‘(III) who provides to the Sec-
retary such information as is nec-
essary for the Secretary to make a de-
termination under subclause (I), with 
respect to such professional. 
‘‘(iii) REQUIREMENT.—For purposes 
of clause (ii)(I)— 
‘‘(I) the requirement described in 
this subclause, with respect to pay-
ments described in item (aa) of such 
clause, is that such payments are 
made to an eligible alternative pay-
ment entity; and 
‘‘(II) the requirement described 
in this subclause, with respect to pay-
ments described in item (bb) of such 
clause, is that such payments are 
made under arrangements in which— 
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‘‘(aa) quality measures com-
parable to measures under the 
performance category described 
in section 1848(q)(2)(B)(i) apply; 
‘‘(bb) certified EHR tech-
nology is used; and 
‘‘(cc) the eligible profes-
sional participates in an entity 
that— 
‘‘(AA) bears more than 
nominal financial risk if ac-
tual aggregate expenditures 
exceeds expected aggregate 
expenditures; or 
‘‘(BB) with respect to 
beneficiaries 
under 
title 
XIX, is a medical home that 
meets criteria comparable to 
medical 
homes 
expanded 
under section 1115A(c). 
‘‘(C) BEGINNING IN 2023.—With respect to 
2023 and each subsequent year, an eligible pro-
fessional described in either of the following 
clauses: 
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‘‘(i) MEDICARE PAYMENT THRESHOLD 
OPTION.—An 
eligible 
professional 
for 
whom the Secretary determines that at 
least 75 percent of payments under this 
part for covered professional services fur-
nished by such professional during the 
most recent period for which data are 
available (which may be less than a year) 
were attributable to such services furnished 
under this part through an eligible alter-
native payment entity. 
‘‘(ii) COMBINATION
ALL-PAYER
AND 
MEDICARE
PAYMENT
THRESHOLD
OP-
TION.—An eligible professional— 
‘‘(I) for whom the Secretary de-
termines, with respect to items and 
services furnished by such professional 
during the most recent period for 
which data are available (which may 
be less than a year), that at least 75 
percent of the sum of— 
‘‘(aa) payments described in 
clause (i); and 
‘‘(bb) all other payments, re-
gardless of payer (other than 
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payments made by the Secretary 
of Defense or the Secretary of 
Veterans Affairs and other than 
payments made under title XIX 
in a State in which no medical 
home or alternative payment 
model is available under the 
State program under that title), 
meet the requirement described in 
clause (iii)(I) with respect to pay-
ments described in item (aa) and meet 
the requirement described in clause 
(iii)(II) with respect to payments de-
scribed in item (bb); 
‘‘(II) for whom the Secretary de-
termines at least 25 percent of pay-
ments under this part for covered pro-
fessional services furnished by such 
professional during the most recent 
period for which data are available 
(which may be less than a year) were 
attributable to such services furnished 
under this part through an eligible al-
ternative payment entity; and 
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‘‘(III) who provides to the Sec-
retary such information as is nec-
essary for the Secretary to make a de-
termination under subclause (I), with 
respect to such professional. 
‘‘(iii) REQUIREMENT.—For purposes 
of clause (ii)(I)— 
‘‘(I) the requirement described in 
this subclause, with respect to pay-
ments described in item (aa) of such 
clause, is that such payments are 
made to an eligible alternative pay-
ment entity; and 
‘‘(II) the requirement described 
in this subclause, with respect to pay-
ments described in item (bb) of such 
clause, is that such payments are 
made under arrangements in which— 
‘‘(aa) quality measures com-
parable to measures under the 
performance category described 
in section 1848(q)(2)(B)(i) apply; 
‘‘(bb) certified EHR tech-
nology is used; and 
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‘‘(cc) the eligible profes-
sional participates in an entity 
that— 
‘‘(AA) bears more than 
nominal financial risk if ac-
tual aggregate expenditures 
exceeds expected aggregate 
expenditures; or 
‘‘(BB) with respect to 
beneficiaries 
under 
title 
XIX, is a medical home that 
meets criteria comparable to 
medical 
homes 
expanded 
under section 1115A(c). 
‘‘(D) USE OF PATIENT APPROACH.—The 
Secretary may base the determination of wheth-
er an eligible professional is a qualifying APM 
participant under this subsection and the deter-
mination of whether an eligible professional is a 
partial qualifying APM participant under sec-
tion 1848(q)(1)(C)(iii) by using counts of pa-
tients in lieu of using payments and using the 
same or similar percentage criteria (as specified 
in this subsection and such section, respec-
tively), as the Secretary determines appropriate. 
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‘‘(3) ADDITIONAL DEFINITIONS.—In this sub-
section: 
‘‘(A) 
COVERED
PROFESSIONAL
SERV-
ICES.—The term ‘covered professional services’ 
has the meaning given that term in section 
1848(k)(3)(A). 
‘‘(B) ELIGIBLE PROFESSIONAL.—The term 
‘eligible professional’ has the meaning given 
that term in section 1848(k)(3)(B) and includes 
a group that includes such professionals. 
‘‘(C) 
ALTERNATIVE
PAYMENT
MODEL 
(APM).—The term ‘alternative payment model’ 
means, other than for purposes of subpara-
graphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of para-
graph (2), any of the following: 
‘‘(i) A model under section 1115A 
(other than a health care innovation 
award). 
‘‘(ii) The shared savings program 
under section 1899. 
‘‘(iii) A demonstration under section 
1866C. 
‘‘(iv) A demonstration required by 
Federal law. 
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‘‘(D) ELIGIBLE
ALTERNATIVE
PAYMENT 
ENTITY.—The term ‘eligible alternative pay-
ment entity’ means, with respect to a year, an 
entity that— 
‘‘(i) participates in an alternative pay-
ment model that— 
‘‘(I) requires participants in such 
model to use certified EHR tech-
nology (as defined in subsection 
(o)(4)); and 
‘‘(II) provides for payment for 
covered professional services based on 
quality measures comparable to meas-
ures under the performance category 
described in section 1848(q)(2)(B)(i); 
and 
‘‘(ii)(I) bears financial risk for mone-
tary losses under such alternative payment 
model that are in excess of a nominal 
amount; or 
‘‘(II) is a medical home expanded 
under section 1115A(c). 
‘‘(4) LIMITATION.—There shall be no adminis-
trative or judicial review under section 1869, 1878, 
or otherwise, of the following: 
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‘‘(A) The determination that an eligible 
professional is a qualifying APM participant 
under paragraph (2) and the determination 
that an entity is an eligible alternative payment 
entity under paragraph (3)(D). 
‘‘(B) The determination of the amount of 
the 5 percent payment incentive under para-
graph (1)(A), including any estimation as part 
of such determination.’’. 
(3) 
COORDINATION
CONFORMING
AMEND-
MENTS.—Section 1833 of the Social Security Act 
(42 U.S.C. 1395l) is further amended— 
(A) in subsection (x)(3), by adding at the 
end the following new sentence: ‘‘The amount 
of the additional payment for a service under 
this subsection and subsection (z) shall be de-
termined without regard to any additional pay-
ment for the service under subsection (z) and 
this subsection, respectively.’’; and 
(B) in subsection (y)(3), by adding at the 
end the following new sentence: ‘‘The amount 
of the additional payment for a service under 
this subsection and subsection (z) shall be de-
termined without regard to any additional pay-
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100 
ment for the service under subsection (z) and 
this subsection, respectively.’’. 
(4) ENCOURAGING DEVELOPMENT AND TEST-
ING OF CERTAIN MODELS.—Section 1115A(b)(2) of 
the Social Security Act (42 U.S.C. 1315a(b)(2)) is 
amended— 
(A) in subparagraph (B), by adding at the 
end the following new clauses: 
‘‘(xxi) Focusing primarily on physi-
cians’ services (as defined in section 
1848(j)(3)) furnished by physicians who 
are not primary care practitioners. 
‘‘(xxii) Focusing on practices of 15 or 
fewer professionals. 
‘‘(xxiii) Focusing on risk-based models 
for small physician practices which may in-
volve two-sided risk and prospective patient 
assignment, and which examine risk-ad-
justed decreases in mortality rates, hos-
pital readmissions rates, and other relevant 
and appropriate clinical measures. 
‘‘(xxiv) Focusing primarily on title 
XIX, working in conjunction with the Cen-
ter for Medicaid and CHIP Services.’’; and 
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101 
(B) in subparagraph (C)(viii), by striking 
‘‘other public sector or private sector payers’’ 
and inserting ‘‘other public sector payers, pri-
vate sector payers, or Statewide payment mod-
els’’. 
(5) CONSTRUCTION
REGARDING
TELEHEALTH 
SERVICES.—Nothing in the provisions of, or amend-
ments made by, this Act shall be construed as pre-
cluding an alternative payment model or a qualifying 
APM participant (as those terms are defined in sec-
tion 1833(z) of the Social Security Act, as added by 
paragraph (1)) from furnishing a telehealth service 
for which payment is not made under section 
1834(m) of the Social Security Act (42 U.S.C. 
1395m(m)). 
(6) INTEGRATING
MEDICARE
ADVANTAGE
AL-
TERNATIVE PAYMENT MODELS.—Not later than July 
1, 2016, the Secretary of Health and Human Serv-
ices shall submit to Congress a study that examines 
the feasibility of integrating alternative payment 
models in the Medicare Advantage payment system. 
The study shall include the feasibility of including a 
value-based modifier and whether such modifier 
should be budget neutral. 
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102 
(7) STUDY AND REPORT ON FRAUD RELATED 
TO
ALTERNATIVE
PAYMENT
MODELS
UNDER
THE 
MEDICARE PROGRAM.— 
(A) STUDY.—The Secretary of Health and 
Human Services, in consultation with the In-
spector General of the Department of Health 
and Human Services, shall conduct a study 
that— 
(i) examines the applicability of the 
Federal fraud prevention laws to items and 
services furnished under title XVIII of the 
Social Security Act for which payment is 
made under an alternative payment model 
(as defined in section 1833(z)(3)(C) of 
such Act (42 U.S.C. 1395l(z)(3)(C))); 
(ii) identifies aspects of such alter-
native payment models that are vulnerable 
to fraudulent activity; and 
(iii) examines the implications of waiv-
ers to such laws granted in support of such 
alternative 
payment 
models, 
including 
under any potential expansion of such 
models. 
(B) REPORT.—Not later than 2 years after 
the date of the enactment of this Act, the Sec-
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103 
retary shall submit to Congress a report con-
taining the results of the study conducted under 
subparagraph (A). Such report shall include 
recommendations for actions to be taken to re-
duce the vulnerability of such alternative pay-
ment models to fraudulent activity. Such report 
also shall include, as appropriate, recommenda-
tions of the Inspector General for changes in 
Federal fraud prevention laws to reduce such 
vulnerability. 
(f) COLLABORATING WITH THE PHYSICIAN, PRACTI-
TIONER, AND OTHER STAKEHOLDER COMMUNITIES TO 
IMPROVE RESOURCE USE MEASUREMENT.—Section 1848 
of the Social Security Act (42 U.S.C. 1395w–4), as 
amended by subsection (c), is further amended by adding 
at the end the following new subsection: 
‘‘(r) COLLABORATING WITH THE PHYSICIAN, PRAC-
TITIONER, AND OTHER STAKEHOLDER COMMUNITIES TO 
IMPROVE RESOURCE USE MEASUREMENT.— 
‘‘(1) IN GENERAL.—In order to involve the phy-
sician, practitioner, and other stakeholder commu-
nities in enhancing the infrastructure for resource 
use measurement, including for purposes of the 
Merit-based Incentive Payment System under sub-
section (q) and alternative payment models under 
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104 
section 1833(z), the Secretary shall undertake the 
steps described in the succeeding provisions of this 
subsection. 
‘‘(2) DEVELOPMENT OF CARE EPISODE AND PA-
TIENT
CONDITION
GROUPS
AND
CLASSIFICATION 
CODES.— 
‘‘(A) IN
GENERAL.—In order to classify 
similar patients into care episode groups and 
patient condition groups, the Secretary shall 
undertake the steps described in the succeeding 
provisions of this paragraph. 
‘‘(B) PUBLIC AVAILABILITY OF EXISTING 
EFFORTS TO DESIGN AN EPISODE GROUPER.— 
Not later than 180 days after the date of the 
enactment of this subsection, the Secretary 
shall post on the Internet website of the Cen-
ters for Medicare & Medicaid Services a list of 
the episode groups developed pursuant to sub-
section (n)(9)(A) and related descriptive infor-
mation. 
‘‘(C) STAKEHOLDER
INPUT.—The Sec-
retary shall accept, through the date that is 
120 days after the day the Secretary posts the 
list pursuant to subparagraph (B), suggestions 
from physician specialty societies, applicable 
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105 
practitioner organizations, and other stake-
holders for episode groups in addition to those 
posted pursuant to such subparagraph, and 
specific clinical criteria and patient characteris-
tics to classify patients into— 
‘‘(i) care episode groups; and 
‘‘(ii) patient condition groups. 
‘‘(D) DEVELOPMENT OF PROPOSED CLAS-
SIFICATION CODES.— 
‘‘(i) IN
GENERAL.—Taking into ac-
count the information described in sub-
paragraph (B) and the information re-
ceived under subparagraph (C), the Sec-
retary shall— 
‘‘(I) establish care episode groups 
and patient condition groups, which 
account for a target of an estimated 
1⁄2 of expenditures under parts A and 
B (with such target increasing over 
time as appropriate); and 
‘‘(II) 
assign 
codes 
to 
such 
groups. 
‘‘(ii) CARE EPISODE GROUPS.—In es-
tablishing the care episode groups under 
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106 
clause (i), the Secretary shall take into ac-
count— 
‘‘(I) the patient’s clinical prob-
lems at the time items and services 
are furnished during an episode of 
care, such as the clinical conditions or 
diagnoses, whether or not inpatient 
hospitalization occurs, and the prin-
cipal procedures or services furnished; 
and 
‘‘(II) other factors determined 
appropriate by the Secretary. 
‘‘(iii) PATIENT CONDITION GROUPS.— 
In 
establishing 
the 
patient 
condition 
groups under clause (i), the Secretary shall 
take into account— 
‘‘(I) the patient’s clinical history 
at the time of a medical visit, such as 
the patient’s combination of chronic 
conditions, current health status, and 
recent significant history (such as 
hospitalization and major surgery dur-
ing a previous period, such as 3 
months); and 
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107 
‘‘(II) other factors determined 
appropriate by the Secretary, such as 
eligibility status under this title (in-
cluding 
eligibility 
under 
section 
226(a), 226(b), or 226A, and dual eli-
gibility under this title and title XIX). 
‘‘(E) DRAFT CARE EPISODE AND PATIENT 
CONDITION
GROUPS
AND
CLASSIFICATION 
CODES.—Not later than 270 days after the end 
of the comment period described in subpara-
graph (C), the Secretary shall post on the 
Internet website of the Centers for Medicare & 
Medicaid Services a draft list of the care epi-
sode and patient condition codes established 
under subparagraph (D) (and the criteria and 
characteristics assigned to such code). 
‘‘(F) SOLICITATION OF INPUT.—The Sec-
retary shall seek, through the date that is 120 
days after the Secretary posts the list pursuant 
to subparagraph (E), comments from physician 
specialty societies, applicable practitioner orga-
nizations, and other stakeholders, including rep-
resentatives of individuals entitled to benefits 
under part A or enrolled under this part, re-
garding the care episode and patient condition 
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108 
groups (and codes) posted under subparagraph 
(E). In seeking such comments, the Secretary 
shall use one or more mechanisms (other than 
notice and comment rulemaking) that may in-
clude use of open door forums, town hall meet-
ings, or other appropriate mechanisms. 
‘‘(G) OPERATIONAL
LIST
OF
CARE
EPI-
SODE AND PATIENT CONDITION GROUPS AND 
CODES.—Not later than 270 days after the end 
of the comment period described in subpara-
graph (F), taking into account the comments 
received under such subparagraph, the Sec-
retary shall post on the Internet website of the 
Centers for Medicare & Medicaid Services an 
operational list of care episode and patient con-
dition codes (and the criteria and characteris-
tics assigned to such code). 
‘‘(H) SUBSEQUENT REVISIONS.—Not later 
than November 1 of each year (beginning with 
2018), the Secretary shall, through rulemaking, 
make revisions to the operational lists of care 
episode and patient condition codes as the Sec-
retary determines may be appropriate. Such re-
visions may be based on experience, new infor-
mation 
developed 
pursuant 
to 
subsection 
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109 
(n)(9)(A), and input from the physician spe-
cialty societies, applicable practitioner organiza-
tions, and other stakeholders, including rep-
resentatives of individuals entitled to benefits 
under part A or enrolled under this part. 
‘‘(3) ATTRIBUTION
OF
PATIENTS
TO
PHYSI-
CIANS OR PRACTITIONERS.— 
‘‘(A) IN GENERAL.—In order to facilitate 
the attribution of patients and episodes (in 
whole or in part) to one or more physicians or 
applicable practitioners furnishing items and 
services, the Secretary shall undertake the steps 
described in the succeeding provisions of this 
paragraph. 
‘‘(B) DEVELOPMENT
OF
PATIENT
RELA-
TIONSHIP CATEGORIES AND CODES.—The Sec-
retary shall develop patient relationship cat-
egories and codes that define and distinguish 
the relationship and responsibility of a physi-
cian or applicable practitioner with a patient at 
the time of furnishing an item or service. Such 
patient relationship categories shall include dif-
ferent relationships of the physician or applica-
ble practitioner to the patient (and the codes 
may reflect combinations of such categories), 
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110 
such as a physician or applicable practitioner 
who— 
‘‘(i) considers themself to have the 
primary responsibility for the general and 
ongoing care for the patient over extended 
periods of time; 
‘‘(ii) considers themself to be the lead 
physician or practitioner and who furnishes 
items and services and coordinates care 
furnished by other physicians or practi-
tioners for the patient during an acute epi-
sode; 
‘‘(iii) furnishes items and services to 
the patient on a continuing basis during an 
acute episode of care, but in a supportive 
rather than a lead role; 
‘‘(iv) furnishes items and services to 
the patient on an occasional basis, usually 
at the request of another physician or 
practitioner; or 
‘‘(v) furnishes items and services only 
as ordered by another physician or practi-
tioner. 
‘‘(C) DRAFT LIST OF PATIENT RELATION-
SHIP CATEGORIES AND CODES.—Not later than 
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one year after the date of the enactment of this 
subsection, the Secretary shall post on the 
Internet website of the Centers for Medicare & 
Medicaid Services a draft list of the patient re-
lationship categories and codes developed under 
subparagraph (B). 
‘‘(D) STAKEHOLDER
INPUT.—The Sec-
retary shall seek, through the date that is 120 
days after the Secretary posts the list pursuant 
to subparagraph (C), comments from physician 
specialty societies, applicable practitioner orga-
nizations, and other stakeholders, including rep-
resentatives of individuals entitled to benefits 
under part A or enrolled under this part, re-
garding the patient relationship categories and 
codes posted under subparagraph (C). In seek-
ing such comments, the Secretary shall use one 
or more mechanisms (other than notice and 
comment rulemaking) that may include open 
door forums, town hall meetings, web-based fo-
rums, or other appropriate mechanisms. 
‘‘(E) OPERATIONAL LIST OF PATIENT RE-
LATIONSHIP
CATEGORIES
AND
CODES.—Not 
later than 240 days after the end of the com-
ment period described in subparagraph (D), 
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taking into account the comments received 
under such subparagraph, the Secretary shall 
post on the Internet website of the Centers for 
Medicare & Medicaid Services an operational 
list of patient relationship categories and codes. 
‘‘(F) SUBSEQUENT REVISIONS.—Not later 
than November 1 of each year (beginning with 
2018), the Secretary shall, through rulemaking, 
make revisions to the operational list of patient 
relationship categories and codes as the Sec-
retary determines appropriate. Such revisions 
may be based on experience, new information 
developed pursuant to subsection (n)(9)(A), and 
input from the physician specialty societies, ap-
plicable practitioner organizations, and other 
stakeholders, including representatives of indi-
viduals entitled to benefits under part A or en-
rolled under this part. 
‘‘(4) REPORTING
OF
INFORMATION
FOR
RE-
SOURCE USE MEASUREMENT.—Claims submitted for 
items and services furnished by a physician or appli-
cable practitioner on or after January 1, 2018, shall, 
as determined appropriate by the Secretary, in-
clude— 
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113 
‘‘(A) applicable codes established under 
paragraphs (2) and (3); and 
‘‘(B) the national provider identifier of the 
ordering physician or applicable practitioner (if 
different from the billing physician or applicable 
practitioner). 
‘‘(5) METHODOLOGY FOR RESOURCE USE ANAL-
YSIS.— 
‘‘(A) IN GENERAL.—In order to evaluate 
the resources used to treat patients (with re-
spect to care episode and patient condition 
groups), the Secretary shall, as the Secretary 
determines appropriate— 
‘‘(i) use the patient relationship codes 
reported on claims pursuant to paragraph 
(4) to attribute patients (in whole or in 
part) to one or more physicians and appli-
cable practitioners; 
‘‘(ii) use the care episode and patient 
condition codes reported on claims pursu-
ant to paragraph (4) as a basis to compare 
similar patients and care episodes and pa-
tient condition groups; and 
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114 
‘‘(iii) conduct an analysis of resource 
use (with respect to care episodes and pa-
tient condition groups of such patients). 
‘‘(B) ANALYSIS OF PATIENTS OF PHYSI-
CIANS AND PRACTITIONERS.—In conducting the 
analysis described in subparagraph (A)(iii) with 
respect to patients attributed to physicians and 
applicable practitioners, the Secretary shall, as 
feasible— 
‘‘(i) use the claims data experience of 
such patients by patient condition codes 
during a common period, such as 12 
months; and 
‘‘(ii) use the claims data experience of 
such patients by care episode codes— 
‘‘(I) in the case of episodes with-
out a hospitalization, during periods 
of time (such as the number of days) 
determined appropriate by the Sec-
retary; and 
‘‘(II) in the case of episodes with 
a hospitalization, during periods of 
time (such as the number of days) be-
fore, during, and after the hospitaliza-
tion. 
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115 
‘‘(C) MEASUREMENT OF RESOURCE USE.— 
In measuring such resource use, the Sec-
retary— 
‘‘(i) shall use per patient total allowed 
charges for all services under part A and 
this part (and, if the Secretary determines 
appropriate, part D) for the analysis of pa-
tient resource use, by care episode codes 
and by patient condition codes; and 
‘‘(ii) may, as determined appropriate, 
use other measures of allowed charges 
(such as subtotals for categories of items 
and services) and measures of utilization of 
items and services (such as frequency of 
specific items and services and the ratio of 
specific items and services among attrib-
uted patients or episodes). 
‘‘(D) STAKEHOLDER
INPUT.—The Sec-
retary shall seek comments from the physician 
specialty societies, applicable practitioner orga-
nizations, and other stakeholders, including rep-
resentatives of individuals entitled to benefits 
under part A or enrolled under this part, re-
garding the resource use methodology estab-
lished pursuant to this paragraph. In seeking 
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116 
comments the Secretary shall use one or more 
mechanisms (other than notice and comment 
rulemaking) that may include open door fo-
rums, town hall meetings, web-based forums, or 
other appropriate mechanisms. 
‘‘(6) IMPLEMENTATION.—To the extent that 
the Secretary contracts with an entity to carry out 
any part of the provisions of this subsection, the 
Secretary may not contract with an entity or an en-
tity with a subcontract if the entity or subcon-
tracting entity currently makes recommendations to 
the Secretary on relative values for services under 
the fee schedule for physicians’ services under this 
section. 
‘‘(7) LIMITATION.—There shall be no adminis-
trative or judicial review under section 1869, section 
1878, or otherwise of— 
‘‘(A) care episode and patient condition 
groups and codes established under paragraph 
(2); 
‘‘(B) patient relationship categories and 
codes established under paragraph (3); and 
‘‘(C) measurement of, and analyses of re-
source use with respect to, care episode and pa-
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tient condition codes and patient relationship 
codes pursuant to paragraph (5). 
‘‘(8) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to this section. 
‘‘(9) DEFINITIONS.—In this subsection: 
‘‘(A) PHYSICIAN.—The term ‘physician’ 
has the meaning given such term in section 
1861(r)(1). 
‘‘(B) APPLICABLE
PRACTITIONER.—The 
term ‘applicable practitioner’ means— 
‘‘(i) a physician assistant, nurse prac-
titioner, and clinical nurse specialist (as 
such 
terms 
are 
defined 
in 
section 
1861(aa)(5)), and a certified registered 
nurse anesthetist (as defined in section 
1861(bb)(2)); and 
‘‘(ii) beginning January 1, 2019, such 
other eligible professionals (as defined in 
subsection (k)(3)(B)) as specified by the 
Secretary. 
‘‘(10) CLARIFICATION.—The provisions of sec-
tions 1890(b)(7) and 1890A shall not apply to this 
subsection.’’. 
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SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVEL-
OPMENT. 
Section 1848 of the Social Security Act (42 U.S.C. 
1395w–4), as amended by subsections (c) and (f) of sec-
tion 2, is further amended by inserting at the end the fol-
lowing new subsection: 
‘‘(s) PRIORITIES AND FUNDING FOR MEASURE DE-
VELOPMENT.— 
‘‘(1) PLAN IDENTIFYING MEASURE DEVELOP-
MENT PRIORITIES AND TIMELINES.— 
‘‘(A) DRAFT
MEASURE
DEVELOPMENT 
PLAN.—Not later than January 1, 2016, the 
Secretary shall develop, and post on the Inter-
net website of the Centers for Medicare & Med-
icaid Services, a draft plan for the development 
of quality measures for application under the 
applicable provisions (as defined in paragraph 
(5)). Under such plan the Secretary shall— 
‘‘(i) address how measures used by 
private payers and integrated delivery sys-
tems could be incorporated under title 
XVIII; 
‘‘(ii) describe how coordination, to the 
extent possible, will occur across organiza-
tions developing such measures; and 
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‘‘(iii) take into account how clinical 
best practices and clinical practice guide-
lines should be used in the development of 
quality measures. 
‘‘(B) QUALITY DOMAINS.—For purposes of 
this subsection, the term ‘quality domains’ 
means at least the following domains: 
‘‘(i) Clinical care. 
‘‘(ii) Safety. 
‘‘(iii) Care coordination. 
‘‘(iv) Patient and caregiver experience. 
‘‘(v) Population health and preven-
tion. 
‘‘(C) CONSIDERATION.—In developing the 
draft plan under this paragraph, the Secretary 
shall consider— 
‘‘(i) gap analyses conducted by the en-
tity with a contract under section 1890(a) 
or other contractors or entities; 
‘‘(ii) whether measures are applicable 
across health care settings; 
‘‘(iii) clinical practice improvement ac-
tivities 
submitted 
under 
subsection 
(q)(2)(C)(iv) for identifying possible areas 
for future measure development and identi-
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fying existing gaps with respect to such 
measures; and 
‘‘(iv) the quality domains applied 
under this subsection. 
‘‘(D) PRIORITIES.—In developing the draft 
plan under this paragraph, the Secretary shall 
give priority to the following types of measures: 
‘‘(i) Outcome measures, including pa-
tient reported outcome and functional sta-
tus measures. 
‘‘(ii) Patient experience measures. 
‘‘(iii) Care coordination measures. 
‘‘(iv) Measures of appropriate use of 
services, including measures of over use. 
‘‘(E) STAKEHOLDER
INPUT.—The Sec-
retary shall accept through March 1, 2016, 
comments on the draft plan posted under para-
graph (1)(A) from the public, including health 
care providers, payers, consumers, and other 
stakeholders. 
‘‘(F) 
FINAL
MEASURE
DEVELOPMENT 
PLAN.—Not later than May 1, 2016, taking 
into account the comments received under this 
subparagraph, the Secretary shall finalize the 
plan and post on the Internet website of the 
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Centers for Medicare & Medicaid Services an 
operational plan for the development of quality 
measures for use under the applicable provi-
sions. Such plan shall be updated as appro-
priate. 
‘‘(2) CONTRACTS AND OTHER ARRANGEMENTS 
FOR QUALITY MEASURE DEVELOPMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enter into contracts or other arrangements with 
entities for the purpose of developing, improv-
ing, updating, or expanding in accordance with 
the plan under paragraph (1) quality measures 
for application under the applicable provisions. 
Such entities shall include organizations with 
quality measure development expertise. 
‘‘(B) PRIORITIZATION.— 
‘‘(i) IN
GENERAL.—In entering into 
contracts or other arrangements under 
subparagraph (A), the Secretary shall give 
priority to the development of the types of 
measures described in paragraph (1)(D). 
‘‘(ii) CONSIDERATION.—In selecting 
measures for development under this sub-
section, the Secretary shall consider— 
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‘‘(I) 
whether 
such 
measures 
would be electronically specified; and 
‘‘(II) clinical practice guidelines 
to the extent that such guidelines 
exist. 
‘‘(3) ANNUAL REPORT BY THE SECRETARY.— 
‘‘(A) IN GENERAL.—Not later than May 1, 
2017, and annually thereafter, the Secretary 
shall post on the Internet website of the Cen-
ters for Medicare & Medicaid Services a report 
on the progress made in developing quality 
measures for application under the applicable 
provisions. 
‘‘(B) REQUIREMENTS.—Each report sub-
mitted pursuant to subparagraph (A) shall in-
clude the following: 
‘‘(i) A description of the Secretary’s 
efforts to implement this paragraph. 
‘‘(ii) With respect to the measures de-
veloped during the previous year— 
‘‘(I) a description of the total 
number of quality measures developed 
and the types of such measures, such 
as an outcome or patient experience 
measure; 
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‘‘(II) the name of each measure 
developed; 
‘‘(III) the name of the developer 
and steward of each measure; 
‘‘(IV) with respect to each type 
of measure, an estimate of the total 
amount expended under this title to 
develop all measures of such type; and 
‘‘(V) whether the measure would 
be electronically specified. 
‘‘(iii) With respect to measures in de-
velopment at the time of the report— 
‘‘(I) the information described in 
clause (ii), if available; and 
‘‘(II) a timeline for completion of 
the development of such measures. 
‘‘(iv) A description of any updates to 
the plan under paragraph (1) (including 
newly identified gaps and the status of pre-
viously identified gaps) and the inventory 
of measures applicable under the applicable 
provisions. 
‘‘(v) Other information the Secretary 
determines to be appropriate. 
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‘‘(4) STAKEHOLDER
INPUT.—With respect to 
paragraph (1), the Secretary shall seek stakeholder 
input with respect to— 
‘‘(A) the identification of gaps where no 
quality measures exist, particularly with respect 
to the types of measures described in paragraph 
(1)(D); 
‘‘(B) prioritizing quality measure develop-
ment to address such gaps; and 
‘‘(C) other areas related to quality measure 
development determined appropriate by the Sec-
retary. 
‘‘(5) 
DEFINITION
OF
APPLICABLE
PROVI-
SIONS.—In this subsection, the term ‘applicable pro-
visions’ means the following provisions: 
‘‘(A) Subsection (q)(2)(B)(i). 
‘‘(B) Section 1833(z)(2)(C). 
‘‘(6) FUNDING.—For purposes of carrying out 
this subsection, the Secretary shall provide for the 
transfer, from the Federal Supplementary Medical 
Insurance Trust Fund under section 1841, of 
$15,000,000 to the Centers for Medicare & Medicaid 
Services Program Management Account for each of 
fiscal years 2015 through 2019. Amounts trans-
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ferred under this paragraph shall remain available 
through the end of fiscal year 2022. 
‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to the collection 
of information for the development of quality meas-
ures.’’. 
SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVID-
UALS WITH CHRONIC CARE NEEDS. 
(a) IN GENERAL.—Section 1848(b) of the Social Se-
curity Act (42 U.S.C. 1395w–4(b)) is amended by adding 
at the end the following new paragraph: 
‘‘(8) ENCOURAGING
CARE
MANAGEMENT
FOR 
INDIVIDUALS WITH CHRONIC CARE NEEDS.— 
‘‘(A) IN GENERAL.—In order to encourage 
the management of care for individuals with 
chronic care needs the Secretary shall, subject 
to subparagraph (B), make payment (as the 
Secretary determines to be appropriate) under 
this section for chronic care management serv-
ices furnished on or after January 1, 2015, by 
a physician (as defined in section 1861(r)(1)), 
physician assistant or nurse practitioner (as de-
fined in section 1861(aa)(5)(A)), clinical nurse 
specialist 
(as 
defined 
in 
section 
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126 
1861(aa)(5)(B)), or certified nurse midwife (as 
defined in section 1861(gg)(2)). 
‘‘(B) POLICIES RELATING TO PAYMENT.— 
In carrying out this paragraph, with respect to 
chronic care management services, the Sec-
retary shall— 
‘‘(i) make payment to only one appli-
cable provider for such services furnished 
to an individual during a period; 
‘‘(ii) not make payment under sub-
paragraph (A) if such payment would be 
duplicative of payment that is otherwise 
made under this title for such services; and 
‘‘(iii) not require that an annual 
wellness visit (as defined in section 
1861(hhh)) or an initial preventive phys-
ical examination (as defined in section 
1861(ww)) be furnished as a condition of 
payment for such management services.’’. 
(b) EDUCATION AND OUTREACH.— 
(1) CAMPAIGN.— 
(A) 
IN
GENERAL.—The 
Secretary 
of 
Health and Human Services (in this subsection 
referred to as the ‘‘Secretary’’) shall conduct an 
education and outreach campaign to inform 
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professionals who furnish items and services 
under part B of title XVIII of the Social Secu-
rity Act and individuals enrolled under such 
part of the benefits of chronic care management 
services described in section 1848(b)(8) of the 
Social Security Act, as added by subsection (a), 
and encourage such individuals with chronic 
care needs to receive such services. 
(B) 
REQUIREMENTS.—Such 
campaign 
shall— 
(i) be directed by the Office of Rural 
Health Policy of the Department of Health 
and Human Services and the Office of Mi-
nority Health of the Centers for Medicare 
& Medicaid Services; and 
(ii) focus on encouraging participation 
by underserved rural populations and ra-
cial and ethnic minority populations. 
(2) REPORT.—Not later than December 31, 
2017, the Secretary shall submit to Congress a re-
port on the use of chronic care management services 
described in such section 1848(b)(8) by individuals 
living in rural areas and by racial and ethnic minor-
ity populations. Such report shall— 
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128 
(A) identify barriers to receiving chronic 
care management services; and 
(B) make recommendations for increasing 
the appropriate use of chronic care manage-
ment services. 
SEC. 5. EMPOWERING BENEFICIARY CHOICES THROUGH 
CONTINUED ACCESS TO INFORMATION ON 
PHYSICIANS’ SERVICES. 
(a) IN GENERAL.—On an annual basis (beginning 
with 2015), the Secretary shall make publicly available, 
in an easily understandable format, information with re-
spect to physicians and, as appropriate, other eligible pro-
fessionals on items and services furnished to Medicare 
beneficiaries under title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.). 
(b) TYPE AND MANNER OF INFORMATION.—The in-
formation made available under this section shall be simi-
lar to the type of information in the Medicare Provider 
Utilization and Payment Data: Physician and Other Sup-
plier Public Use File released by the Secretary with re-
spect to 2012 and shall be made available in a manner 
similar to the manner in which the information in such 
File is made available. 
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129 
(c) REQUIREMENTS.—The information made avail-
able under this section shall include, at a minimum, the 
following: 
(1) Information on the number of services fur-
nished by the physician or other eligible professional 
under part B of title XVIII of the Social Security 
Act (42 U.S.C. 1395j et seq.), which may include in-
formation on the most frequent services furnished or 
groupings of services. 
(2) Information on submitted charges and pay-
ments for services under such part. 
(3) A unique identifier for the physician or 
other eligible professional that is available to the 
public, such as a national provider identifier. 
(d) SEARCHABILITY.—The information made avail-
able under this section shall be searchable by at least the 
following: 
(1) The specialty or type of the physician or 
other eligible professional. 
(2) Characteristics of the services furnished, 
such as volume or groupings of services. 
(3) The location of the physician or other eligi-
ble professional. 
(e) INTEGRATION ON PHYSICIAN COMPARE.—Begin-
ning with 2016, the Secretary shall integrate the informa-
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130 
tion made available under this section on Physician Com-
pare. 
(f) DEFINITIONS.—In this section: 
(1) ELIGIBLE PROFESSIONAL; PHYSICIAN; SEC-
RETARY.—The terms ‘‘eligible professional’’, ‘‘physi-
cian’’, and ‘‘Secretary’’ have the meaning given such 
terms in section 10331(i) of Public Law 111–148. 
(2) PHYSICIAN COMPARE.—The term ‘‘Physi-
cian Compare’’ means the Physician Compare Inter-
net website of the Centers for Medicare & Medicaid 
Services (or a successor website). 
SEC. 6. EXPANDING AVAILABILITY OF MEDICARE DATA. 
(a) EXPANDING USES
OF MEDICARE DATA
BY 
QUALIFIED ENTITIES.— 
(1) ADDITIONAL ANALYSES.— 
(A) IN
GENERAL.—Subject to subpara-
graph (B), to the extent consistent with appli-
cable information, privacy, security, and disclo-
sure laws (including paragraph (3)), notwith-
standing paragraph (4)(B) of section 1874(e) of 
the Social Security Act (42 U.S.C. 1395kk(e)) 
and the second sentence of paragraph (4)(D) of 
such section, beginning July 1, 2016, a quali-
fied entity may use the combined data described 
in paragraph (4)(B)(iii) of such section received 
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131 
by such entity under such section, and informa-
tion derived from the evaluation described in 
such paragraph (4)(D), to conduct additional 
non-public analyses (as determined appropriate 
by the Secretary) and provide or sell such anal-
yses to authorized users for non-public use (in-
cluding for the purposes of assisting providers 
of services and suppliers to develop and partici-
pate in quality and patient care improvement 
activities, including developing new models of 
care). 
(B) LIMITATIONS WITH RESPECT TO ANAL-
YSES.— 
(i) EMPLOYERS.—Any analyses pro-
vided or sold under subparagraph (A) to 
an 
employer 
described 
in 
paragraph 
(9)(A)(iii) may only be used by such em-
ployer for purposes of providing health in-
surance to employees and retirees of the 
employer. 
(ii) HEALTH INSURANCE ISSUERS.—A 
qualified entity may not provide or sell an 
analysis to a health insurance issuer de-
scribed in paragraph (9)(A)(iv) unless the 
issuer is providing the qualified entity with 
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132 
data under section 1874(e)(4)(B)(iii) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395kk(e)(4)(B)(iii)). 
(2) ACCESS TO CERTAIN DATA.— 
(A) ACCESS.—To the extent consistent 
with applicable information, privacy, security, 
and disclosure laws (including paragraph (3)), 
notwithstanding paragraph (4)(B) of section 
1874(e) of the Social Security Act (42 U.S.C. 
1395kk(e)) and the second sentence of para-
graph (4)(D) of such section, beginning July 1, 
2016, a qualified entity may— 
(i) provide or sell the combined data 
described in paragraph (4)(B)(iii) of such 
section to authorized users described in 
clauses (i), (ii), and (v) of paragraph 
(9)(A) for non-public use, including for the 
purposes described in subparagraph (B); 
or 
(ii) subject to subparagraph (C), pro-
vide Medicare claims data to authorized 
users described in clauses (i), (ii), and (v), 
of paragraph (9)(A) for non-public use, in-
cluding for the purposes described in sub-
paragraph (B). 
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(B) PURPOSES DESCRIBED.—The purposes 
described in this subparagraph are assisting 
providers of services and suppliers in developing 
and participating in quality and patient care 
improvement activities, including developing 
new models of care. 
(C) MEDICARE
CLAIMS
DATA
MUST
BE 
PROVIDED AT NO COST.—A qualified entity may 
not charge a fee for providing the data under 
subparagraph (A)(ii). 
(3) PROTECTION OF INFORMATION.— 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), an analysis or data that is 
provided or sold under paragraph (1) or (2) 
shall not contain information that individually 
identifies a patient. 
(B) INFORMATION ON PATIENTS OF THE 
PROVIDER OF SERVICES OR SUPPLIER.—To the 
extent consistent with applicable information, 
privacy, security, and disclosure laws, an anal-
ysis or data that is provided or sold to a pro-
vider of services or supplier under paragraph 
(1) or (2) may contain information that individ-
ually identifies a patient of such provider or 
supplier, including with respect to items and 
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services furnished to the patient by other pro-
viders of services or suppliers. 
(C) PROHIBITION ON USING ANALYSES OR 
DATA FOR MARKETING PURPOSES.—An author-
ized user shall not use an analysis or data pro-
vided or sold under paragraph (1) or (2) for 
marketing purposes. 
(4) DATA USE AGREEMENT.—A qualified entity 
and an authorized user described in clauses (i), (ii), 
and (v) of paragraph (9)(A) shall enter into an 
agreement regarding the use of any data that the 
qualified entity is providing or selling to the author-
ized user under paragraph (2). Such agreement shall 
describe the requirements for privacy and security of 
the data and, as determined appropriate by the Sec-
retary, any prohibitions on using such data to link 
to other individually identifiable sources of informa-
tion. If the authorized user is not a covered entity 
under the rules promulgated pursuant to the Health 
Insurance Portability and Accountability Act of 
1996, the agreement shall identify the relevant regu-
lations, as determined by the Secretary, that the 
user shall comply with as if it were acting in the ca-
pacity of such a covered entity. 
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(5) NO
REDISCLOSURE
OF
ANALYSES
OR 
DATA.— 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), an authorized user that is 
provided or sold an analysis or data under 
paragraph (1) or (2) shall not redisclose or 
make public such analysis or data or any anal-
ysis using such data. 
(B) PERMITTED REDISCLOSURE.—A pro-
vider of services or supplier that is provided or 
sold an analysis or data under paragraph (1) or 
(2) may, as determined by the Secretary, redis-
close such analysis or data for the purposes of 
performance improvement and care coordination 
activities but shall not make public such anal-
ysis or data or any analysis using such data. 
(6) OPPORTUNITY FOR PROVIDERS OF SERV-
ICES AND SUPPLIERS TO REVIEW.—Prior to a quali-
fied entity providing or selling an analysis to an au-
thorized user under paragraph (1), to the extent 
that such analysis would individually identify a pro-
vider of services or supplier who is not being pro-
vided or sold such analysis, such qualified entity 
shall provide such provider or supplier with the op-
portunity to appeal and correct errors in the manner 
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described in section 1874(e)(4)(C)(ii) of the Social 
Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)). 
(7) ASSESSMENT FOR A BREACH.— 
(A) IN GENERAL.—In the case of a breach 
of a data use agreement under this section or 
section 1874(e) of the Social Security Act (42 
U.S.C. 1395kk(e)), the Secretary shall impose 
an assessment on the qualified entity both in 
the case of— 
(i) an agreement between the Sec-
retary and a qualified entity; and 
(ii) an agreement between a qualified 
entity and an authorized user. 
(B) ASSESSMENT.—The assessment under 
subparagraph (A) shall be an amount up to 
$100 for each individual entitled to, or enrolled 
for, benefits under part A of title XVIII of the 
Social Security Act or enrolled for benefits 
under part B of such title— 
(i) in the case of an agreement de-
scribed in subparagraph (A)(i), for whom 
the Secretary provided data on to the 
qualified entity under paragraph (2); and 
(ii) in the case of an agreement de-
scribed in subparagraph (A)(ii), for whom 
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137 
the qualified entity provided data on to the 
authorized user under paragraph (2). 
(C) DEPOSIT OF AMOUNTS COLLECTED.— 
Any amounts collected pursuant to this para-
graph shall be deposited in Federal Supple-
mentary Medical Insurance Trust Fund under 
section 1841 of the Social Security Act (42 
U.S.C. 1395t). 
(8) ANNUAL
REPORTS.—Any qualified entity 
that provides or sells an analysis or data under 
paragraph (1) or (2) shall annually submit to the 
Secretary a report that includes— 
(A) a summary of the analyses provided or 
sold, including the number of such analyses, the 
number of purchasers of such analyses, and the 
total amount of fees received for such analyses; 
(B) a description of the topics and pur-
poses of such analyses; 
(C) information on the entities who re-
ceived the data under paragraph (2), the uses 
of the data, and the total amount of fees re-
ceived for providing, selling, or sharing the 
data; and 
(D) other information determined appro-
priate by the Secretary. 
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138 
(9) DEFINITIONS.—In this subsection and sub-
section (b): 
(A) AUTHORIZED USER.—The term ‘‘au-
thorized user’’ means the following: 
(i) A provider of services. 
(ii) A supplier. 
(iii) An employer (as defined in sec-
tion 3(5) of the Employee Retirement In-
surance Security Act of 1974). 
(iv) A health insurance issuer (as de-
fined in section 2791 of the Public Health 
Service Act). 
(v) A medical society or hospital asso-
ciation. 
(vi) Any entity not described in 
clauses (i) through (v) that is approved by 
the Secretary (other than an employer or 
health insurance issuer not described in 
clauses (iii) and (iv), respectively, as deter-
mined by the Secretary). 
(B) PROVIDER
OF
SERVICES.—The term 
‘‘provider of services’’ has the meaning given 
such term in section 1861(u) of the Social Se-
curity Act (42 U.S.C. 1395x(u)). 
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(C) QUALIFIED ENTITY.—The term ‘‘quali-
fied entity’’ has the meaning given such term in 
section 1874(e)(2) of the Social Security Act 
(42 U.S.C. 1395kk(e)). 
(D) SECRETARY.—The term ‘‘Secretary’’ 
means the Secretary of Health and Human 
Services. 
(E) SUPPLIER.—The term ‘‘supplier’’ has 
the meaning given such term in section 1861(d) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395x(d)). 
(b) ACCESS
TO MEDICARE DATA
BY QUALIFIED 
CLINICAL DATA REGISTRIES TO FACILITATE QUALITY 
IMPROVEMENT.— 
(1) ACCESS.— 
(A) IN
GENERAL.—To the extent con-
sistent with applicable information, privacy, se-
curity, and disclosure laws, beginning July 1, 
2016, the Secretary shall, at the request of a 
qualified clinical data registry under section 
1848(m)(3)(E) of the Social Security Act (42 
U.S.C. 1395w–4(m)(3)(E)), provide the data 
described in subparagraph (B) (in a form and 
manner determined to be appropriate) to such 
qualified clinical data registry for purposes of 
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140 
linking such data with clinical outcomes data 
and performing risk-adjusted, scientifically valid 
analyses and research to support quality im-
provement or patient safety, provided that any 
public reporting of such analyses or research 
that identifies a provider of services or supplier 
shall only be conducted with the opportunity of 
such provider or supplier to appeal and correct 
errors in the manner described in subsection 
(a)(6). 
(B) DATA
DESCRIBED.—The data de-
scribed in this subparagraph is— 
(i) claims data under the Medicare 
program under title XVIII of the Social 
Security Act; and 
(ii) if the Secretary determines appro-
priate, claims data under the Medicaid 
program under title XIX of such Act and 
the State Children’s Health Insurance Pro-
gram under title XXI of such Act. 
(2) FEE.—Data described in paragraph (1)(B) 
shall be provided to a qualified clinical data registry 
under paragraph (1) at a fee equal to the cost of 
providing such data. Any fee collected pursuant to 
the preceding sentence shall be deposited in the Cen-
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141 
ters for Medicare & Medicaid Services Program 
Management Account. 
(c) EXPANSION OF DATA AVAILABLE TO QUALIFIED 
ENTITIES.—Section 1874(e) of the Social Security Act 
(42 U.S.C. 1395kk(e)) is amended— 
(1) in the subsection heading, by striking 
‘‘MEDICARE’’; and 
(2) in paragraph (3)— 
(A) by inserting after the first sentence the 
following new sentence: ‘‘Beginning July 1, 
2016, if the Secretary determines appropriate, 
the data described in this paragraph may also 
include standardized extracts (as determined by 
the Secretary) of claims data under titles XIX 
and XXI for assistance provided under such ti-
tles for one or more specified geographic areas 
and time periods requested by a qualified enti-
ty.’’; and 
(B) in the last sentence, by inserting ‘‘or 
under titles XIX or XXI’’ before the period at 
the end. 
(d) REVISION OF PLACEMENT OF FEES.—Section 
1874(e)(4)(A) of the Social Security Act (42 U.S.C. 
1395kk(e)(4)(A)) is amended, in the second sentence— 
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(1) by inserting ‘‘, for periods prior to July 1, 
2016,’’ after ‘‘deposited’’; and 
(2) by inserting the following before the period 
at the end: ‘‘, and, beginning July 1, 2016, into the 
Centers for Medicare & Medicaid Services Program 
Management Account’’. 
SEC. 7. REDUCING ADMINISTRATIVE BURDEN AND OTHER 
PROVISIONS. 
(a) MEDICARE PHYSICIAN AND PRACTITIONER OPT- 
OUT TO PRIVATE CONTRACT.— 
(1) INDEFINITE, CONTINUING AUTOMATIC EX-
TENSION OF OPT OUT ELECTION.— 
(A) IN GENERAL.—Section 1802(b)(3) of 
the Social Security Act (42 U.S.C. 1395a(b)(3)) 
is amended— 
(i) in subparagraph (B)(ii), by strik-
ing ‘‘during the 2-year period beginning on 
the date the affidavit is signed’’ and insert-
ing ‘‘during the applicable 2-year period 
(as defined in subparagraph (D))’’; 
(ii) in subparagraph (C), by striking 
‘‘during the 2-year period described in sub-
paragraph (B)(ii)’’ and inserting ‘‘during 
the applicable 2-year period’’; and 
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143 
(iii) by adding at the end the fol-
lowing new subparagraph: 
‘‘(D) APPLICABLE
2-YEAR
PERIODS
FOR 
EFFECTIVENESS OF AFFIDAVITS.—In this sub-
section, the term ‘applicable 2-year period’ 
means, with respect to an affidavit of a physi-
cian or practitioner under subparagraph (B), 
the 2-year period beginning on the date the af-
fidavit is signed and includes each subsequent 
2-year period unless the physician or practi-
tioner involved provides notice to the Secretary 
(in a form and manner specified by the Sec-
retary), not later than 30 days before the end 
of the previous 2-year period, that the physician 
or practitioner does not want to extend the ap-
plication of the affidavit for such subsequent 2- 
year period.’’. 
(B) EFFECTIVE DATE.—The amendments 
made by subparagraph (A) shall apply to affi-
davits entered into on or after the date that is 
60 days after the date of the enactment of this 
Act. 
(2) PUBLIC AVAILABILITY OF INFORMATION ON 
OPT-OUT PHYSICIANS AND PRACTITIONERS.—Section 
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1802(b) of the Social Security Act (42 U.S.C. 
1395a(b)) is amended— 
(A) in paragraph (5), by adding at the end 
the following new subparagraph: 
‘‘(D) OPT-OUT PHYSICIAN OR PRACTITIONER.— 
The term ‘opt-out physician or practitioner’ means 
a physician or practitioner who has in effect an affi-
davit under paragraph (3)(B).’’; 
(B) by redesignating paragraph (5) as 
paragraph (6); and 
(C) by inserting after paragraph (4) the 
following new paragraph: 
‘‘(5) POSTING OF INFORMATION ON OPT-OUT 
PHYSICIANS AND PRACTITIONERS.— 
‘‘(A) IN
GENERAL.—Beginning not later 
than February 1, 2016, the Secretary shall 
make publicly available through an appropriate 
publicly accessible website of the Department of 
Health and Human Services information on the 
number and characteristics of opt-out physi-
cians and practitioners and shall update such 
information on such website not less often than 
annually. 
‘‘(B) INFORMATION
TO
BE
INCLUDED.— 
The information to be made available under 
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subparagraph (A) shall include at least the fol-
lowing with respect to opt-out physicians and 
practitioners: 
‘‘(i) Their number. 
‘‘(ii) Their physician or professional 
specialty or other designation. 
‘‘(iii) Their geographic distribution. 
‘‘(iv) The timing of their becoming 
opt-out physicians and practitioners, rel-
ative, to the extent feasible, to when they 
first enrolled in the program under this 
title and with respect to applicable 2-year 
periods. 
‘‘(v) The proportion of such physi-
cians and practitioners who billed for 
emergency or urgent care services.’’. 
(b) GAINSHARING STUDY AND REPORT.—Not later 
than 6 months after the date of the enactment of this Act, 
the Secretary of Health and Human Services, in consulta-
tion with the Inspector General of the Department of 
Health and Human Services, shall submit to Congress a 
report with legislative recommendations to amend existing 
fraud and abuse laws, through exceptions, safe harbors, 
or other narrowly targeted provisions, to permit 
gainsharing or similar arrangements between physicians 
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146 
and hospitals that improve care while reducing waste and 
increasing efficiency. The report shall— 
(1) consider whether such provisions should 
apply to ownership interests, compensation arrange-
ments, or other relationships; 
(2) describe how the recommendations address 
accountability, transparency, and quality, including 
how best to limit inducements to stint on care, dis-
charge patients prematurely, or otherwise reduce or 
limit medically necessary care; and 
(3) consider whether a portion of any savings 
generated by such arrangements should accrue to 
the Medicare program under title XVIII of the So-
cial Security Act. 
(c) PROMOTING INTEROPERABILITY OF ELECTRONIC 
HEALTH RECORD SYSTEMS.— 
(1) RECOMMENDATIONS FOR ACHIEVING WIDE-
SPREAD EHR INTEROPERABILITY.— 
(A) OBJECTIVE.—As a consequence of a 
significant Federal investment in the implemen-
tation of health information technology through 
the Medicare and Medicaid EHR incentive pro-
grams, Congress declares it a national objective 
to achieve widespread exchange of health infor-
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147 
mation through interoperable certified EHR 
technology nationwide by December 31, 2018. 
(B) DEFINITIONS.—In this paragraph: 
(i) 
WIDESPREAD
INTEROPER-
ABILITY.—The term ‘‘widespread inter-
operability’’ means interoperability between 
certified EHR technology systems em-
ployed by meaningful EHR users under 
the Medicare and Medicaid EHR incentive 
programs and other clinicians and health 
care providers on a nationwide basis. 
(ii) INTEROPERABILITY.—The term 
‘‘interoperability’’ means the ability of two 
or more health information systems or 
components to exchange clinical and other 
information and to use the information 
that has been exchanged using common 
standards as to provide access to longitu-
dinal information for health care providers 
in order to facilitate coordinated care and 
improved patient outcomes. 
(C) ESTABLISHMENT
OF
METRICS.—Not 
later than July 1, 2016, and in consultation 
with stakeholders, the Secretary shall establish 
metrics to be used to determine if and to the 
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148 
extent that the objective described in subpara-
graph (A) has been achieved. 
(D) RECOMMENDATIONS
IF
OBJECTIVE 
NOT
ACHIEVED.—If the Secretary of Health 
and Human Services determines that the objec-
tive described in subparagraph (A) has not been 
achieved by December 31, 2018, then the Sec-
retary shall submit to Congress a report, by not 
later than December 31, 2019, that identifies 
barriers to such objective and recommends ac-
tions that the Federal Government can take to 
achieve such objective. Such recommended ac-
tions may include recommendations— 
(i) to adjust payments for not being 
meaningful EHR users under the Medicare 
EHR incentive programs; and 
(ii) for criteria for decertifying cer-
tified EHR technology products. 
(2) PREVENTING BLOCKING THE SHARING OF 
INFORMATION.— 
(A) FOR MEANINGFUL USE EHR PROFES-
SIONALS.—Section 1848(o)(2)(A)(ii) of the So-
cial 
Security 
Act 
(42 
U.S.C. 
1395w– 
4(o)(2)(A)(ii)) is amended by inserting before 
the period at the end the following: ‘‘, and the 
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149 
professional demonstrates (through a process 
specified by the Secretary, such as the use of an 
attestation) that the professional has not know-
ingly and willfully taken action (such as to dis-
able functionality) to limit or restrict the com-
patibility or interoperability of the certified 
EHR technology’’. 
(B) FOR
MEANINGFUL
USE
EHR
HOS-
PITALS.—Section 1886(n)(3)(A)(ii) of the So-
cial 
Security 
Act 
(42 
U.S.C. 
1395ww(n)(3)(A)(ii)) is amended by inserting 
before the period at the end the following: ‘‘, 
and the hospital demonstrates (through a proc-
ess specified by the Secretary, such as the use 
of an attestation) that the hospital has not 
knowingly and willfully taken action (such as to 
disable functionality) to limit or restrict the 
compatibility or interoperability of the certified 
EHR technology’’. 
(C) EFFECTIVE DATE.—The amendments 
made by this subsection shall apply to meaning-
ful EHR users as of the date that is one year 
after the date of the enactment of this Act. 
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150 
(3) STUDY AND REPORT ON THE FEASIBILITY 
OF ESTABLISHING A MECHANISM TO COMPARE CER-
TIFIED EHR TECHNOLOGY PRODUCTS.— 
(A) STUDY.—The Secretary shall conduct 
a study to examine the feasibility of estab-
lishing one or more mechanisms to assist pro-
viders in comparing and selecting certified 
EHR technology products. Such mechanisms 
may include— 
(i) a website with aggregated results 
of surveys of meaningful EHR users on 
the functionality of certified EHR tech-
nology products to enable such users to di-
rectly compare the functionality and other 
features of such products; and 
(ii) information from vendors of cer-
tified products that is made publicly avail-
able in a standardized format. 
The aggregated results of the surveys described 
in clause (i) may be made available through 
contracts with physicians, hospitals, or other or-
ganizations that maintain such comparative in-
formation described in such clause. 
(B) REPORT.—Not later than 1 year after 
the date of the enactment of this Act, the Sec-
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151 
retary shall submit to Congress a report on 
mechanisms that would assist providers in com-
paring and selecting certified EHR technology 
products. The report shall include information 
on the benefits of, and resources needed to de-
velop and maintain, such mechanisms. 
(4) DEFINITIONS.—In this subsection: 
(A) The term ‘‘certified EHR technology’’ 
has the meaning given such term in section 
1848(o)(4) of the Social Security Act (42 
U.S.C. 1395w–4(o)(4)). 
(B) The term ‘‘meaningful EHR user’’ has 
the meaning given such term under the Medi-
care EHR incentive programs. 
(C) The term ‘‘Medicare and Medicaid 
EHR incentive programs’’ means— 
(i) in the case of the Medicare pro-
gram under title XVIII of the Social Secu-
rity Act, the incentive programs under sec-
tion 1814(l)(3), section 1848(o), sub-
sections (l) and (m) of section 1853, and 
section 1886(n) of the Social Security Act 
(42 
U.S.C. 
1395f(l)(3), 
1395w–4(o), 
1395w–23, 1395ww(n)); and 
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(ii) in the case of the Medicaid pro-
gram under title XIX of such Act, the in-
centive 
program 
under 
subsections 
(a)(3)(F) and (t) of section 1903 of such 
Act (42 U.S.C. 1396b). 
(D) The term ‘‘Secretary’’ means the Sec-
retary of Health and Human Services. 
(d) GAO STUDIES AND REPORTS ON THE USE OF 
TELEHEALTH UNDER FEDERAL PROGRAMS AND ON RE-
MOTE PATIENT MONITORING SERVICES.— 
(1) STUDY ON TELEHEALTH SERVICES.—The 
Comptroller General of the United States shall con-
duct a study on the following: 
(A) How the definition of telehealth across 
various Federal programs and Federal efforts 
can inform the use of telehealth in the Medicare 
program under title XVIII of the Social Secu-
rity Act (42 U.S.C. 1395 et seq.). 
(B) Issues that can facilitate or inhibit the 
use of telehealth under the Medicare program 
under such title, including oversight and profes-
sional licensure, changing technology, privacy 
and security, infrastructure requirements, and 
varying needs across urban and rural areas. 
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(C) Potential implications of greater use of 
telehealth with respect to payment and delivery 
system transformations under the Medicare 
program under such title XVIII and the Med-
icaid program under title XIX of such Act (42 
U.S.C. 1396 et seq.). 
(D) How the Centers for Medicare & Med-
icaid Services monitors payments made under 
the Medicare program under such title XVIII to 
providers for telehealth services. 
(2) STUDY ON REMOTE PATIENT MONITORING 
SERVICES.— 
(A) IN GENERAL.—The Comptroller Gen-
eral of the United States shall conduct a 
study— 
(i) of the dissemination of remote pa-
tient monitoring technology in the private 
health insurance market; 
(ii) of the financial incentives in the 
private health insurance market relating to 
adoption of such technology; 
(iii) of the barriers to adoption of 
such services under the Medicare program 
under title XVIII of the Social Security 
Act; 
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(iv) that evaluates the patients, condi-
tions, and clinical circumstances that could 
most benefit from remote patient moni-
toring services; and 
(v) that evaluates the challenges re-
lated to establishing appropriate valuation 
for remote patient monitoring services 
under the Medicare physician fee schedule 
under section 1848 of the Social Security 
Act (42 U.S.C. 1395w–4) in order to accu-
rately reflect the resources involved in fur-
nishing such services. 
(B) DEFINITIONS.—For purposes of this 
paragraph: 
(i) REMOTE
PATIENT
MONITORING 
SERVICES.—The term ‘‘remote patient 
monitoring services’’ means services fur-
nished through remote patient monitoring 
technology. 
(ii) REMOTE
PATIENT
MONITORING 
TECHNOLOGY.—The term ‘‘remote patient 
monitoring technology’’ means a coordi-
nated system that uses one or more home- 
based or mobile monitoring devices that 
automatically transmit vital sign data or 
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information on activities of daily living and 
may include responses to assessment ques-
tions collected on the devices wirelessly or 
through a telecommunications connection 
to a server that complies with the Federal 
regulations (concerning the privacy of indi-
vidually identifiable health information) 
promulgated under section 264(c) of the 
Health Insurance Portability and Account-
ability Act of 1996, as part of an estab-
lished plan of care for that patient that in-
cludes the review and interpretation of that 
data by a health care professional. 
(3) REPORTS.—Not later than 24 months after 
the date of the enactment of this Act, the Comp-
troller General shall submit to Congress— 
(A) a report containing the results of the 
study conducted under paragraph (1); and 
(B) a report containing the results of the 
study conducted under paragraph (2). 
A report required under this paragraph shall be sub-
mitted together with recommendations for such leg-
islation and administrative action as the Comptroller 
General determines appropriate. The Comptroller 
General may submit one report containing the re-
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sults described in subparagraphs (A) and (B) and 
the recommendations described in the previous sen-
tence. 
(e) RULE OF CONSTRUCTION REGARDING HEALTH 
CARE PROVIDERS.— 
(1) IN GENERAL.—Subject to paragraph (3), 
the development, recognition, or implementation of 
any guideline or other standard under any Federal 
health care provision shall not be construed to estab-
lish the standard of care or duty of care owed by a 
health care provider to a patient in any medical mal-
practice or medical product liability action or claim. 
(2) DEFINITIONS.—For purposes of this sub-
section: 
(A) FEDERAL HEALTH CARE PROVISION.— 
The term ‘‘Federal health care provision’’ 
means any provision of the Patient Protection 
and Affordable Care Act (Public Law 111– 
148), title I or subtitle B of title II of the 
Health Care and Education Reconciliation Act 
of 2010 (Public Law 111–152), or title XVIII 
or XIX of the Social Security Act (42 U.S.C. 
1395 et seq., 42 U.S.C. 1396 et seq.). 
(B) HEALTH CARE PROVIDER.—The term 
‘‘health care provider’’ means any individual, 
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group practice, corporation of health care pro-
fessionals, or hospital— 
(i) licensed, registered, or certified 
under Federal or State laws or regulations 
to provide health care services; or 
(ii) required to be so licensed, reg-
istered, or certified but that is exempted 
by other statute or regulation. 
(C) MEDICAL MALPRACTICE OR MEDICAL 
PRODUCT
LIABILITY
ACTION
OR
CLAIM.—The 
term ‘‘medical malpractice or medical product 
liability action or claim’’ means a medical mal-
practice action or claim (as defined in section 
431(7) of the Health Care Quality Improve-
ment Act of 1986 (42 U.S.C. 11151(7))) and 
includes a liability action or claim relating to a 
health care provider’s prescription or provision 
of a drug, device, or biological product (as such 
terms are defined in section 201 of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 321) 
or section 351 of the Public Health Service Act 
(42 U.S.C. 262)). 
(D) STATE.—The term ‘‘State’’ includes 
the District of Columbia, Puerto Rico, and any 
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other commonwealth, possession, or territory of 
the United States. 
(3) NO
PREEMPTION.—Nothing in paragraph 
(1) or any provision of the Patient Protection and 
Affordable Care Act (Public Law 111–148), title I 
or subtitle B of title II of the Health Care and Edu-
cation Reconciliation Act of 2010 (Public Law 111– 
152), or title XVIII or XIX of the Social Security 
Act (42 U.S.C. 1395 et seq., 42 U.S.C. 1396 et 
seq.) shall be construed to preempt any State or 
common law governing medical professional or med-
ical product liability actions or claims. 
Æ 
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