[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2810 Reported in House (RH)]
Union Calendar No. 283
113th CONGRESS
2d Session
H. R. 2810
[Report No. 113-257, Parts I and II]
To amend title XVIII of the Social Security Act to reform the
sustainable growth rate and Medicare payment for physicians' services,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 24, 2013
Mr. Burgess (for himself, Mr. Pallone, Mr. Upton, Mr. Waxman, Mr.
Pitts, and Mr. Dingell) 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
November 12, 2013
Reported from the Committee on Energy and Commerce with an amendment
[Strike out all after the enacting clause and insert the part printed
in italic]
November 12, 2013
The Committee on the Judiciary discharged
November 12, 2013
Referral to the Committee on Ways and Means extended for a period
ending not later than December 2, 2013
December 2, 2013
Referral to the Committee on Ways and Means extended for a period
ending not later than January 10, 2014
January 10, 2014
Referral to the Committee on Ways and Means extended for a period
ending not later than March 14, 2014
March 14, 2014
Additional sponsors: Mr. Cassidy, Mr. Bucshon, Mrs. Christensen, Mr.
Gingrey of Georgia, Mr. Stockman, Mr. Thornberry, Mr. Benishek, Mr.
Murphy of Pennsylvania, Mr. Gosar, Ms. Matsui, Ms. Castor of Florida,
Mr. Engel, Mr. Cuellar, Mr. Sessions, Mr. Young of Alaska, Mr. Gene
Green of Texas, Mr. Olson, Mrs. Ellmers, Mr. Roe of Tennessee, Mrs.
Blackburn, Mr. Latta, Mrs. McMorris Rodgers, Mr. Terry, Mr. Rogers of
Michigan, Mr. Walden, Mr. Bilirakis, Ms. Schakowsky, Mr. Braley of
Iowa, Mrs. Capps, Mr. Carter, Mr. Barton, Mr. Whitfield, Mr. Lance, Mr.
Holding, Mr. Westmoreland, Mr. Latham, Mrs. Brooks of Indiana, Mr.
Walberg, Mr. Rice of South Carolina, Mr. Loebsack, Mr. Coffman, Mr.
Bera of California, Mr. Ruiz, Mr. Stivers, Mr. McKinley, Mr. Kennedy,
Mr. Ben Ray Lujan of New Mexico, Mr. Rush, Mr. Yoder, Mr. Marino, Mr.
McNerney, and Mr. Langevin
March 14, 2014
Reported from the Committee on Ways and Means with an amendment,
committed to the Committee of the Whole House on the State of the
Union, and ordered to be printed
[Strike out all after the enacting clause and insert the part printed
in boldface roman]
[For text of introduced bill, see copy of bill as introduced on July
24, 2013]
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to reform the
sustainable growth rate and Medicare payment for physicians' services,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare Patient
Access and Quality Improvement Act of 2013''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Reform of sustainable growth rate (SGR) and Medicare payment
for physicians' services.
Sec. 3. Expanding availability of Medicare data.
Sec. 4. Encouraging care coordination and medical homes.
Sec. 5. Miscellaneous.
SEC. 2. REFORM OF SUSTAINABLE GROWTH RATE (SGR) AND MEDICARE PAYMENT
FOR PHYSICIANS' SERVICES.
(a) Stabilizing Fee Updates (phase I).--
(1) Repeal of sgr payment methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A), by inserting ``or
a subsequent paragraph or section 1848A'' after
``paragraph (4)''; and
(ii) in paragraph (4)--
(I) in the heading, by striking
``years beginning with 2001'' and
inserting ``2001, 2002, and 2003''; and
(II) in subparagraph (A), by
striking ``a year beginning with 2001''
and inserting ``2001, 2002, and 2003'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2013'' after ``of each succeeding
year''; and
(ii) in paragraph (2), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for 2014 through 2018.--Subsection (d)
of section 1848 of the Social Security Act (42 U.S.C. 1395w-4)
is amended by adding at the end the following new paragraph:
``(15) Update for 2014 through 2018.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2014 through 2018 shall be 0.5 percent.''.
(b) Quality Update Incentive Program (phase II).--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4), as amended by subsection (a), is further
amended--
(A) in subsection (d), by adding at the end the
following new paragraph:
``(16) Update beginning with 2019.--
``(A) In general.--Subject to subparagraph (B), the
update to the single conversion factor established in
paragraph (1)(C) for each year beginning with 2019
shall be 0.5 percent.
``(B) Adjustment.--In the case of an eligible
professional (as defined in subsection (k)(3)) who does
not have a payment arrangement described in section
1848A(a) in effect, the update under subparagraph (A)
for a year beginning with 2019 shall be adjusted by the
applicable quality adjustment determined under
subsection (q)(3) for the year involved.''; and
(B) in subsection (i)(1)--
(i) by striking ``and'' at the end of
subparagraph (D);
(ii) by striking the period at the end of
subparagraph (E) and inserting ``, and''; and
(iii) by adding at the end the following
new subparagraph:
``(F) the implementation of subsection (q).''.
(2) Enhancing physician quality reporting system to support
quality update incentive program.--Section 1848 of the Social
Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (k)(1), in the first sentence, by
inserting ``and, if applicable, clinical practice
improvement activities,'' after ``quality measures'';
(B) in subsection (k)(2)--
(i) in subparagraph (C)--
(I) in the subparagraph heading, by
striking ``and subsequent years'' and
inserting ``through 2018''; and
(II) in clause (i), by inserting
``(before 2019)'' after ``subsequent
year'';
(ii) by redesignating subparagraph (D) as
subparagraph (E);
(iii) by inserting after subparagraph (C)
the following new subparagraph:
``(D) For 2019 and subsequent years.--For purposes
of reporting data on quality measures and, as
applicable clinical practice improvement activities,
for covered professional services furnished during the
performance period (as defined in subsection (q)(2)(B))
with respect to 2019 and the performance period with
respect to each subsequent year, subject to subsection
(q)(1)(D), the quality measures and clinical practice
improvement activities specified under this paragraph
shall be, with respect to an eligible professional, the
quality measures and, as applicable, clinical practice
improvement activities within the final core measure
set under paragraph (9)(F) applicable to the peer
cohort of such provider and year involved.''; and
(iv) in subparagraph (E), as redesignated
by subparagraph (B)(ii) of this paragraph, by
striking ``and subsequent years'';
(C) in subsection (k)(3)--
(i) in the paragraph heading, by striking
``Covered professional services and eligible
professionals defined'' and inserting
``Definitions''; and
(ii) by adding at the end the following new
subparagraphs:
``(C) Clinical practice improvement activities.--
The term `clinical practice improvement activity' means
an activity that relevant eligible professional
organizations and other relevant stakeholders identify
as improving clinical practice or care delivery and
that the Secretary determines, when effectively
executed, is likely to result in improved outcomes.
``(D) Eligible professional organization.--The term
`eligible professional organization' means a
professional organization as defined by nationally
recognized multispecialty boards of certification or
equivalent certification boards.
``(E) Peer cohort.--The term `peer cohort' means a
peer cohort identified on the list under paragraph
(9)(B), as updated under clause (ii) of such
paragraph.'';
(D) in subsection (k)(7), by striking `` and the
application of paragraphs (4) and (5)'' and inserting
``, the application of paragraphs (4) and (5), and the
implementation of paragraph (9)'';
(E) by adding at the end of subsection (k) the
following new paragraph:
``(9) Establishment of final core measure sets.--
``(A) In general.--Under the system under this
subsection--
``(i) for each peer cohort identified under
subparagraph (B) and in accordance with this
paragraph, there shall be published a final
core measure set under subparagraph (F), which
shall consist of quality measures and may also
consist of clinical practice improvement
activities, with respect to which eligible
professionals shall, subject to subsection
(m)(3)(C), be assessed for purposes of
determining, for years beginning with 2019, the
quality adjustment under subsection (q)(3)
applicable to such professionals; and
``(ii) each eligible professional shall
self-identify, in accordance with subparagraph
(B), within such a peer cohort for purposes of
such assessments.
``(B) Peer cohorts.--The Secretary shall identify
(and publish a list of) peer cohorts by which eligible
professionals shall self-identify for purposes of this
subsection and subsection (q) with respect to a
performance period (as defined in subsection (q)(2)(B))
for a year beginning with 2019. For purposes of this
subsection and subsection (q), the Secretary shall
develop one or more peer cohorts for multispecialty
groups, each of which shall be included as a peer
cohort under this subparagraph. Such self-
identification will be made through such a process and
at such time as specified under the system under this
subsection. Such list--
``(i) shall include, as peer cohorts,
provider specialties defined by nationally
recognized multispecialty boards of
certification or equivalent certification
boards and such other cohorts as established
under this section in order to capture
classifications of providers across eligible
professional organizations and other practice
areas, groupings, or categories; and
``(ii) shall be updated from time to time.
``(C) Quality measures for core measure sets.--
``(i) Development.--Under the system under
this subsection there shall be established a
process for the development of quality measures
under this subparagraph for purposes of
potential inclusion of such measures in core
measure sets under this paragraph. Under such
process--
``(I) there shall be coordination,
to the extent possible, across
organizations developing such measures;
``(II) eligible professional
organizations and other relevant
stakeholders may submit best practices
and clinical practice guidelines for
the development of quality measures
that address quality domains (as
defined under clause (ii)) for
potential inclusion in such core
measure sets;
``(III) there is encouraged to be
developed, as appropriate, meaningful
outcome measures (or quality of life
measures in cases for which outcomes
may not be a valid measurement),
functional status measures, and patient
experience measures; and
``(IV) measures developed under
this clause shall be developed, to the
extent possible, in accordance with
best practices and clinical practice
guidelines.
``(ii) Quality domains.--For purposes of
this paragraph, 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
prevention.
``(D) Process for establishing core measure sets.--
``(i) In general.--Under the system under
this subsection, for purposes of subparagraph
(A), there shall be established a process to
approve final core measure sets under this
paragraph for peer cohorts. Each such final
core measure set shall be composed of quality
measures (and, as applicable, clinical practice
improvement activities) with respect to which
eligible professionals within such peer cohort
shall report under this subsection and be
assessed under subsection (q). Such process
shall provide--
``(I) for the establishment of
criteria, which shall be made publicly
available before the request is made
under clause (ii), for selecting such
measures and activities for potential
inclusion in such a final core measure
set; and
``(II) that all peer cohorts, and
to the extent practicable all quality
domains, are addressed by measures and,
as applicable, clinical practice
improvement activities selected to be
included in a core measure set under
this paragraph, which may include
through the use of such a measure or
clinical practice improvement activity
that addresses more than one such
domain or cohort.
``(ii) Solicitation of public input on
quality measures and clinical practice
improvement activities.--Under the process
established under clause (i), relevant eligible
professional organizations and other relevant
stakeholders shall be requested to identify and
submit quality measures and clinical practice
improvement activities (as defined in paragraph
(3)(C)) for selection under this paragraph. For
purposes of the previous sentence, measures and
activities may be submitted regardless of
whether such measures were previously published
in a proposed rule or endorsed by an entity
with a contract under section 1890(a).
``(E) Core measure sets.--
``(i) In general.--Under the process
established under subparagraph (D)(i), the
Secretary--
``(I) shall select, from quality
measures described in clause (ii)
applicable to a peer cohort, quality
measures to be included in a core
measure set for such cohort;
``(II) shall, to the extent there
are insufficient quality measures
applicable to a peer cohort to address
one or more applicable quality domains,
select to be included in a core measure
set for such cohort such clinical
practice improvement activities
described in clause (ii)(IV) as are
needed and available to sufficiently
address such an applicable domain with
respect to such peer cohort; and
``(III) may select, to the extent
determined appropriate, any additional
clinical practice improvement
activities described in clause (ii)(IV)
applicable to a peer cohort to be
included in a core measure set for such
cohort.
Activities selected under this paragraph shall
be selected with consideration of best
practices and clinical practice guidelines
identified under subparagraph (C)(i)(II).
``(ii) Sources of quality measures and
clinical practice improvement activities.--A
quality measure or clinical practice
improvement activity selected for inclusion in
a core measure set under the process under
subparagraph (D)(i) shall be--
``(I) a measure endorsed by a
consensus-based entity;
``(II) a measure developed under
paragraph (2)(C) or a measure otherwise
applied or developed for a similar
purpose under this section;
``(III) a measure developed under
subparagraph (C); or
``(IV) a measure or activity
submitted under subparagraph (D)(ii).
A measure or activity may be selected under
this subparagraph, regardless of whether such
measure or activity was previously published in
a proposed rule. A measure so selected shall be
evidence-based but (other than a measure
described in subclause (I)) shall not be
required to be consensus-based.
``(iii) Transparency.--Before publishing in
a final regulation a core measure set under
clause (i) as a final core measure set under
subparagraph (F), the Secretary shall--
``(I) submit for publication in
applicable specialty-appropriate peer-
reviewed journals such core measure set
under clause (i) and the method for
developing and selecting measures
within such set, including clinical and
other data supporting such measures,
and, as applicable, the method for
selecting clinical practice improvement
activities included within such set;
and
``(II) regardless of whether or not
the core measure set or method is
published in such a journal under
subclause (I), provide for notice of
the proposed regulation in the Federal
Register, including with respect to the
applicable methods and data described
in subclause (I), and a period for
public comment thereon.
``(F) Final core measure sets.--Not later than
November 15 of the year prior to the first day of a
performance period, the Secretary shall publish a final
regulation in the Federal Register that includes a
final core measure set (and the applicable methods and
data described in subparagraph (E)(iii)(I)) for each
peer cohort to be applied for such performance period.
``(G) Periodic review and updates.--
``(i) In general.--In carrying out this
paragraph, under the system under this
subsection, there shall periodically be
reviewed--
``(I) the quality measures and
clinical practice improvement
activities selected for inclusion in
final core measure sets under this
paragraph for each year such measures
and activities are to be applied under
this subsection or subsection (q) to
ensure that such measures and
activities continue to meet the
conditions applicable to such measures
and activities for such selection; and
``(II) the final core measure sets
published under subparagraph (F) for
each year such sets are to be applied
to peer cohorts of eligible
professionals to ensure that each
applicable set continues to meet the
conditions applicable to such sets
before being so published.
``(ii) Collaboration with stakeholders.--In
carrying out clause (i), relevant eligible
professional organizations and other relevant
stakeholders may identify and submit updates to
quality measures and clinical practice
improvement activities selected under this
paragraph for inclusion in final core measure
sets as well as any additional quality measures
and clinical practice improvement activities.
Not later than November 15 of the year prior to
the first day of a performance period,
submissions under this clause shall be
reviewed.
``(iii) Additional, and updates to,
measures and activities.--Based on the review
conducted under this subparagraph for a period,
as needed, there shall be--
``(I) selected additional, and
updates to, quality measures and
clinical practice improvement
activities selected under this
paragraph for potential inclusion in
final core measure sets in the same
manner such quality measures and
clinical practice improvement
activities are selected under this
paragraph for such potential inclusion;
``(II) removed, from final core
measure sets, quality measures and
clinical practice improvement
activities that are no longer
meaningful; and
``(III) updated final core measure
sets published under subparagraph (F)
in the same manner as such sets are
approved under such subparagraph.
For purposes of this subsection and subsection
(q), a final core measure set, as updated under
this subparagraph, shall be treated in the same
manner as a final core measure set published
under subparagraph (F).
``(iv) Transparency.--
``(I) Notification required for
certain updates.--In the case of an
update under subclause (II) or (III) of
clause (iii) that adds, materially
changes, or removes a measure or
activity from a measure set, such
update shall not apply under this
subsection or subsection (q) unless
notification of such update is made
available to applicable eligible
professionals.
``(II) Public availability of
updated final core measure sets.--
Subparagraph (E)(iii) shall apply with
respect to measure sets updated under
subclause (II) or (III) of clause (iii)
in the same manner as such subparagraph
applies to applicable core measure sets
under subparagraph (E).
``(H) Coordination with existing programs.--The
development and selection of quality measures and
clinical practice improvement activities under this
paragraph shall, as appropriate, be coordinated with
the development and selection of existing measures and
requirements, such as the development of the Physician
Compare Website under subsection (m)(5)(G) and the
application of resource use management under subsection
(n). To the extent feasible, such measures and
activities shall align with measures used by other
payers and with measures and activities in use under
other programs in order to streamline the process of
such development and selection under this paragraph.
The Secretary shall develop a plan to integrate
reporting on quality measures under this subsection
with reporting requirements under subsection (o)
relating to the meaningful use of certified EHR
technology.
``(I) Consultation with relevant eligible
professional organizations and other relevant
stakeholders.--Relevant eligible professional
organizations (as defined in paragraph (3)(D)) and
other relevant stakeholders, including State and
national medical societies, shall be consulted in
carrying out this paragraph.
``(J) Optional application.--The process under
section 1890A is not required to apply to the
development or selection of measures under this
paragraph.''; and
(F) in subsection (m)(3)(C)(i), by adding at the
end the following new sentence: ``Such process shall,
beginning for 2019, treat eligible professionals in
such a group practice as reporting on measures for
purposes of application of subsections (q) and
(a)(8)(A)(iii) if, in lieu of reporting measures under
subsection (k)(2)(D), the group practice reports
measures determined appropriate by the Secretary.''.
(3) Establishment of quality update incentive program.--
(A) 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) Quality Update Incentive Program.--
``(1) Establishment.--
``(A) In general.--The Secretary shall establish an
eligible professional quality update incentive program
(in this section referred to as the `quality update
incentive program') under which--
``(i) there is developed and applied, in
accordance with paragraph (2), appropriate
methodologies for assessing the performance of
eligible professionals with respect to quality
measures and clinical practice improvement
activities included within the final core
measure sets published under subsection
(k)(9)(F) applicable to the peer cohorts of
such providers;
``(ii) there is applied, consistent with
the system under subsection (k), methods for
collecting information needed for such
assessments (which shall involve the minimum
amount of administrative burden required to
ensure reliable results); and
``(iii) the applicable update adjustments
under paragraph (3) are determined by such
assessments.
``(B) Definitions.--
``(i) Eligible professional.--In this
subsection, the term `eligible professional'
has the meaning given such term in subsection
(k)(3), except that such term shall not include
a professional who has a payment arrangement
described in section 1848A(a)(1) in effect.
``(ii) Peer cohorts; clinical practice
improvement activities; eligible professional
organizations.--In this subsection, the terms
`peer cohort', `clinical practice improvement
activity', and `eligible professional
organization' have the meanings given such
terms in subsection (k)(3).
``(C) Consultation with eligible professional
organizations and other relevant stakeholders.--
Eligible professional organizations and other relevant
stakeholders, including State and national medical
societies, shall be consulted in carrying out this
subsection.
``(D) Application at group practice level.--The
Secretary shall establish a process, consistent with
subsection (m)(3)(C), under which the provisions of
this subsection are applied to eligible professionals
in a group practice if the group practice reports
measures determined appropriate by the Secretary under
such subsection.
``(E) Coordination with existing programs.--The
application of measures and clinical practice
improvement activities and assessment of performance
under this subsection shall, as appropriate, be
coordinated with the application of measures and
assessment of performance under other provisions of
this section.
``(2) Assessing performance with respect to final core
measure sets for applicable peer cohorts.--
``(A) Establishment of methods for assessment.--
``(i) In general.--Under the quality update
incentive program, the Secretary shall--
``(I) establish one or more
methods, applicable with respect to a
performance period, to assess (using a
scoring scale of 0 to 100) the
performance of an eligible professional
with respect to, subject to paragraph
(1)(D), quality measures and clinical
practice improvement activities
included within the final core measure
set published under subsection
(k)(9)(F) applicable for the period to
the peer cohort in which the provider
self-identified under subsection
(k)(9)(B) for such period; and
``(II) subject to paragraph (1)(D),
compute a composite score for such
provider for such performance period
with respect to the measures and
activities included within such final
core measure set.
``(ii) Methods.--Such methods shall, with
respect to an eligible professional, provide
that the performance of such professional
shall, subject to paragraph (1)(D), be assessed
for a performance period with respect to the
quality measures and clinical practice
improvement activities within the final core
measure set for such period for the peer cohort
of such professional and on which information
is collected from such professional.
``(iii) Weighting of measures.--Such a
method may provide for the assignment of
different scoring weights or, as appropriate,
other factors--
``(I) for quality measures and
clinical practice improvement
activities;
``(II) based on the type or
category of measure or activity; and
``(III) based on the extent to
which a quality measure or clinical
practice improvement activity
meaningfully assesses quality.
``(iv) Risk adjustment.--Such a method
shall provide for appropriate risk adjustments.
``(v) Incorporation of other methods of
measuring physician quality.--In establishing
such methods, there shall be, as appropriate,
incorporated comparable methods of measurement
from physician quality incentive programs under
this subsection.
``(B) Performance period.--There shall be
established a period (in this subsection referred to as
a `performance period'), with respect to a year
(beginning with 2019) for which the quality adjustment
is applied under paragraph (3), to assess performance
on quality measures and clinical practice improvement
activities. Each such performance period shall be a
period of 12 consecutive months and shall end as close
as possible to the beginning of the year for which such
adjustment is applied.
``(3) Quality adjustment taking into account quality
assessments.--
``(A) Quality adjustment.--For purposes of
subsection (d)(16), if the composite score computed
under paragraph (2)(A) for an eligible professional for
a year (beginning with 2019) is--
``(i) a score of 67 or higher, the quality
adjustment under this paragraph for the
eligible professional and year is 1 percentage
point;
``(ii) a score of at least 34, but below
67, the quality adjustment under this paragraph
for the eligible professional and year is zero;
or
``(iii) a score below 34, the quality
adjustment under this paragraph for the
eligible professional and year is -1 percentage
point.
``(B) No effect on subsequent years' quality
adjustments.--Each such quality adjustment shall be
made each year without regard to the quality adjustment
for a previous year under this paragraph.
``(4) Transition for new eligible professionals.--In the
case of a physician, practitioner, or other supplier that
during a performance period, with respect to a year for which a
quality adjustment is applied under paragraph (3), first
becomes an eligible professional (and had not previously
submitted claims under this title as a person, as an entity, or
as part of a physician group or under a different billing
number or tax identifier), the quality adjustment under this
subsection applicable to such physician, practitioner, or
supplier--
``(A) for such year, with respect to such first
performance period, shall be zero; and
``(B) for a year, with respect to a subsequent
performance period, shall be the quality adjustment
that would otherwise be applied under this subsection.
``(5) Feedback.--
``(A) Feedback.--
``(i) Ongoing feedback.--Under the process
under subsection (m)(5)(H), there shall be
provided, as real time as possible, but at
least quarterly, beginning not later than 6
months after the first day of the first
performance period, to each eligible
professional feedback--
``(I) on the performance of such
provider with respect to quality
measures and clinical practice
improvement activities within the final
core measure set published under
subsection (k)(9)(F) for the applicable
performance period and the peer cohort
of such professional; and
``(II) to assess the progress of
such professional under the quality
update incentive program with respect
to a performance period for a year.
``(ii) Use of registries and other
mechanisms.--Feedback under this subparagraph
shall, to the extent an eligible professional
chooses to participate in a data registry for
purposes of this subsection (including
registries under subsections (k) and (m)), be
provided and based on performance received
through the use of such registry, and to the
extent that an eligible professional chooses
not to participate in such a registry for such
purposes, be provided through other similar
mechanisms that allow for the provision of such
feedback and receipt of such performance
information.
``(B) Data mechanism.--Under the quality update
incentive program, there shall be developed an
electronic interactive eligible professional mechanism
through which such a professional may receive
performance data, including data with respect to
performance on the measures and activities developed
and selected under this section. Such mechanism shall
be developed in consultation with private payers and
health insurance issuers (as defined in section
2791(b)(2) of the Public Health Service Act) as
appropriate.
``(C) Transfer of funds.--The Secretary shall
provide for the transfer of $100,000,000 from the
Federal Supplementary Medical Insurance Trust Fund
established in section 1841 to the Center for Medicare
& Medicaid Services Program Management Account to
support such efforts to develop the infrastructure as
necessary to carry out subsection (k)(9) and this
subsection and for purposes of section 1889(h). Such
funds shall be so transferred on the date of the
enactment of this subsection and shall remain available
until expended.''.
(B) Incentive to report under quality update
incentive program.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``With
respect to'' and inserting ``Subject to clause
(iii), with respect to''; and
(ii) by adding at the end the following new
clause:
``(iii) Application to eligible
professionals not reporting.--With respect to
covered professional services (as defined in
subsection (k)(3)) furnished by an eligible
professional during 2019 or any subsequent
year, if the eligible professional does not
submit data for the performance period (as
defined in subsection (q)(2)(B)) with respect
to such year on, subject to subsection
(q)(1)(D), the quality measures and, as
applicable, clinical practice improvement
activities within the final core measure set
under subsection (k)(9)(F) applicable to the
peer cohort of such provider, the fee schedule
amount for such services furnished by such
professional during the year (including the fee
schedule amount for purposes of determining a
payment based on such amount) shall be equal to
95 percent (in lieu of the applicable percent)
of the fee schedule amount that would otherwise
apply to such services under this subsection
(determined after application of paragraphs
(3), (5), and (7), but without regard to this
paragraph). The Secretary shall develop a
minimum per year caseload threshold, with
respect to eligible professionals, and the
previous sentence shall not apply to eligible
professionals with a caseload for a year below
such threshold for such year.''.
(C) Education on quality update incentive
program.--Section 1889 of the Social Security Act (42
U.S.C. 1395zz) is amended by adding at the end the
following new subsection:
``(h) Quality Update Incentive Program.--Under this section,
information shall be disseminated to educate and assist eligible
professionals (as defined in section 1848(k)(3)) about the quality
update incentive program under section 1848(q) and quality measures
under section 1848(k)(9) through multiple approaches, including a
national dissemination strategy and outreach by medicare
contractors.''.
(4) Conforming amendments.--
(A) Treatment of satisfactorily reporting pqrs
measures through participation in a qualified clinical
data registry.--Section 1848(m)(3)(D) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(D)) is amended by
striking ``For 2014 and subsequent years'' and
inserting ``For each of 2014 through 2018''.
(B) Coordinating enhanced pqrs reporting with
ehr.--Section 1848(o)(2)(B)(iii) of the Social Security
Act (42 U.S.C. 1395w-4(o)(2)(B)(iii)) is amended by
striking ``subsection (k)(2)(C)'' and inserting
``subparagraph (C) or (D) of subsection (k)(2)''.
(C) Coordinating pqrs reporting period with quality
update incentive program performance period.--Section
1848(m)(6)(C) of the Social Security Act (42 U.S.C.
1395w-4(m)(6)(C)) is amended--
(i) in clause (i), by striking ``and
(iii)'' and inserting ``, (iii), and (iv)'';
and
(ii) by adding at the end the following new
clause:
``(iv) Coordination with quality update
incentive program.--For 2019 and each
subsequent year the reporting period shall be
coordinated with the performance period under
subsection (q)(2)(B).''.
(D) Coordinating ehr reporting with quality update
incentive program performance period.--Section
1848(o)(5)(B) of the Social Security Act (42 U.S.C.
1395w-4(o)(5)(B)) is amended by adding at the end the
following: ``Beginning for 2019, the EHR reporting
period shall be coordinated with the performance period
under subsection (q)(2)(B).''.
(c) Advancing Alternative Payment Models.--
(1) In general.--Part B of title XVIII of the Social
Security Act (42 U.S.C. 1395w-4 et seq.) is amended by adding
at the end the following new section:
``SEC. 1848A. ADVANCING ALTERNATIVE PAYMENT MODELS.
``(a) Payment Model Choice Program.--Payment for covered
professional services (as defined in section 1848(k)) that are
furnished by an eligible professional (as defined in such section)
under an Alternative Payment Model specified on the list under
subsection (h) (in this section referred to as an `eligible APM') shall
be made under this title in accordance with the payment arrangement
under such model. In applying the previous sentence, such a
professional with such a payment arrangement in effect, shall be deemed
for purposes of section 1848(a)(8) to be satisfactorily submitting data
on quality measures for such covered professional services.
``(b) Process for Implementing Eligible APMs.--
``(1) In general.--For purposes of subsection (a) and in
accordance with this section, the Secretary shall establish a
process under which--
``(A) a contract is entered into, in accordance
with paragraph (2);
``(B) proposals for potential Alternative Payment
Models are submitted in accordance with subsection (c);
``(C) Alternative Payment Models so proposed are
recommended, in accordance with subsection (d), for
testing and evaluation, including through the
demonstration program under subsection (e), and
approval under subsection (f);
``(D) applicable Alternative Payment Models are
tested and evaluated under such demonstration program;
``(E) models are implemented as eligible APMs in
accordance with subsection (f); and
``(F) a comprehensive list of all eligible APMs is
made publicly available, in accordance with subsection
(h), for application under subsection (a).
``(2) Contract with apm contracting entity.--
``(A) In general.--For purposes of paragraph
(1)(A), the Secretary shall identify and have in effect
a contract with an independent entity that has
appropriate expertise to carry out the functions
applicable to such entity under this section. Such
entity shall be referred to in this section as the `APM
contracting entity'.
``(B) Timing for first contract.--The Secretary
shall enter into the first contract under subparagraph
(A) to be in effect January 1, 2019.
``(C) Competitive procedures.--Competitive
procedures (as defined in section 4(5) of the Office of
Federal Procurement Policy Act (41 U.S.C. 403(5)) shall
be used to enter into a contract under subparagraph
(A).
``(c) Submission of Proposed Alternative Payment Models.--Beginning
not later than 90 days after the date the Secretary enters into a
contract under subsection (b)(2) with the APM contracting entity,
physicians, eligible professional organizations, health care provider
organizations, and other entities may submit to the APM contracting
entity proposals for Alternative Payment Models for application under
this section. Such a proposal of a model shall include suggestions for
measures to be used under subsection (e)(1)(B) for purposes of
evaluating such model. In reviewing submissions under this subsection
for purposes of making recommendations under subsection (d)(1), the
contracting entity shall focus on submissions for such models that are
intended to improve care coordination and quality for patients through
modifying the manner in which physicians and other providers are paid
under this title.
``(d) Recommendation by APM Contracting Entity of Proposed
Models.--
``(1) Recommendation.--
``(A) Recommendations to secretary.--
``(i) In general.--Under the process under
subsection (b), the APM contracting entity
shall at least quarterly recommend, in
accordance with clause (ii), to the Secretary--
``(I) Alternative Payment Models
submitted under subsection (c) to be
tested and evaluated through a
demonstration program under subsection
(e); and
``(II) Alternative Payment Models
submitted under subsection (c) to be
implemented under subsection (f)
without testing and evaluation through
such a demonstration program.
Such a recommendation under subclause (I) may
be made with respect to a model for which a
waiver would be required under paragraph (2).
Any reference in this subsection to an
Alternative Payment Model under this clause is
a reference to such model as may be modified
under clause (iii).
``(ii) Requirements.--In recommending an
Alternative Payment Model under clause (i),
each of the following shall apply:
``(I) The APM contracting entity
may recommend an Alternative Payment
Model under clause (i)(I) only if the
entity determines that the model
satisfies the criteria described in
subparagraph (B), including the
criteria described in subparagraph
(B)(iv).
``(II) The APM contracting entity
may recommend an Alternative Payment
Model under clause (i)(II) only if the
entity determines that the model
satisfies the criteria described in
subparagraph (C), including the
criteria described in subparagraph
(C)(iii).
``(III) The APM contracting entity
shall include with the recommended
Alternative Payment Model
recommendations for rules of
coordination described in clause (v).
``(iii) Modifications by apm contracting
entity.--For purposes of this subparagraph, to
the extent necessary to meet the applicable
requirements of clause (ii), the APM
contracting entity may modify an Alternative
Payment Model submitted under subsection (c) to
ensure that the model would--
``(I) reduce spending under this
title without reducing the quality of
care; or
``(II) improve the quality of care
without increasing spending under this
title.
``(iv) Forms of modifications.--Such a
modification under clause (iii) may include one
or more of the following:
``(I) A change to the payment
arrangement under which eligible
professionals participating in such
model would be paid for covered
professional services furnished under
such model.
``(II) A change to the criteria for
eligible professionals to be eligible
to participate under such model in
order to ensure that the requirement
described in subclause (I) or (II) is
satisfied.
``(III) A change to the rules of
coordination described in clause (v).
``(IV) The application of a
withhold mechanism under the payment
arrangement under which the
distribution of withheld amounts is
based on the success of the model in
meeting spending reduction
requirements.
``(V) Such other change as the
contracting entity may specify.
``(v) Rules of coordination for application
of payment arrangements under models.--
``(I) In general.--Rules of
coordination described in this clause
for an Alternative Payment Model shall
be designed to determine, for purposes
of applying subsection (a) and section
1848(d)(16), under what circumstances
an eligible professional is treated as
having a payment arrangement under a
particular model.
``(II) Nonduplication of payment.--
Such rules of coordination shall ensure
coordination and nonduplication of
payment of services that might be
covered under more than one payment
arrangement or under section
1848(d)(16).
``(III) Application to non-apm
payment.--In applying such rules of
coordination for purposes of section
1848(d)(16), an eligible professional
shall not be treated as having a
payment arrangement in effect under
such a model for any covered
professional services not treated as
furnished under the model.
``(B) Criteria for recommending models for
demonstration.--For purposes of subparagraph
(A)(ii)(I), the criteria described in this
subparagraph, with respect to an Alternative Payment
Model, are each of the following:
``(i) The model has been supported by
meaningful clinical and non-clinical data, with
respect to a sufficient population sample, that
indicates the model would be successful at
addressing each of the abilities described in
clause (iv).
``(ii)(I) In the case of a model that has
already been evaluated and supported by data
with respect to a population of individuals
enrolled under this part, if the model were
evaluated under the demonstration under
subsection (e) such a population would
represent a sufficient number of individuals
enrolled under this part to ensure a meaningful
evaluation of the likely effect of expanding
the demonstration.
``(II) In the case of a model that has not
been so evaluated and supported by data with
respect to such a population, the population
that would be furnished services under such
model if the model were evaluated under the
demonstration under subsection (e) would
represent a sufficient number of individuals
enrolled under this part to ensure a meaningful
evaluation of the likely effect of expanding
the demonstration.
``(iii) Such model, including if tested and
evaluated under the demonstration under
subsection (e), would not deny or limit the
coverage or provision of benefits under this
title for applicable individuals.
``(iv) The proposal for such model
demonstrates--
``(I) the significant likelihood to
successfully manage the cost of
furnishing items and services under
this title so as to not result in
expenditures under this title being
greater than expenditures under this
title if the APM were not implemented;
and
``(II) the ability to maintain or
improve the overall quality of patient
care provided to individuals enrolled
under this part.
``(v) The model provides for a payment
arrangement--
``(I) that specifies the items and
services covered under the arrangement
and specifies rules of coordination
described in subparagraph (A)(v)
between the items and services covered
under the arrangement and other items
and services not covered under the
arrangement;
``(II) in the case such payment
arrangement does not provide for
payment under the fee schedule under
section 1848 for such items and
services furnished by such eligible
professionals, that provides for a
payment adjustment based on meaningful
EHR use comparable to such adjustment
that would otherwise apply under
section 1848; and
``(III) that provides for a payment
adjustment based on quality measures
comparable to such adjustment that
would otherwise apply under section
1848.
``(C) Criteria for recommending models for approval
without evaluation under demonstration.--For purposes
of subparagraph (A)(ii)(II), the criteria described in
this subparagraph, with respect to an Alternative
Payment Model, is that the model has already been
tested and evaluated for a sufficient enough period and
through such testing and evaluation the model was
shown--
``(i) to have satisfied the criteria
described in each of clauses (i), (ii), (iii),
and (v) of subparagraph (B); and
``(ii)(I) to have reduced spending under
this title without reducing the quality of
care; or
``(II) to have improved the quality of
patient care without increasing such spending.
``(D) Transparency and disclosures.--
``(i) Disclosures.--Not later than 90 days
after receipt of a submission of a model under
subsection (c) by the APM contracting entity,
the APM contracting entity shall submit to the
Secretary and the model submitter and make
publicly available a notification on whether or
not, and if so how, the model meets criteria
for recommending such model under subparagraph
(A), including whether or not such model
requires a waiver under paragraph (2). In the
case that the APM contracting entity determines
not to recommend such model under this
paragraph, such notification shall include an
explanation of the reasons for not making such
a recommendation. Any information made publicly
available pursuant to the previous sentence
shall not include proprietary data.
``(ii) Submission of recommended models.--
The APM contracting entity shall at least
quarterly submit to the Secretary, the Medicare
Payment Advisory Commission, and the Chief
Actuary of the Centers for Medicare & Medicaid
Services the following:
``(I) The models recommended under
subparagraph (A)(i)(I), including any
such models that require a waiver under
paragraph (2), and the data and
analyses on such recommended models
that support the criteria described in
subparagraph (B).
``(II) The models recommended under
subparagraph (A)(i)(II) and the data
and analyses on such recommended models
that support the criteria described in
subparagraph (C).
``(iii) Explanation for no
recommendations.--For any year beginning with
2015 that the APM contracting entity does not
recommend any models under subparagraph (A)(i),
the entity shall instead satisfy this clause by
submitting to the Secretary and making publicly
available an explanation for not having any
such recommendations.
``(iv) Justifications for
recommendations.--In submitting data and
analyses under subclause (I) or (II) of clause
(ii) with respect to a model, the APM
contracting entity shall include a specific
explanation of how the model would (and
recommendations for ensuring that the model
will) meet the criteria described in
subparagraph (B) or (C), respectively.
``(v) Confirmation of spending estimates by
cms chief actuary.--For each Alternative
Payment Model described in subclause (I) or
(II) of clause (ii), the Chief Actuary of the
Centers for Medicare & Medicaid Services shall
submit to the Secretary a determination of
whether or not the Chief Actuary confirms that
the model satisfies the criterion described in
subparagraph (B)(iv)(I) or (C)(ii),
respectively.
``(2) Models requiring waiver approval.--
``(A) In general.--In the case that an Alternative
Payment Model recommended under paragraph (1)(A)(i)
would require a waiver from any requirement under this
title, in determining approval of such model, the
Secretary may make such a waiver solely in order for
such model to be tested and evaluated under the
demonstration program.
``(B) Approval.--Not later than 180 days after the
date of the receipt of such submission for a model, the
Secretary shall notify the APM contracting entity and
the entity submitting such model under subsection (c)
whether or not such a waiver for such model is approved
and the reason for any denial of such a waiver.
``(e) Demonstration.--
``(1) In general.--Subject to paragraphs (5), (6), and (7),
the Secretary may conduct a demonstration program, with respect
to an Alternative Payment Model approved under paragraph (2),
under which participating APM providers shall be paid under
this title in accordance with the payment arrangement under
such model and such model shall be evaluated by the independent
evaluation entity under paragraph (4). The duration of a
demonstration program under this subsection, with respect to
such a model, shall be 3 years.
``(2) Approval by secretary of models for demonstration.--
``(A) In general.--Not later than 180 days after
the date of receipt of a submission under subsection
(d)(1)(D)(ii), with respect to an Alternative Payment
Model recommended under subsection (d)(1)(A)(i)(I), the
Secretary shall--
``(i) review the basis for such
recommendation in order to assess, taking into
account the determination of the Chief Actuary
under subsection (d)(1)(D)(v) with respect to
such model, if the model is significantly
likely to--
``(I) reduce spending under this
title without reducing the quality of
care; or
``(II) improve the quality of care
without increasing spending under this
title;
``(ii) assess whether the model is
significantly likely to result in participation
under such model of a sufficient number of
those eligible professionals for whom the model
was designed consistent with clause (i) to be
able to evaluate the likely effect of expanding
the demonstration; and
``(iii) approve such model for a
demonstration program under this subsection,
including as modified under subparagraph (B),
only if the Secretary determines--
``(I) the model is significantly
likely to satisfy the criterion
described in subclause (I) or (II) of
clause (i);
``(II) the model is significantly
likely to result in the participation
of a sufficient number of eligible
professionals described in clause (ii);
``(III) the model applies rules of
coordination described in subparagraph
(C) applicable to such model; and
``(IV) the model satisfies the
criteria described in subsection
(d)(1)(B).
The Secretary shall periodically make available a list
of such models approved under clause (iii).
``(B) Modifications by secretary.--
``(i) Before approval.--For purposes of
subparagraph (A), the Secretary may modify an
Alternative Payment Model recommended under
subsection (d)(1)(A)(i)(I) to ensure that the
model meets the requirements described in
subparagraph (A)(iii). Such a modification may
include one or more of the following:
``(I) A change to the payment
arrangement under which eligible
professionals participating in such
model would be paid for covered
professional services furnished under
such model.
``(II) A change to the criteria for
eligible professionals to be eligible
to participate under such model in
order to ensure that such requirements
are satisfied.
``(III) A change to the rules of
coordination described in subparagraph
(C).
``(IV) The application of a
withhold mechanism under the payment
arrangement under which the
distribution of withheld amounts is
based on the success of the model in
meeting spending reduction
requirements.
``(V) Such other change as the
Secretary may specify.
``(ii) Termination or modification during
demonstration.--The Secretary shall terminate
or modify the design and implementation of an
Alternative Payment Model approved under
subparagraph (A)(iii) for a demonstration
program, after testing has begun, unless the
Secretary determines (and the Chief Actuary of
the Centers for Medicare & Medicaid Services,
with respect to program spending under this
title, certifies) that the model is expected to
continue to satisfy the requirements described
in such paragraph relating to quality of care
and reduced spending. Such termination may
occur at any time after such testing has begun
and before completion of the testing.
``(C) Rules of coordination for application of
payment arrangements under models.--
``(i) In general.--Rules of coordination
described in this subparagraph for an
Alternative Payment Model shall be designed to
determine, for purposes of applying subsection
(a) and section 1848(d)(16), under what
circumstances an eligible professional is
treated as having a payment arrangement under a
particular model.
``(ii) Nonduplication of payment.--Such
rules of coordination shall ensure coordination
and nonduplication of payment of services that
might be covered under more than one payment
arrangement or under section 1848(d)(16).
``(iii) Application to non-apm payment.--In
applying such rules for purposes of section
1848(d)(16), an eligible professional shall not
be treated as having a payment arrangement in
effect under such a model for any covered
professional services not treated as furnished
under the model.
``(3) Participating apm providers.--
``(A) In general.--To participate under a
demonstration program under this subsection, with
respect to an Alternative Payment Model, an eligible
professional shall enter into a contract with the
Administrator of the Centers for Medicare & Medicaid
Services under this subsection. For purposes of this
section, such an eligible professional who so
participates under such an Alternative Payment Model in
this section is referred to as a `participating APM
provider'.
``(B) Requirements.--The Secretary shall establish
criteria for eligible professionals to enter into
contracts under this paragraph for purposes of
participation under a demonstration program with
respect to an Alternative Payment Model. Such criteria
shall ensure participation under such model of a
sufficient number of eligible professionals for whom
the model was designed in order to satisfy the
criterion described in paragraph (2)(A)(iii)(II).
``(4) Reporting and evaluation.--
``(A) Independent evaluation entity.--Under this
subsection, the Secretary shall enter into a contract
with an independent entity to evaluate Alternative
Payment Models under demonstration programs under this
subsection based on appropriate measures specified
under subparagraph (B). In this section, such entity
shall be referred to as the `independent evaluation
entity'. Such contract shall be entered into in a
timely manner so as to ensure evaluation of an
Alternative Payment Model under a demonstration program
under this subsection may begin as soon as possible
after the model is approved under paragraph (2).
``(B) Performance measures.--For purposes of this
subsection, the Secretary shall specify--
``(i) measures to evaluate Alternative
Payment Models under demonstration programs
under this subsection, which may include
measures suggested under subsection (c) and
shall be sufficient to allow for a
comprehensive assessment of such a model; and
``(ii) quality measures on which
participating APM providers shall report, which
shall be similar to measures applicable under
section 1848(k).
``(C) Reporting requirements.--A contract entered
into with a participating APM provider under paragraph
(3) shall require such provider to report on
appropriate measures specified under subparagraph (B).
``(D) Periodic review.--The independent evaluation
entity shall periodically review and analyze and submit
such analysis to the Secretary and the participating
APM providers involved data reported under subparagraph
(C) and such other data as deemed necessary to evaluate
the model.
``(E) Final evaluation.--Not later than 6 months
after the date of completion of a demonstration
program, the independent evaluation entity shall submit
to the Secretary, the Medicare Payment Advisory
Commission, and the Chief Actuary of the Centers for
Medicare & Medicaid Services (and make publicly
available) a report on each model evaluated under such
program. Such report shall include--
``(i) outcomes on the clinical and claims
data received through such program with respect
to such model;
``(ii) recommendations on--
``(I) whether or not such model
should be implemented as an eligible
APM under this section; or
``(II) whether or not the
evaluation of such model under the
demonstration program should be
extended or expanded;
``(iii) the justification for each such
recommendation described in clause (ii); and
``(iv) in the case of a recommendation to
implement such model as an eligible APM,
recommendations on standardized rules for
purposes of such implementation.
``(5) Approval of extending evaluation under
demonstration.--Not later than 90 days after the date of
receipt of a submission under paragraph (4)(E), the Secretary
shall, including based on a recommendation submitted under such
paragraph, determine whether an Alternative Payment Model may
be extended or expanded under the demonstration program.
``(6) Termination.--The Secretary shall terminate a
demonstration program for a model under this subsection unless
the Secretary determines (and the Chief Actuary of the Centers
for Medicare & Medicaid Services, with respect to spending
under this title, certifies), after testing has begun, that the
model is expected to--
``(A) improve the quality of care (as determined by
the Administrator of the Centers for Medicare &
Medicaid Services) without increasing spending under
this title;
``(B) reduce spending under this title without
reducing the quality of care; or
``(C) improve the quality of care and reduce
spending.
Such termination may occur at any time after such testing has
begun and before completion of the testing.
``(7) Funding.--
``(A) In general.--There are appropriated, from
amounts in the Federal Supplementary Medical Insurance
Trust Fund under section 1841 not otherwise
appropriated and as of the date of the enactment of
this section, $2,000,000,000 for the purposes described
in subparagraph (B), of which no more than 2.5 percent
may be used for the purpose described in clause (iii)
of such subparagraph. Amounts appropriated under this
subparagraph shall be available until expended.
``(B) Purposes.--Amounts appropriated under
subparagraph (A) shall be used for--
``(i) payments for items and services
furnished by participating APM providers under
an Alternative Payment Model under a
demonstration program under this subsection
that--
``(I) would not otherwise be
eligible for payment under this title;
or
``(II) exceed the amount of payment
that would otherwise be made for such
items and services under this title if
such items and services were not
furnished under such demonstration
program;
``(ii) the evaluations provided for under
this section of models under such a
demonstration program;
``(iii) payment to the APM contracting
entity for carrying out its duties under this
section; and
``(iv) for otherwise carrying out this
subsection.
``(C) Limitation.--The amounts appropriated under
subparagraph (A) are the only amounts authorized or
appropriated to carry out the purposes described in
subparagraph (B).
``(f) Implementation of Recommended Models as Eligible APMs.--
``(1) Assessment.--With respect to each Alternative Payment
Model recommended under subsection (d)(1)(A)(i)(II) or
(e)(4)(E)(ii)(I), the Secretary shall review the basis for such
recommendation and assess and determine, in consultation with
the Chief Actuary of the Centers for Medicare & Medicaid
Services, whether the model is significantly likely to continue
to result in meeting the criterion described in subsection
(e)(2)(A)(iii)(I), with or without a modification described in
paragraph (5).
``(2) Implementation through rulemaking.--
``(A) Publication of nprm.--If the Secretary
determines that such a model is significantly likely to
meet such criterion, the Secretary shall publish as
part of the applicable physician fee schedule
rulemaking process (specified in paragraph (3)) a
notice of proposed rulemaking to implement such model,
including as modified under paragraph (5).
``(B) Comments by medpac.--Not later than 90 days
after the date of issuance of such notice with respect
to a model, the Medicare Payment Advisory Commission
shall submit comments on the proposed rule for such
model to Congress and to the Secretary. Such comments
shall include an evaluation of the reports from the
contracting entity and independent evaluation entity on
such model regarding the model's impact on expenditures
and quality of care under this title.
``(C) Final rule and conditions.--The Secretary
shall publish as part of the applicable physician fee
schedule rulemaking process (specified in paragraph
(3)) a final notice implementing such proposed rule,
including as modified under paragraph (5), as an
eligible APM only if--
``(i) the Secretary determines that such
model is expected to--
``(I) reduce spending under this
title without reducing the quality of
care; or
``(II) improve the quality of
patient care without increasing
spending;
``(ii) the Chief Actuary of the Centers for
Medicare & Medicaid Services certifies that
such model would reduce (or would not result in
any increase in) spending under this title;
``(iii) the Secretary determines that such
model would not deny or limit the coverage or
provision of benefits under this title for
applicable individuals;
``(iv) the Secretary determines that the
model is significantly likely to result in the
participation of a sufficient number of
appropriate eligible professionals for whom the
model was designed in order to satisfy the
criterion described in subsection
(d)(2)(A)(iii)(II);
``(v) the Secretary determines that the
model applies rules of coordination described
in paragraph (6); and
``(vi) the Secretary determines that model
meets such other criteria as the Secretary may
determine.
``(3) Applicable physician fee schedule rulemaking
process.--For purposes of paragraph (2), in the case of an
Alternative Payment Model recommended under subsection
(d)(1)(A)(ii) or (e)(4)(E)(ii)(I)--
``(A) on or before April 1 of a year, the
applicable physician fee schedule rulemaking process is
the process for publication by November 1 of that year
of the fee schedule amounts under this section for the
succeeding year; or
``(B) after April 1 of a year, the applicable
physician fee schedule rulemaking process is the
process for publication by November 1 of the following
year of the fee schedule amounts under this section for
the second succeeding year.
``(4) Justification for disapprovals.--In the case that an
Alternative Payment Model recommended under subsection
(d)(1)(A)(ii) or (e)(4)(E)(ii)(I) is not implemented as an
eligible APM under this subsection, the Secretary shall make
publicly available the rational, in detail, for such decision.
``(5) Modifications by secretary.--For purposes of this
subsection, the Secretary may modify an Alternative Payment
Model recommended under subsection (d)(1)(A)(i)(II) or
(e)(4)(E)(ii)(I) to ensure that the model meets the
requirements under paragraph (1)(B). Such a modification may
include one or more of the following:
``(A) A change to the payment arrangement under
which eligible professionals participating in such
model would be paid for covered professional services
furnished under such model.
``(B) A change to the criteria for eligible
professionals to be eligible to participate under such
model in order to ensure that such requirements are
satisfied.
``(C) A change to the rules of coordination
described in paragraph (6).
``(D) The application of a withhold mechanism under
the payment arrangement under which the distribution of
withheld amounts is based on the success of the model
in meeting spending reduction requirements.
``(E) Such other change as the Secretary may
specify.
``(6) Rules of coordination for application of payment
arrangements under models.--
``(A) In general.--Rules of coordination described
in this paragraph for an Alternative Payment Model
shall be designed to determine, for purposes of
applying subsection (a) and section 1848(d)(16), under
what circumstances an eligible professional is treated
as having a payment arrangement under a particular
model.
``(B) Nonduplication of payment.--Such rules of
coordination shall ensure coordination and
nonduplication of payment of services that might be
covered under more than one payment arrangement or
under section 1848(d)(16).
``(C) Application to non-apm payment.--In applying
such rules for purposes of section 1848(d)(16), an
eligible professional shall not be treated as having a
payment arrangement in effect under such a model for
any covered professional services not treated as
furnished under the model.
``(g) Periodic Review and Termination.--
``(1) Periodic review.--In the case of an Alternative
Payment Model that has been implemented, the Secretary and the
Chief Actuary of the Centers for Medicare & Medicaid Services
shall review such model every 3 years to determine (and
certify, in the case of the Chief Actuary and spending under
this title), for the previous 3 years, whether the model has--
``(A) reduced the quality of care, or
``(B) increased spending under this title,
compared to the quality of care or spending that would have
resulted if the model had not been implemented.
``(2) Termination.--
``(A) Quality of care reduction termination.--If
based upon such review the Secretary determines under
paragraph (1)(A) that the model has reduced the quality
of care, the Secretary may terminate such model.
``(B) Spending increase termination.--Unless such
Chief Actuary certifies under paragraph (1)(B) that the
expenditures under this title under the model do not
exceed the expenditures that would otherwise have been
made if the model had not been implemented for the
period involved, the Secretary shall terminate such
model.
``(h) Dissemination of Eligible APMs.--Under this section there
shall be established a process for specifying, and making publicly
available a list of, all eligible APMs, which shall include at least
those implemented under subsection (f) and demonstrations carried out
with respect to payments under section 1848 through authority in
existence as of the day before the date of the enactment of this
section. Under such process such list shall be periodically updated
and, beginning with January 1, 2015, and annually thereafter, such list
shall be published in the Federal Register.''.
(2) Conforming amendment.--Section 1848(a)(1) of the Social
Security Act (42 U.S.C. 1395w-4(a)(1)) is amended by striking
``shall instead'' and inserting ``shall, subject to section
1848A, instead''.
(d) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and notwithstanding the
previous provisions of this subsection, for services
furnished on or after January 1, 2017, the fee schedule
areas used for payment under this section applicable to
California shall be the following:
``(i) Each Metropolitan Statistical Area
(each in this paragraph referred to as an
`MSA'), as defined by the Director of the
Office of Management and Budget as of December
31 of the previous year, shall be a fee
schedule area.
``(ii) All areas not included in an MSA
shall be treated as a single rest-of-State fee
schedule area.
``(B) Transition for msas previously in rest-of-
state payment locality or in locality 3.--
``(i) In general.--For services furnished
in California during a year beginning with 2017
and ending with 2021 in an MSA in a transition
area (as defined in subparagraph (D)), subject
to subparagraph (C), the geographic index
values to be applied under this subsection for
such year shall be equal to the sum of the
following:
``(I) Current law component.--The
old weighting factor (described in
clause (ii)) for such year multiplied
by the geographic index values under
this subsection for the fee schedule
area that included such MSA that would
have applied in such area (as estimated
by the Secretary) if this paragraph did
not apply.
``(II) MSA-based component.--The
MSA-based weighting factor (described
in clause (iii)) for such year
multiplied by the geographic index
values computed for the fee schedule
area under subparagraph (A) for the
year (determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The
MSA-based weighting factor described in this
clause for a year is 1 minus the old weighting
factor under clause (ii) for that year.
``(C) Hold harmless.--For services furnished in a
transition area in California during a year beginning
with 2017, the geographic index values to be applied
under this subsection for such year shall not be less
than the corresponding geographic index values that
would have applied in such transition area (as
estimated by the Secretary) if this paragraph did not
apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
``(E) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2017, for
California, any reference in this section to a fee
schedule area shall be deemed a reference to a fee
schedule area established in accordance with this
paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(D), the
term''.
(e) Relative Values Under the Medicare Physician Fee Schedule.--
(1) Eligible physicians reporting system to improve
accuracy of relative values.--Section 1848(c) of the Social
Security Act (42 U.S.C. 1395w-4(c)) is amended by adding at the
end the following new paragraph:
``(7) Physician reporting system to improve accuracy of
relative values.--
``(A) In general.--The Secretary shall implement a
system for the periodic reporting by physicians of data
on the accuracy of relative values under this
subsection, such as data relating to service volume and
time. Such data shall be submitted in a form and manner
specified by the Secretary and shall, as appropriate,
incorporate data from existing sources of data, patient
scheduling systems, cost accounting systems, and other
similar systems.
``(B) Identification of reporting cohort.--Not
later than January 1, 2015, the Secretary shall
establish a mechanism for physicians to participate
under the reporting system under this paragraph, all of
whom shall collectively be referred to under this
paragraph as the `reporting group'. The reporting group
shall include physicians across settings that
collectively represent a range of specialties and
practitioner types, furnish a range of physicians'
services, and serve a range of patient populations.
``(C) Incentive to report.--Under the system under
this paragraph, the Secretary may provide for such
payments under this part to physicians included in the
reporting group as the Secretary determines appropriate
to compensate such physicians for reporting data under
the system. Such payments shall be provided in such
form and manner as specified by the Secretary. In
carrying out this subparagraph, reporting by such a
physician under this paragraph shall not be treated as
the furnishing of physicians' services for purposes of
applying this section.
``(D) Funding.--To carry out this paragraph (other
than with respect to payments made under subparagraph
(C)), in addition to funds otherwise appropriated, the
Secretary shall provide for the transfer from the
Federal Supplementary Medical Insurance Trust Fund
under section 1841 of $1,000,000 to the Centers for
Medicare & Medicaid Services Program Management Account
for each fiscal year beginning with fiscal year 2014.
Amounts transferred under this subparagraph for a
fiscal year shall be available until expended.''.
(2) Relative value adjustments for misvalued physicians'
services.--
(A) In general.--Section 1848(c)(2) of the Social
Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by
adding at the end the following new subparagraph:
``(M) Adjustments for misvalued physicians'
services.--
``(i) In general.--Only with respect to fee
schedules established for 2016, 2017, and 2018
(and not for subsequent years), the Secretary
shall--
``(I) identify, based on the data
reported under paragraph (8) and other
relevant data, misvalued services for
which adjustments to the relative
values established under this paragraph
would result in a reduction in
expenditures under the fee schedule
under this section, with respect to
such year, of not more than 1 percent
of the projected amount of expenditures
under such fee schedule for such year;
and
``(II) make such adjustments for
each such year so as only to result in
such a reduction for such year.
``(ii) No effect on subsequent years.--A
reduction under this subparagraph for a year
shall not affect any reduction for any
subsequent year.
``(iii) Rule of construction relating to
undervalued codes.--Nothing in this
subparagraph shall be construed as preventing
the Secretary from increasing the relative
values for codes that are undervalued.''.
(B) Budget neutrality.--Section 1848(c)(2)(B)(v) of
the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v))
is amended by adding at the end the following new
subclause:
``(VIII) Reductions for misvalued
physicians' services.--Reduced
expenditures attributable to
subparagraph (M) for fiscal years 2016,
2017, and 2018.''.
(3) Disclosure of data used to establish multiple procedure
payment reduction policy.--The Secretary of Health and Human
Services shall make publicly available the data used to
establish the multiple procedure payment reduction policy to
the professional component of imaging services in the final
rule published in the Federal Register, v. 77, n. 222, November
16, 2012, pages 68891-69380 under the physician fee schedule
under section 1848 of the Social Security Act (42 U.S.C. 1395w-
4).
SEC. 3. EXPANDING AVAILABILITY OF MEDICARE DATA.
(a) Expanding Uses of Medicare Data by Qualified Entities.--
(1) In general.--To the extent consistent with applicable
information, privacy, security, and disclosure laws, beginning
with 2014, notwithstanding 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, a qualified
entity may use data received by such entity under such section,
and information derived from the evaluation described in such
paragraph (4)(D), for additional non-public analyses (as
determined appropriate by the Secretary of Health and Human
Services) or provide or sell such data to registered or
authorized users and subscribers, including to providers of
services and suppliers, for non-public use (including for the
purposes of assisting providers of services and suppliers to
develop and participate in quality and patient care improvement
activities, including developing new models of care).
(2) Definitions.--In this section:
(A) The term ``qualified entity'' has the meaning
given such term in section 1874(e)(2) of the Social
Security Act (42 U.S.C. 1395kk(e)).
(B) The terms ``supplier'' and ``provider of
services'' have the meanings given such terms in
subsections (d) and (u), respectively, of section 1861
of the Social Security Act (42 U.S.C. 1395x).
(b) Access to Medicare Data to Providers of Services and Suppliers
to Facilitate Development of Alternative Payment Models and to
Qualified Clinical Data Registries to Facilitate Quality Improvement.--
Consistent with applicable laws and regulations with respect to privacy
and other relevant matters, the Secretary shall provide Medicare claims
data (in a form and manner determined to be appropriate) to--
(1) qualified entities, that may share with providers of
services and suppliers that are registered or authorized users
or subscribers, for non-public use including to facilitate the
development of new models of care (including development of
Alternate Payment Models under section 1848A of the Social
Security Act, models for small group specialty practices, and
care coordination models); and
(2) qualified clinical data registries under section
1848(m)(3)(E)) of the Social Security Act (42 U.S.C. 1395w-
4(m)(3)(E)) for purposes of linking such data with clinical
outcomes data and performing and disseminating risk-adjusted,
scientifically valid analysis and research to support quality
improvement or patient safety, provided that any public
reporting of identifiable provider data shall only be conducted
with prior consent of such provider.
SEC. 4. ENCOURAGING CARE COORDINATION AND MEDICAL HOMES.
Section 1848(b) of the Social Security Act (42 U.S.C. 1395w-4(b))
is amended by adding at the end the following new paragraph:
``(8) Encouraging care coordination and medical homes.--
``(A) In general.--In order to promote the
coordination of care by an applicable provider (as
defined in subparagraph (B)) for individuals with
complex chronic care needs who are furnished items and
services by multiple physicians and other suppliers and
providers of services, the Secretary shall--
``(i) develop one or more HCPCS codes for
complex chronic care management services for
individuals with complex chronic care needs;
and
``(ii) for such services furnished on or
after January 1, 2015, by an applicable
provider, make payment (as the Secretary
determines to be appropriate) under the fee
schedule under this section using such HCPCS
codes.
``(B) Applicable provider defined.--For purposes of
this paragraph, the term `applicable provider' means a
physician (as defined in section 1861(r)(1)) or a
physician assistant or nurse practitioner (as defined
in section 1861(aa)(5)(A)) who--
``(i) is certified as a medical home (by
achieving an accreditation status of level 3 by
the National Committee for Quality Assurance);
``(ii) is recognized as a patient-centered
specialty practice by the National Committee
for Quality Assurance;
``(iii) has received equivalent
certification (as determined by the Secretary);
or
``(iv) meets such other comparable
qualifications as the Secretary determines to
be appropriate.
``(C) Budget neutrality.--The budget neutrality
provision under subsection (c)(2)(B)(ii)(II) shall
apply in establishing the payment under subparagraph
(A)(ii).
``(D) Single applicable provider payment.--In
carrying out this paragraph, the Secretary shall only
make payment to a single applicable provider for
complex chronic care management services furnished to
an individual.''.
SEC. 5. MISCELLANEOUS.
(a) Solicitations, Recommendations, and Reports.--
(1) Solicitation for recommendations on episodes of care
definition.--The Administrator of the Centers for Medicare &
Medicaid Services shall request eligible professional
organizations (as defined in section 1848(k)(3) of the Social
Security Act (42 U.S.C. 1395w-4(k)(3))) and other relevant
stakeholders to submit recommendations for defining non-acute
related episodes of care for purposes of applying such
definition under subsections (k) and (q) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) and section 1848A of
such Act, as added by subsections (b) and (c) of section 2.
(2) Solicitation for recommendations on provider fee
schedule payment bundles.--
(A) In general.--The Administrator of the Centers
for Medicare & Medicaid Services shall solicit from
eligible professional organizations (as defined in
section 1848(k)(3) of the Social Security Act (42
U.S.C. 1395w-4(k)(3))) recommendations for payment
bundles for chronic conditions and expensive, high
volume services for which payment is made under title
XVIII of such Act.
(B) Report to congress.--Not later than 24 months
after the date of the enactment of this Act, the
Administrator shall submit to Congress a report on
proposals for such payment bundles.
(3) Reports on modified pfs system and payment system
alternatives.--
(A) Biannual progress reports.--Not later than
January 15, 2016, and annually thereafter, the
Secretary of Health and Human Services shall submit to
Congress and post on the public Internet website of the
Centers for Medicare & Medicaid Services a biannual
progress report--
(i) on the implementation of paragraph (9)
of section 1848(k) of the Social Security Act
(42 U.S.C. 1395w-4(k)), as added by section
2(b)(2), and the quality update incentive
program under subsection (q) of section 1848 of
the Social Security Act (42 U.S.C. 1395w-4), as
added by section 2(b)(3);
(ii) that includes an evaluation of such
paragraph and such quality update incentive
program and recommendations with respect to
such program and appropriate update mechanisms;
and
(iii) on the actions taken to promote and
fulfill the identification of eligible APMs
under section 1848A of the Social Security Act,
as added by section 2(c), for application under
such section 1848A.
(B) GAO and medpac reports.--
(i) GAO report on initial stages of
program.--The Comptroller General of the United
States shall submit to Congress a report for
2019 and each subsequent year analyzing the
extent to which the system under section
1848(k)(9) of the Social Security Act (42
U.S.C. 1395w-4(k)(9)) and such quality update
incentive program under section 1848(q) of the
Social Security Act, as added by section 2(b)
is successfully satisfying performance
objectives, including with respect to--
(I) the process for developing and
selecting measures and activities under
subsection (k)(9) of section 1848 of
such Act (42 U.S.C. 1395w-4);
(II) the process for assessing
performance against such measures and
activities under subsection (q) of such
section; and
(III) the adequacy of the measures
and activities so selected.
(ii) Evaluation by gao and medpac on
implementation of quality update incentive
program.--
(I) GAO.--The Comptroller General
of the United States shall evaluate the
initial phase of the quality update
incentive program under subsection (q)
of section 1848 of the Social Security
Act (42 U.S.C. 1395w-4) and shall
submit to Congress, not later than
2019, a report with recommendations for
improving such quality update incentive
program.
(II) MedPAC.--In the course of its
March Report to Congress on Medicare
payment policy, MedPAC shall analyze
the initial phase of such quality
update incentive program and make
recommendations, as appropriate, for
improving such quality update incentive
program.
(iii) MedPAC report on payment system
alternatives.--
(I) In general.--Not later than
June 15, 2016, the Medicare Payment
Advisory Commission shall submit to
Congress a report that analyzes
multiple options for alternative
payment models in lieu of section 1848
of the Social Security Act (42 U.S.C.
1395w-4). In analyzing such models, the
Medicare Payment Advisory Commission
shall examine at least the following
models:
(aa) Accountable care
organization payment models.
(bb) Primary care medical
home payment models.
(cc) Bundled or episodic
payments for certain conditions
and services.
(dd) Gainsharing
arrangements
(II) Items to be included.--Such
report shall include information on how
each recommended new payment model will
achieve maximum flexibility to reward
high quality, efficient care.
(C) Tracking expenditure growth and access.--
Beginning in 2015, the Chief Actuary of the Centers for
Medicare & Medicaid Services shall track expenditure
growth and beneficiary access to physicians' services
under section 1848 of the Social Security Act (42
U.S.C. 1395w-4) and shall post on the public Internet
website of the Centers for Medicare & Medicaid Services
annual reports on such topics.
(4) Report on clinical decision support mechanisms.--Not
later than one year after the date of the enactment of this
Act, the Secretary of Health and Human Services shall submit to
Congress a report on the extent to which clinical decision
support mechanisms and other provider support tools could be
used to further program objectives under section 1848 of the
Social Security Act (42 U.S.C. 1395w-4)) and recommendation for
how such mechanisms and tools should be so used.
(b) Rule of Construction Regarding Health Care Provider Standards
of Care.--
(1) In general.--The development, recognition, or
implementation of any guideline or other standard under any
Federal health care provision shall not be construed to
establish the standard of care or duty of care owed by a health
care provider to a patient in any medical malpractice or
medical product liability action or claim.
(2) Definitions.--For purposes of this subsection:
(A) The term ``Federal health care provision''
means any provision of the Patient Protection and
Affordable Care Act (Public Law 111-148), title I and
subtitle B of title III of the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-
152), and titles XVIII and XIX of the Social Security
Act.
(B) The term ``health care provider'' means any
individual or entity--
(i) licensed, registered, or certified
under Federal or State laws or regulations to
provide health care services; or
(ii) required to be so licensed,
registered, or certified but that is exempted
by other statute or regulation.
(C) The term ``medical malpractice or medical
liability action or claim'' means a medical malpractice
action or claim (as defined in section 431(7) of the
Health Care Quality Improvement 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 or section 351 of the
Public Health Service Act).
(D) The term ``State'' includes the District of
Columbia, Puerto Rico, and any other commonwealth,
possession, or territory of the United States.
(3) No preemption.--No provision of the Patient Protection
and Affordable Care Act (Public Law 111-148), title I or
subtitle B of title III of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), or title XVIII
or XIX of the Social Security Act shall be construed to preempt
any State or common law governing medical professional or
medical product liability actions or claims.
SEC. 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``SGR Repeal and
Medicare Beneficiary Access Act of 2013''.
(b) Table of Contents.--The table of contents for 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 quality measure development.
Sec. 4. Encouraging care management for individuals with chronic care
needs.
Sec. 5. Ensuring accurate valuation of services under the physician fee
schedule.
Sec. 6. Promoting evidence-based care.
Sec. 7. Empowering beneficiary choices through access to information on
physicians' services.
Sec. 8. Expanding claims data availability to improve care.
Sec. 9. 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 methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A), by inserting ``or
a subsequent paragraph'' after ``paragraph
(4)''; and
(ii) in paragraph (4)--
(I) in the heading, by inserting
``and ending with 2013'' after ``years
beginning with 2001''; and
(II) in subparagraph (A), by
inserting ``and ending with 2013''
after ``a year beginning with 2001'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2013'' after ``of each succeeding
year''; and
(ii) in paragraph (2), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for 2014 and subsequent years.--
Subsection (d) of section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended by adding at the end the following
new paragraphs:
``(15) Update for 2014 through 2016.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2014 through 2016 shall be 0.5 percent.
``(16) Update for 2017 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2017 through 2023 shall be zero percent.
``(17) Update for 2024 and subsequent years.--The update to
the single conversion factor established in paragraph (1)(C)
for 2024 and each subsequent year shall be--
``(A) for items and services furnished by a
qualifying APM participant (as defined in section
1833(z)(2)) for such year, 2 percent; and
``(B) for other items and services, 1 percent.''.
(3) MedPAC reports.--
(A) Initial report.--Not later than July 1, 2016,
the Medicare Payment Advisory Commission shall submit
to Congress a report on the relationship between--
(i) physician and other health professional
utilization and expenditures (and the rate of
increase of such utilization and expenditures)
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 describe
such relationship and the impact of changes in such
physician and other health professional 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, 2020, the
Medicare Payment Advisory Commission 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
submitted under such subparagraph.
(b) Consolidation of Certain Current Law Performance Programs With
New Value-based Performance Incentive Program.--
(1) EHR meaningful use incentive program.--
(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 ``or any
subsequent payment year'' and inserting ``or
2016'';
(ii) in clause (ii)--
(I) in the matter preceding
subclause (I), by striking ``Subject to
clause (iii), for'' and inserting
``For'';
(II) in subclause (I), by adding at
the end ``and'';
(III) in subclause (II), by
striking ``; and'' and inserting a
period; and
(IV) by striking subclause (III);
and
(iii) by striking clause (iii).
(B) Continuation of meaningful use determinations
for vbp program.--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)--
(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
period 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 purposes of vbp
program.--With respect to 2017 and each subsequent
payment year, the Secretary shall, for purposes of
subsection (q) and in accordance with paragraph (1)(F)
of such subsection, determine whether an eligible
professional who is a VBP 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 reporting
incentives.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``or any
subsequent year'' and inserting ``or 2016'';
and
(ii) in clause (ii)(II), by striking ``and
each subsequent year''.
(B) Continuation of quality measures and processes
for vbp program.--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 vbp program.--
The Secretary shall, in accordance with subsection (q)(1)(F),
carry out the provisions of this subsection for purposes of
subsection (q).''; and
(ii) in subsection (m)--
(I) by redesignating the paragraph
(7) added by section 10327(a) of Public
Law 111-148 as paragraph (8); and
(II) by adding at the end the
following new paragraph:
``(9) Continued application for purposes of vbp program.--
The Secretary shall, in accordance with subsection (q)(1)(F),
carry out the processes under this subsection for purposes of
subsection (q).''.
(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 established under
this subsection for items and services
furnished on or after January 1, 2015, but
before January 1, 2017, with respect to
specific physicians and groups of physicians
the Secretary determines appropriate. Such
payment modifier shall not be applied for items
and services furnished on or after January 1,
2017.''.
(B) Continuation of value-based payment modifier
measures for vbp program.--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 purposes of vbp
program.--The Secretary shall, in accordance 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 2017 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Value-based Performance Incentive Program.--
(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) Value-based Performance Incentive Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional value-based
performance incentive program (in this subsection
referred to as the `VBP program') under which the
Secretary shall--
``(i) develop a methodology for assessing
the total performance of each VBP eligible
professional according to performance 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 accordance
with paragraph (5) for each such professional
for each performance period; and
``(iii) use such composite performance
score of the VBP eligible professional for a
performance period for a year to make VBP
program incentive payments under paragraph (7)
to the professional for the year.
``(B) Program implementation.--The VBP program
shall apply to payments for items and services
furnished on or after January 1, 2017.
``(C) VBP eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `VBP eligible professional' means--
``(I) for the first and second
years for which the VBP program applies
to payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)(1)), a physician assistant,
nurse practitioner, 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) for the third year for which
the VBP program 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) and such other eligible
professionals (as defined in subsection
(k)(3)(B)) as specified by the
Secretary.
``(ii) Exclusions.--For purposes of clause
(i), the term `VBP eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B))--
``(I) who is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) who, subject to clause
(vii), is a partial qualifying APM
participant (as defined in clause
(iii)) for the most recent period for
which data are available and who, for
the performance period with respect to
such year, does not report on
applicable measures and activities
described in paragraph (2)(B) that are
required to be reported by such a
professional under the VBP program; or
``(III) who, for the performance
period with respect to such year, does
not exceed the low-volume threshold
measurement selected under clause (iv).
``(iii) Partial qualifying apm
participant.--For purposes of this
subparagraph, the term `partial qualifying APM
participant' means, with respect to a year, an
eligible professional for whom the Secretary
determines the minimum payment percentage (or
percentages), as applicable, described in
paragraph (2) of section 1833(z) for such year
have not been satisfied, but who would be
considered a qualifying APM participant (as
defined in such paragraph) for such year if--
``(I) with respect to 2017 and
2018, the reference in subparagraph (A)
of such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2019 and
2020--
``(aa) the reference in
subparagraph (B)(i) of such
paragraph to 50 percent was
instead a reference to 40
percent; and
``(bb) the references in
subparagraph (B)(ii) of such
paragraph to 50 percent and 25
percent of such paragraph were
instead references to 40
percent and 20 percent,
respectively; and
``(III) with respect to 2021 and
subsequent years--
``(aa) the reference in
subparagraph (C)(i) of such
paragraph to 75 percent was
instead a reference to 50
percent; and
``(bb) the references in
subparagraph (C)(ii) of such
paragraph to 75 percent and 25
percent of such paragraph were
instead references to 50
percent and 20 percent,
respectively.
``(iv) Selection of low-volume threshold
measurement.--The Secretary shall select one of
the following low-volume threshold measurements
to apply for purposes of clause (ii)(III):
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the VBP 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
professional for such performance
period.
``(III) The minimum amount (as
determined by the Secretary) of allowed
charges billed by such professional
under this part for such performance
period.
``(v) Treatment of new medicare enrolled
eligible professionals.--In the case of a
professional who first becomes a Medicare
enrolled eligible professional 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
VBP eligible professional until the subsequent
year and performance period for such subsequent
year.
``(vi) Clarification.--In the case of items
and services furnished during a year by an
individual who is not a VBP eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a reduction under paragraph (6) or a
VBP program incentive payment under paragraph
(7) apply to such individual for such year.
``(vii) Partial qualifying apm participant
clarification.--In the case of an eligible
professional who is a partial qualifying APM
participant, with respect to a year, and who
for the performance period for such year
reports on applicable measures and activities
described in paragraph (2)(B) that are required
to be reported by such a professional under the
VBP program, such eligible professional is
considered to be a VBP eligible professional
with respect to such year.
``(D) Application to group practices.--
``(i) In general.--Under the VBP program:
``(I) Quality performance
category.--The Secretary shall
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for VBP eligible
professionals in a group practice with
respect to assessing performance of
such group with respect to the
performance category described in
clause (i) of paragraph (2)(A).
``(II) Other performance
categories.--The Secretary may
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for VBP eligible
professionals in a group practice with
respect to assessing the performance of
such group with respect to the
performance categories described in
clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group
practice assessment.--The process established
under clause (i) shall to the extent
practicable reflect the full range of items and
services furnished by the VBP eligible
professionals in the group practice involved.
``(iii) Clarification.--VBP eligible
professionals electing to be a virtual group
under paragraph (5)(J) shall not be considered
VBP eligible professionals in a group practice
for purposes of applying this subparagraph.
``(E) Use of registries.--Under the VBP program,
the Secretary shall encourage the use of qualified
clinical data registries pursuant to subsection
(m)(3)(E) in carrying out this subsection.
``(F) Application of certain provisions.--In
applying a provision of subsection (k), (m), (o), or
(p) for purposes of this subsection, the Secretary
shall--
``(i) adjust the application of such
provision to ensure the provision is consistent
with the provisions of this subsection; and
``(ii) not apply such provision to the
extent that the provision is duplicative with a
provision of this subsection.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the VBP
program, the Secretary shall use the following
performance categories (each of which is referred to in
this subsection as a performance category) in
determining the composite performance 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 specified for each
category.--For purposes of paragraph (3)(A) and subject
to subparagraph (C), measures and activities specified
for a performance period (as established under
paragraph (4)) for a year are as follows:
``(i) Quality.--For the performance
category described in subparagraph (A)(i), the
quality measures established for such period
under subsections (k) and (m), including under
subsection (m)(3)(E), and the measures of
quality of care established for such period
under subsection (p)(2).
``(ii) Resource use.--For the performance
category described in subparagraph (A)(ii), the
measurement of resource use for such period
under subsection (p)(3), using the methodology
under subsection (r), as appropriate, and, as
feasible and applicable, accounting for the
cost of covered part D drugs.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities under
subcategories specified by the Secretary for
such period, which shall include at least the
following:
``(I) The subcategory of expanded
practice access, which shall include
activities such as same day
appointments for urgent needs and after
hours access to clinician advice.
``(II) The subcategory of
population management, which shall
include activities such as monitoring
health conditions of individuals to
provide timely health care
interventions or participation in a
qualified clinical data registry.
``(III) The subcategory of care
coordination, which shall include
activities such as timely communication
of test results, timely exchange of
clinical information to patients and
other providers, and use of remote
monitoring or telehealth.
``(IV) The subcategory of
beneficiary engagement, which shall
include activities such as the
establishment of care plans for
individuals with complex care needs,
beneficiary self-management 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
participation in an alternative payment
model (as defined in section
1833(z)(3)(C)).
In establishing activities under this clause,
the Secretary shall give consideration to the
circumstances of small practices (consisting of
fewer than 20 professionals) and practices
located in rural areas and in health
professional shortage areas (as designated
under section 332(a)(1)(A) of the Public Health
Service Act).
``(iv) Meaningful ehr use.--For the
performance category described in subparagraph
(A)(iv), the requirements established for such
period under subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
``(C) Additional provisions.--
``(i) Emphasizing outcome measures under
quality performance category.--In applying
subparagraph (B)(i), the Secretary shall, as
feasible, emphasize the application of outcome
measures.
``(ii) Application of additional system
measures.--The Secretary may use measures used
for a payment system other than for physicians
for purposes of the performance category
described in subparagraph (A)(i).
``(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome measures, and
population-based measures for purposes of the
performance category described in subparagraph
(A)(i).
``(iv) Request for information for clinical
practice improvement activities.--In initially
applying subparagraph (B)(iii), the Secretary
shall use a request for information to solicit
recommendations from stakeholders for
identifying activities described in such
subparagraph and specifying criteria for such
activities.
``(v) Contract authority for clinical
practice improvement activities performance
category.--In applying subparagraph (B)(iii),
the Secretary may contract with entities to
assist the Secretary in--
``(I) identifying activities
described in subparagraph (B)(iii);
``(II) specifying criteria for such
activities; and
``(III) determining whether a VBP
eligible professional meets such
criteria.
``(vi) Application of measures and
activities to non-patient-facing providers.--In
carrying out this paragraph, with respect to
measures and activities specified in
subparagraph (B) for performance categories
described in subparagraph (A), the Secretary--
``(I) shall give consideration to
the circumstances of professional types
(or subcategories of those types
determined by practice characteristics)
who typically provide services that do
not involve face-to-face interaction
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 VBP eligible
professionals of such professional
types or subcategories, in lieu of such
a measure or activity, a comparable
measure or activity that fulfills the
goals of the applicable performance
category.
In carrying out the previous sentence, the
Secretary shall consult with professionals of
such professional types or subcategories.
``(3) Performance standards.--
``(A) Establishment.--Under the VBP program, the
Secretary shall establish performance standards with
respect to measures and activities specified under
paragraph (2)(B) for a performance period (as
established under paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph
(2)(B), the Secretary shall take into account the
following:
``(i) Historical performance standards.
``(ii) Improvement rates.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with the
year described in paragraph (1)(B)). Such performance period
(or periods) shall begin and end prior to the beginning of such
year and be as close as possible to such year. In this
subsection, such performance period (or periods) for a year
shall be referred to as the performance period for the year.
``(5) Composite performance score.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and consistent with
section 2(g)(2) of the SGR Repeal and Medicare
Beneficiary Access Act of 2013, the Secretary shall
develop a methodology for assessing the total
performance of each VBP eligible professional according
to performance standards under paragraph (3) with
respect to applicable measures and activities specified
in paragraph (2)(B) with respect to each performance
category applicable to such professional for a
performance period (as established under paragraph (4))
for a year. Using such methodology, the Secretary shall
provide for a composite assessment (in this subsection
referred to as the `composite performance score') for
each such professional for each performance period.
``(B) Weighting performance categories, measures,
and activities.--Under the methodology under
subparagraph (A), the Secretary--
``(i) may assign different scoring weights
(including a weight of 0) for--
``(I) each performance category
based on the extent to which the
category is applicable to the type of
eligible professional involved; and
``(II) each measure and activity
specified under paragraph (2)(B) with
respect to each such category based on
the extent to which the measure or
activity is applicable to the type of
eligible professional involved; and
``(ii) with respect to the performance
category described in paragraph (2)(A)(i)--
``(I) shall assign a higher scoring
weight to outcomes measures than to
other measures and increase the scoring
weight for outcome measures over time;
and
``(II) may assign a higher scoring
weight to patient experience measures.
``(C) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
``(i) Incentive to report.--Under the
methodology established under subparagraph (A),
the Secretary shall provide that in the case of
a VBP eligible professional who fails to report
on an applicable measure or activity that is
required to be reported by the professional,
the professional shall be treated as achieving
the lowest potential score applicable to such
measure or activity.
``(ii) Encouraging use of certified ehr
technology for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage VBP eligible
professionals to report on applicable
measures with respect to the
performance category described in
paragraph (2)(A)(i) through the use of
certified EHR technology; and
``(II) with respect to a
performance period, with respect to a
year, for which a VBP eligible
professional reports such measures
through the use of such EHR technology,
treat such professional as satisfying
the clinical quality measures reporting
requirement described in subsection
(o)(2)(A)(iii) for such year.
``(D) Clinical practice improvement activities
performance score.--
``(i) Rule for accreditation.--A VBP
eligible professional who is in a practice that
is certified as a patient-centered medical home
or comparable specialty practice pursuant to
subsection (b)(8)(B)(i) with respect to a
performance period shall be given the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
period.
``(ii) APM participation.--Participation by
a VBP 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
one-half of the highest potential score for the
performance category described in paragraph
(2)(A)(iii) for such performance period.
Nothing in the previous sentence shall prevent
such professional from earning more than one-
half of such highest potential score for such
performance period by performing additional
activities with respect to such performance
category.
``(iii) Subcategories.--A VBP eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) to achieve the highest potential
score for the performance category described in
paragraph (2)(A)(iii).
``(E) Distribution.--The Secretary shall ensure
that the application of the methodology developed under
subparagraph (A) results in a continuous distribution
of performance scores, which shall result in
differential payments under paragraph (7).
``(F) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the VBP
program applies, in addition to the achievement
score of a VBP eligible professional, the
methodology developed under subparagraph (A)--
``(I) in the case of the
performance score for the performance
category described in clauses (i) and
(ii) of paragraph (2)(A), shall take
into account the improvement of the
professional; and
``(II) in the case of performance
scores for other performance
categories, may take into account the
improvement of the professional.
``(ii) Assigning higher weight for
achievement.--Beginning with the fourth year to
which the VBP program applies, under the
methodology developed under subparagraph (A),
the Secretary may assign a higher scoring
weight under subparagraph (B) with respect to
the achievement score of a VBP eligible
professional with respect to a measure or
activity specified under paragraph (2)(B) (or
with respect to such a measure or activity and
with respect to categories described in
paragraph (2)(A)) than to any improvement score
applied under clause (i) with respect to such
measure or activity (or such measure or
activity and categories).
``(G) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
clauses (ii) and (iii), the composite
performance score shall be determined as
follows:
``(I) Quality.--
``(aa) In general.--Subject
to item (bb), 30 percent of
such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A).
``(bb) First 2 years and
test year.--For the first and
second years for which the VBP
program applies to payments, 60
percent of such score shall be
based on performance with
respect to the category
described in clause (i) of
paragraph (2)(A). With respect
to the subsequent year, the
percent described in item (aa)
of such score shall be based on
performance with respect to
such category only for purposes
of feedback and 60 percent of
such score shall be based on
performance with respect to
such category for any other
purpose under this subsection.
``(II) Resource use.--
``(aa) In general.--Subject
to item (bb), 30 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 and
test year.--For the first and
second years for which the VBP
program applies to payments,
zero percent of such score
shall be based on performance
with respect to the category
described in clause (ii) of
paragraph (2)(A). With respect
to the subsequent year, the
percent described in item (aa)
of such score shall be based on
performance with respect to
such category only for purposes
of feedback and zero percent of
such score shall be based on
performance with respect to
such category for any other
purpose under this subsection.
``(III) Clinical practice
improvement activities.--Fifteen
percent of such score shall be based on
performance with respect to the
category described in clause (iii) of
paragraph (2)(A).
``(IV) Meaningful use of certified
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 percentages in
case of high ehr meaningful use adoption.--In
any year in which the Secretary estimates that
the proportion of eligible professionals (as
defined in subsection (o)(5)) who are
meaningful EHR users (as determined under
subsection (o)(2)) is 75 percent or greater,
the Secretary may reduce the percent applicable
under clause (i)(IV), but not below 15 percent.
If the Secretary makes such reduction for a
year, the percentages applicable under one or
more of subclauses (I), (II), and (III) of
clause (i) for such year (or, in the case of a
year described in clause (i)(II)(bb),
applicable under one or more of subclauses (I)
and (III)) shall be increased in a manner such
that the total percentage points of the
increase under this clause for such year equals
the total number of percentage points reduced
under the preceding sentence for such year.
``(iii) Authority to adjust percentages for
quality and resource use.--Other than for a
year described in clause (i)(II)(bb), the
percentages described in subclauses (I) and
(II) of clause (i), including after application
of clause (ii), shall be equal.
``(H) Resource use.--Analysis of the performance
category described in paragraph (2)(A)(ii) shall
include results from the methodology described in
subsection (r)(5), as appropriate.
``(I) Inclusion of quality measure data from
multiple payers.--In applying subsections (k), (m), and
(p) with respect to measures described in paragraph
(2)(B)(i), analysis of the performance category
described in paragraph (2)(A)(i) may include data
submitted by VBP eligible professionals with respect to
multiple payers.
``(J) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of VBP
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)--
``(I) the assessment of performance
provided under such methodology with
respect to the performance categories
described in clauses (i) and (ii) of
paragraph (2)(A) 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) the composite score provided
under this paragraph for such
performance period with respect to each
such performance category for each such
VBP eligible professional in such
virtual group shall be based on the
assessment of the combined performance
under subclause (I) for the performance
category and performance period.
``(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with clause (iii), establish and
have in place a process to allow an individual
VBP eligible professional or a group practice
consisting of not more than 10 VBP eligible
professionals to elect, with respect to a
performance period for a year, for such
individual VBP eligible professional or all
such VBP eligible professionals in such group
practice, respectively, to be a virtual group
under this subparagraph with at least one other
such individual VBP eligible professional or
group practice making such an election.
``(iii) Requirements.--The process under
clause (ii) shall provide that--
``(I) an election under such
clause, with respect to a performance
period, shall be made before the
beginning of such performance period
and may not be changed during such
performance period; and
``(II) a practice described in such
clause, and each VBP eligible
professional in such practice, may
elect to be in no more than one virtual
group for a performance period.
``(6) Funding for vbp program incentive payments.--
``(A) Total amount for incentive payments.--The
total amount for VBP program incentive payments under
paragraph (7) for all VBP eligible professionals for a
year shall be equal to the total amount of the
performance funding pool for all VBP eligible
professionals under subparagraph (B) for such year, as
estimated by the Secretary.
``(B) Performance funding pool.--
``(i) In general.--In the case of items and
services furnished by a VBP eligible
professional during a year (beginning with
2017), the otherwise applicable fee schedule
amount (as defined in clause (iii)) with
respect to such items and services and eligible
professional for such year shall be reduced by
the applicable percent under clause (ii). The
total amount of such reductions for a year
shall be referred to in this subsection as the
`performance funding pool' for such year.
``(ii) Applicable percent defined.--For
purposes of clause (i), the term `applicable
percent' means--
``(I) for 2017, 4 percent;
``(II) for 2018, 6 percent;
``(III) for 2019, 8 percent;
``(IV) for 2020, 10 percent; and
``(V) for 2021 and subsequent
years, a percent specified by the
Secretary (but in no case less than 10
percent or more than 12 percent).
``(iii) Otherwise applicable fee schedule
amount.--For purposes of this subparagraph and
paragraph (7), the term `otherwise applicable
fee schedule amount' means, with respect to
items and services furnished by a VBP eligible
professional during a year, the fee schedule
amount for such items and services and year
that would otherwise apply (without application
of this subparagraph or paragraph (7)) with
respect to such eligible professional under
subsection (b), after application of subsection
(a)(3), or under another fee schedule under
this part.
``(7) VBP program incentive payments.--
``(A) VBP program incentive payment adjustment
factor.--Consistent with section 2(g)(2) of the SGR
Repeal and Medicare Beneficiary Access Act of 2013, the
Secretary shall specify a VBP program incentive payment
adjustment factor for each VBP eligible professional
for a year. Such VBP program incentive payment
adjustment factor for a VBP eligible professional for a
year shall be determined--
``(i) by the composite performance score of
the eligible professional for such year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year results in differential payments under
this paragraph reflecting the full range of the
distribution of composite performance scores of
VBP eligible professionals determined under
paragraph (5)(E) for such year, with such
professionals having higher composite
performance scores receiving higher payment;
and
``(iii) in a manner such that the
adjustment factors specified under this
subparagraph for a year--
``(I) does not result in a payment
reduction for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year; and
``(II) does not result in a payment
increase for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year.
``(B) Calculation of vbp program incentive payment
amounts.--The VBP program incentive payment amount with
respect to items and services furnished by a VBP
eligible professional during a year shall be equal to
the difference between--
``(i) the product of--
``(I) the VBP program incentive
payment adjustment factor determined
under subparagraph (A) for such VBP
eligible professional for such year;
and
``(II) the otherwise applicable fee
schedule amount (as defined in
paragraph (6)(B)(iii)) with respect to
such items and services and eligible
professional for such year; and
``(ii) the otherwise applicable fee
schedule amount, as reduced under paragraph
(6)(B), with respect to such items and
services, eligible professional, and year.
The application of the preceding sentence may result in
the VBP program incentive payment amount being 0.0 with
respect to an item or service furnished by a VBP
eligible professional.
``(C) Application of vbp program incentive payment
amount.--In the case of items and services furnished by
a VBP eligible professional during a year (beginning
with 2017), the otherwise applicable fee schedule
amount, as reduced under paragraph (6)(B), with respect
to such items and services and eligible professional
for such year shall be increased, if applicable, by the
VBP program incentive payment amount determined under
subparagraph (B) with respect to such items and
services, professional, and year.
``(D) Budget neutrality.--In specifying the VBP
program incentive payment adjustment factor for each
VBP eligible professional for a year under subparagraph
(A), the Secretary shall ensure that the total amount
of VBP program incentive payment amounts under this
paragraph for all VBP eligible professionals in a year
shall be equal to the performance funding pool for such
year under paragraph (6), as estimated by the
Secretary.
``(8) Announcement of result of adjustments.--Under the VBP
program, the Secretary shall, not later than 60 days prior to
the year involved, make available to each VBP eligible
professional the VBP program incentive payment adjustment
factor under paragraph (7) and the payment reduction under
paragraph (6) applicable to the eligible professional for items
and services furnished by the professional in such year. The
Secretary may include such information in the confidential
feedback under paragraph (13).
``(9) No effect in subsequent years.--The VBP program
incentive payment under paragraph (7) and the payment reduction
under paragraph (6) shall each apply only with respect to the
year involved, and the Secretary shall not take into account
such VBP program incentive payment or payment reduction in
making payments to a VBP eligible professional under this part
in a subsequent year.
``(10) Public reporting.--
``(A) In general.--The Secretary shall, in an
easily understandable format, make available on the
Physician Compare Internet website under subsection (t)
the following:
``(i) Information regarding the performance
of VBP eligible professionals under the VBP
program, which--
``(I) shall include the composite
score for each such VBP eligible
professional and the performance of
each such VBP eligible professional
with respect to each performance
category; and
``(II) may include the performance
of each such VBP eligible professional
with respect to each measure or
activity specified in paragraph (2)(B).
``(ii) The names of eligible professionals
in eligible alternative payment models (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 indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(C) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for a professional described in
subparagraph (A) to review, and submit corrections for,
the information to be made public with respect to the
professional under such subparagraph prior to such
information being made public.
``(D) Aggregate information.--The Secretary shall
periodically post on the Physician Compare Internet
website aggregate information on the VBP program,
including the range of composite scores for all VBP
eligible professionals and the range of the performance
of all VBP eligible professionals with respect to each
performance category.
``(11) Consultation.--The Secretary shall consult with
stakeholders in carrying out the VBP program, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (7). Such consultation shall include the use of a request
for information or other mechanisms determined appropriate.
``(12) Technical assistance to small practices and
practices in health professional shortage areas.--
``(A) In general.--The Secretary shall enter into
contracts or agreements with appropriate entities (such
as quality improvement organizations, regional
extension centers (as described in section 3012(c) of
the Public Health Service Act), or regional health
collaboratives) to offer guidance and assistance to VBP
eligible professionals in practices of fewer than 20
professionals (with priority given to such practices
located in rural areas, health professional shortage
areas (as designated under in section 332(a)(1)(A) of
the Public Health Service Act), or practices with low
composite scores) with respect to--
``(i) the performance categories described
in clauses (i) through (iv) of paragraph
(2)(A); or
``(ii) how to transition to the
implementation of and participation in an
alternative payment model as described in
section 1833(z)(3)(C).
``(B) Funding for implementation.--For purposes of
implementing subparagraph (A), the Secretary shall
provide for the transfer from the Federal Supplementary
Medical Insurance Trust Fund established under section
1841 to the Centers for Medicare & Medicaid Services
Program Management Account of $50,000,000 for each of
fiscal years 2014 through 2018. Amounts transferred
under this subparagraph for a fiscal year shall be
available until expended.
``(13) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2015,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to each VBP eligible
professional on the performance of such
professional with respect to the
performance categories under clauses
(i) and (ii) of paragraph (2)(A); and
``(II) may make available
confidential feedback to each such
professional on the performance of such
professional with respect to the
performance 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 may include
use of a web-based portal or other mechanisms
determined appropriate by the Secretary. The
Secretary shall encourage provision of feedback
through qualified clinical data registries as
described in subsection (m)(3)(E)).
``(iii) Use of data.--For purposes of
clause (i), the Secretary may use data, with
respect to a VBP eligible professional, from
periods prior to the current performance period
and may use rolling periods in order to make
illustrative calculations about the performance
of such professional.
``(iv) Disclosure exemption.--Feedback made
available under this subparagraph shall be
exempt from disclosure under section 552 of
title 5, United States Code.
``(v) Receipt of information.--The
Secretary may use the mechanisms established
under clause (ii) to receive information from
professionals, such as information with respect
to this subsection.
``(B) Additional information.--
``(i) In general.--Beginning July 1, 2016,
the Secretary shall make available to each VBP
eligible professional information, with respect
to individuals who are patients of such VBP
eligible professional, about items and services
for which payment is made under this title that
are furnished to such individuals by other
suppliers and providers of services, which may
include information described in clause (ii).
Such information shall be made available under
the previous sentence to such VBP eligible
professionals by mechanisms determined
appropriate by the Secretary, which may include
use of a web-based portal. Such information
shall be made available in accordance with the
same or similar terms as data are made
available to accountable care organizations
under section 1899, including a beneficiary
opt-out.
``(ii) Type of information.--For purposes
of clause (i), the information described in
this clause, is the following:
``(I) With respect to selected
items and services (as determined
appropriate by the Secretary) for which
payment is made under this title and
that are furnished to individuals, who
are patients of a VBP eligible
professional, by another supplier or
provider of services during the most
recent period for which data are
available (such as the most recent
three-month period), the name of such
providers furnishing such items and
services to such patients during such
period, the types of such items and
services so furnished, and the dates
such items and services were so
furnished.
``(II) Historical averages (and
other measures of the distribution if
appropriate) of the total, and
components of, allowed charges (and
other figures as determined appropriate
by the Secretary) for care episodes for
such period.
``(14) Review.--
``(A) Targeted review.--The Secretary shall
establish a process under which a VBP eligible
professional may seek an informal review of the
calculation of the VBP program incentive payment
adjustment factor 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 account for purposes
of paragraph (7) with respect to a year (other than
with respect to the calculation of such eligible
professional's VBP program incentive payment adjustment
factor for such year) after the factors determined in
subparagraph (A) of such paragraph have been determined
for such year.
``(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the VBP program incentive payment
adjustment factor under paragraph (7) and the
determination of such amount.
``(ii) The determination of the amount of
funding available for such VBP program
incentive payments under paragraph (6)(A) and
the payment reduction under paragraph
(6)(B)(i).
``(iii) The establishment of the
performance standards under paragraph (3) and
the performance period under paragraph (4).
``(iv) 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 (10).
``(v) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation of such
scores, including the weighting of measures and
activities under such methodology.''.
(2) GAO reports.--
(A) Evaluation of eligible professional vbp
program.--Not later than October 1, 2018, and October
1, 2021, the Comptroller General of the United States
shall submit to Congress a report evaluating the
eligible professional value-based performance incentive
program under subsection (q) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4), as added by
paragraph (1). Such report shall--
(i) examine the distribution of the
performance and incentive payments for VBP
eligible professionals (as defined in
subsection (q)(1)(C) of such section) under
such program, and patterns relating to such
performance and incentive payments, including
based on type of provider, practice size,
geographic location, and patient mix; and
(ii) provide recommendations for improving
such program.
(B) Study to examine alignment of quality measures
used in public and private programs.--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--
(i) compares the similarities and
differences in the use of quality measures
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, and private
payer arrangements; and
(ii) makes recommendations on how to reduce
the administrative burden involved in applying
such quality measures.
(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 $50,000,000 from the Supplementary
Medical Insurance Trust Fund established under section 1841 of
the Social Security Act (42 U.S.C. 1395t) to the Centers for
Medicare & Medicaid Program Management Account for each of the
fiscal years 2014 through 2017. Amounts transferred under this
paragraph shall be available until expended.
(d) Improving Quality Reporting for Composite Scores.--
(1) Changes for group reporting option.--
(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 2014 and subsequent
years, may provide'' after ``shall provide''.
(B) Clarification of qualified clinical data
registry reporting to group practices.--Section
1848(m)(3)(D) of the Social Security Act (42 U.S.C.
1395w-4(m)(3)(D)) is amended by inserting ``and, for
2015 and subsequent years, subparagraph (A) or (C)''
after ``subparagraph (A)''.
(2) Changes for multiple reporting periods and alternative
criteria for satisfactory reporting.--Section 1848(m)(5)(F)) of
the 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 occurring in
2013''; and
(B) by inserting ``and, for reporting periods
occurring in 2014 and subsequent years, the Secretary
may establish'' following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under vbp program.--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 2016.--Reports under the Program
shall not be provided after December 31, 2016. See subsection
(q)(13) for reports beginning with 2017.''.
(4) Coordination with satisfying meaningful ehr use
clinical quality measure reporting 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 subsection
(q)(5)(C)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) 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 following 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 2017 and ending with 2022 and for which
the professional is a qualifying APM participant, in
addition to the amount of payment that would otherwise
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
payment amount for the covered professional services
under this part for the preceding year. For purposes of
the previous sentence, the payment amount for the
preceding year may be an estimation for the full
preceding year based on a period of such preceding year
that is less than the full year. The Secretary shall
establish policies to implement this subparagraph in
cases where payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model is made to an entity
participating in the alternative payment model rather
than directly to the qualifying APM participant.
``(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 incentive.--Payments
under this subsection shall not be taken into account
for purposes of determining actual expenditures under
an alternative payment model and for purposes of
determining or rebasing any benchmarks used under the
alternative payment model.
``(D) Coordination.--The amount of the additional
payment for an item or service under this subsection or
subsection (m) shall be determined without regard to
any additional payment for the item or service under
subsection (m) and this subsection, respectively. The
amount of the additional payment for an item or service
under this subsection or subsection (x) shall be
determined without regard to any additional payment for
the item or service under subsection (x) and this
subsection, respectively. The amount of the additional
payment for an item or service under this subsection or
subsection (y) shall be determined without regard to
any additional payment for the item or service under
subsection (y) and this subsection, respectively.
``(2) Qualifying apm participant.--For purposes of this
subsection, the term `qualifying APM participant' means the
following:
``(A) 2017 and 2018.--With respect to 2017 and
2018, 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 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 entity that participates in
an eligible alternative payment model with respect to
such services.
``(B) 2019 and 2020.--With respect to 2019 and
2020, an eligible professional described in either of
the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 50 percent of payments
under this part for covered professional
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 entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, 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 50 percent
of the sum of--
``(aa) payments described
in clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional 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 entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination 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
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional bears more than
nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures.
``(C) Beginning in 2021.--With respect to 2021 and
each subsequent year, an eligible professional
described in either of the following clauses:
``(i) Medicare revenue threshold option.--
An eligible professional for whom the Secretary
determines that at least 75 percent of payments
under this part for covered professional
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 entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, 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,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional 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 entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the
Secretary such information as is
necessary for the Secretary to make a
determination 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
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional bears more than
nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures.
``(2) Additional definitions.--In this subsection:
``(A) Covered professional services.--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).
``(C) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(i) A model under section 1115A (other
than a health care innovation award).
``(ii) An accountable care organization
under section 1899.
``(iii) A demonstration under section
1866C.
``(iv) A demonstration required by Federal
law.
``(D) Eligible alternative payment model (apm).--
``(i) In general.--The term `eligible
alternative payment model' means, with respect
to a year, an alternative payment model--
``(I) that requires use of
certified EHR technology (as defined in
subsection (o)(4));
``(II) that provides for payment
for covered professional services based
on quality measures comparable to
measures under the performance category
described in section 1848(q)(2)(B)(i);
and
``(III) that satisfies the
requirement described in clause (ii).
``(ii) Additional requirement.--For
purposes of clause (i)(III), the requirement
described in this clause, with respect to a
year and an alternative payment model, is that
the alternative payment model--
``(I) is one in which one or more
entities bear financial risk for
monetary losses under such model that
are in excess of a nominal amount; or
``(II) is a medical home expanded
under section 1115A(c).
``(3) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise, of the
following:
``(A) The determination that an eligible
professional is a qualifying APM participant under
paragraph (2) and the determination that an alternative
payment model is an eligible alternative payment model
under paragraph (3)(D).
``(B) The determination of the amount of the 5
percent payment incentive under paragraph (1)(A),
including any estimation as part of such
determination.''.
(2) Coordination conforming amendments.--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 determined without regard to
any additional payment 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 determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''.
(3) Encouraging development and testing 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 physicians'
services (as defined in section 1848(j)(3))
furnished by physicians who are not primary
care practitioners.
``(xxii) Focusing on practices of fewer
than 20 professionals.''; and
(B) in subparagraph (C)(viii), by striking ``other
public sector or private sector payers'' and inserting
``other public sector payers, private sector payers, or
Statewide payment models''.
(f) Study and Report on Fraud Related to Alternative Payment Models
Under the Medicare Program.--
(1) Study.--The Secretary of Health and Human Services, in
consultation with the Inspector General of the Department of
Health and Human Services, shall conduct a study that--
(A) 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)));
(B) identifies aspects of such alternative payment
models that are vulnerable to fraudulent activity; and
(C) examines the implications of waivers to such
laws granted in support of such alternative payment
models, including under any potential expansion of such
models.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit to Congress a
report containing the results of the study conducted under
paragraph (1). Such report shall include recommendations for
actions to be taken to reduce the vulnerability of such
alternative payment models to fraudulent activity. Such report
also shall include, as appropriate, recommendations of the
Inspector General for changes in Federal fraud prevention laws
to reduce such vulnerability.
(g) Improving Payment Accuracy.--
(1) Studies and reports of effect of certain information on
quality and resource use .--
(A) Study using existing medicare data.--
(i) Study.--The Secretary of Health and
Human Services (in this subsection referred to
as the ``Secretary'') shall conduct a study
that examines the effect of individuals'
socioeconomic status on quality and resource
use outcome measures for individuals under the
Medicare program (such as to recognize that
less healthy individuals may require more
intensive interventions). The study shall use
information collected on such individuals in
carrying out such program, such as urban and
rural location, eligibility for Medicaid
(recognizing and accounting for varying
Medicaid eligibility across States), and
eligibility for benefits under the supplemental
security income (SSI) program. The Secretary
shall carry out this paragraph acting through
the Assistant Secretary for Planning and
Evaluation.
(ii) Report.--Not later than 2 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(B) Study using other data.--
(i) Study.--The Secretary shall conduct a
study that examines the impact of risk factors,
such as those described in section 1848(p)(3)
of the Social Security Act (42 U.S.C. 1395w-
4(p)(3)), race, health literacy, limited
English proficiency (LEP), and patient
activation, on quality and resource use outcome
measures under the Medicare program (such as to
recognize that less healthy individuals may
require more intensive interventions). In
conducting such study the Secretary may use
existing Federal data and collect such
additional data as may be necessary to complete
the study.
(ii) Report.--Not later than 5 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(C) Examination of data in conducting studies.--In
conducting the studies under subparagraphs (A) and (B),
the Secretary shall examine what non-Medicare data
sets, such as data from the American Community Survey
(ACS), can be useful in conducting the types of studies
under such paragraphs and how such data sets that are
identified as useful can be coordinated with Medicare
administrative data in order to improve the overall
data set available to do such studies and for the
administration of the Medicare program.
(D) Recommendations to account for information in
payment adjustment mechanisms.--If the studies
conducted under subparagraphs (A) and (B) find a
relationship between the factors examined in the
studies and quality and resource use outcome measures,
then the Secretary shall also provide recommendations
for how the Centers for Medicare & Medicaid Services
should--
(i) obtain access to the necessary data (if
such data is not already being collected) on
such factors, including recommendations on how
to address barriers to the Centers in accessing
such data; and
(ii) account for such factors in
determining payment adjustments based on
quality and resource use outcome measures under
the eligible professional value-based
performance incentive program under section
1848(q) of the Social Security Act (42 U.S.C.
1395w-4(q)) and, as the Secretary determines
appropriate, other similar provisions of title
XVIII of such Act.
(E) Funding.--There are hereby appropriated from
the Federal Supplemental Medical Insurance Trust Fund
to the Secretary to carry out this paragraph
$6,000,000, to remain available until expended.
(2) CMS activities.--
(A) Hierarchal condition category (hcc)
improvement.--Taking into account the relevant studies
conducted and recommendations made in reports under
paragraph (1), the Secretary, on an ongoing basis,
shall estimate how an individual's health status and
other risk factors affect quality and resource use
outcome measures and, as feasible, shall incorporate
information from quality and resource use outcome
measurement (including care episode and patient
condition groups) into the eligible professional value-
based performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(B) Accounting for other factors in payment
adjustment mechanisms.--
(i) In general.--Taking into account the
studies conducted and recommendations made in
reports under paragraph (1), the Secretary
shall account for identified factors (other
than those applied under subparagraph (A)) with
an effect on quality and resource use outcome
measures when determining payment adjustments
under the eligible professional value-based
performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(ii) Accessing data.--The Secretary shall
collect or otherwise obtain access to the data
necessary to carry out this paragraph through
existing and new data sources.
(iii) Periodic analyses.--The Secretary
shall carry out periodic analyses, at least
every 3 years, based on the factors referred to
in clause (i) so as to monitor changes in
possible relationships.
(C) Funding.--There are hereby appropriated from
the Federal Supplemental Medical Insurance Trust Fund
to the Secretary to carry out this paragraph
$10,000,000, to remain available until expended.
(3) Strategic plan for accessing race and ethnicity data.--
Not later than 18 months after the date of the enactment of
this Act, the Secretary shall develop and report to Congress on
a strategic plan for collecting or otherwise accessing data on
race and ethnicity for purposes of carrying out the eligible
professional value-based performance incentive program under
section 1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar provisions of
title XVIII of such Act.
(h) Collaborating With the Physician, Practitioner, 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, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
``(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in enhancing
the infrastructure for resource use measurement, including for
purposes of the value-based performance incentive program under
subsection (q) and alternative payment models under section
1833(z), the Secretary shall undertake the steps described in
the succeeding provisions of this subsection.
``(2) Development of care episode and patient condition
groups and classification codes.--
``(A) In general.--In order to classify similar
patients into distinct care episode groups and distinct
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 60 days
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 list of the
episode groups developed pursuant to subsection
(n)(9)(A) and related descriptive information.
``(C) Stakeholder input.--The Secretary shall
accept, through the date that is 60 days after the day
the Secretary posts the list pursuant to subparagraph
(B), suggestions from physician specialty societies,
applicable practitioner organizations, and other
stakeholders for episode groups in addition to those
posted pursuant to such subparagraph, and specific
clinical criteria and patient characteristics to
classify patients into--
``(i) distinct care episode groups; and
``(ii) distinct patient condition groups.
``(D) Development of proposed classification
codes.--
``(i) In general.--Taking into account the
information described in subparagraph (B) and
the information received under subparagraph
(C), the Secretary shall--
``(I) establish distinct care
episode groups and distinct patient
condition groups, which account for at
least an estimated two-thirds of
expenditures under parts A and B; and
``(II) assign codes to such groups.
``(ii) Care episode groups.--In
establishing the care episode groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical
problems 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 is anticipated or
occurs, and the principal procedures or
services planned or 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 each medical
visit, such as the patient's
combination of chronic conditions,
current health status, and recent
significant history (such as
hospitalization and major surgery
during a previous period, such as 3
months); and
``(II) other factors determined
appropriate by the Secretary, such as
eligibility status under this title
(including eligibility under section
226(a), 226(b), or 226A, and dual
eligibility under this title and title
XIX).
``(E) Draft care episode and patient condition
groups and classification codes.--Not later than 120
days after the end of the comment period described in
subparagraph (C), the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a draft list of the care episode and patient
condition codes established under subparagraph (D) (and
the criteria and characteristics assigned to such
code).
``(F) Solicitation of input.--The Secretary shall
seek, through the date that is 60 days after the
Secretary posts the list pursuant to subparagraph (E),
comments from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the care episode and patient condition 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 include use of open door forums, town hall
meetings, or other appropriate mechanisms.
``(G) Operational list of care episode and patient
condition groups and codes.--Not later than 120 days
after the end of the comment period described in
subparagraph (F), 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
care episode and patient condition codes (and the
criteria and characteristics assigned to such code).
``(H) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2016), the
Secretary shall, through rulemaking, make revisions to
the operational lists of care episode and patient
condition codes as the Secretary determines may be
appropriate. Such revisions may be based on experience,
new information developed pursuant to subsection
(n)(9)(A), and input from the physician specialty
societies, applicable practitioner organizations, and
other stakeholders, including representatives of
individuals entitled to benefits under part A or
enrolled under this part.
``(3) Attribution of patients to physicians 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 relationship
categories and codes.--The Secretary shall develop
patient relationship categories and codes that define
and distinguish the relationship and responsibility of
a physician or applicable practitioner with a patient
at the time of furnishing an item or service. Such
patient relationship categories shall include different
relationships of the physician or applicable
practitioner to the patient (and the codes may reflect
combinations of such categories), 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 practitioners
for the patient during an acute episode;
``(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 practitioner.
``(C) Draft list of patient relationship categories
and codes.--Not later than 180 days 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 relationship categories and codes developed
under subparagraph (B).
``(D) Stakeholder input.--The Secretary shall seek,
through the date that is 60 days after the Secretary
posts the list pursuant to subparagraph (C), comments
from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the patient relationship categories and codes
posted under subparagraph (C). In seeking 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,
or other appropriate mechanisms.
``(E) Operational list of patient relationship
categories and codes.--Not later than 120 days after
the end of the comment period described in subparagraph
(D), 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 2016), the
Secretary shall, through rulemaking, make revisions to
the operational list of patient relationship categories
and codes as the Secretary 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, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part.
``(4) Reporting of information for resource use
measurement.--Claims submitted for items and services furnished
by a physician or applicable practitioner on or after January
1, 2016, shall, as determined appropriate by the Secretary,
include--
``(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 analysis.--
``(A) In general.--In order to evaluate the
resources used to treat patients (with respect to care
episode and patient condition groups), the Secretary
shall--
``(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 applicable
practitioners;
``(ii) use the care episode and patient
condition codes reported on claims pursuant to
paragraph (4) as a basis to compare similar
patients and care episodes and patient
condition groups; and
``(iii) conduct an analysis of resource use
(with respect to care episodes and patient
condition groups of such patients), as the
Secretary determines appropriate.
``(B) Analysis of patients of physicians 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
without a hospitalization, during
periods of time (such as the number of
days) determined appropriate by the
Secretary; and
``(II) in the case of episodes with
a hospitalization, during periods of
time (such as the number of days)
before, during, and after the
hospitalization.
``(C) Measurement of resource use.--In measuring
such resource use, the Secretary--
``(i) shall use per patient total allowed
amounts for all services under part A and this
part (and, if the Secretary determines
appropriate, part D) for the analysis of
patient resource use, by care episode codes and
by patient condition codes; and
``(ii) may, as determined appropriate, use
other measures of allowed amounts (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 attributed patients or
episodes).
``(D) Stakeholder input.--The Secretary shall seek
comments from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including representatives of individuals
entitled to benefits under part A or enrolled under
this part, regarding the resource use methodology
established pursuant to this paragraph. In seeking
comments the Secretary shall use one or more mechanisms
(other than notice and comment rulemaking) that may
include open door forums, town hall meetings, or other
appropriate mechanisms.
``(6) Limitation.--There shall be no administrative 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 resource use
with respect to, care episode and patient condition
codes and patient relationship codes pursuant to
paragraph (5).
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(8) Definitions.--In this section:
``(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
practitioner, and clinical nurse specialist (as
such terms are defined in section 1861(aa)(5));
and
``(ii) beginning January 1, 2017, such
other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(9) Clarification.--The provisions of sections 1890(b)(7)
and 1890A shall not apply to this subsection.''.
SEC. 3. PRIORITIES AND FUNDING FOR QUALITY MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (h) of section 2, is further amended by
inserting at the end the following new subsection:
``(s) Priorities and Funding for Quality Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--
``(i) Draft plan.--
``(I) In general.--Not later than
October 1, 2014, the Secretary shall
develop, and post on the Internet
website of the Centers for Medicare &
Medicaid Services, a draft plan for the
development of quality measures for
application under the applicable
provisions.
``(II) Requirement.--Such plan
shall address how measures used by
private payers and integrated delivery
systems could be incorporated under
such subsection.
``(ii) Consideration.--In developing the
draft plan under subparagraph (A), the
Secretary shall consider--
``(I) gap analyses conducted by the
entity with a contract under section
1890(a) or other contractors or
entities; and
``(II) whether measures are
applicable across health care settings.
``(iii) Priorities.--In developing the
draft plan under subparagraph (A), the
Secretary shall give priority to the following
types of measures:
``(I) Outcome measures including
patient reported outcome and functional
status measures.
``(II) Patient experience measures.
``(III) Care coordination measures.
``(IV) Measures of appropriate use
of services, including measures of over
use.
``(iv) Definition of applicable
provisions.--In this subsection, the term
`applicable provisions' means the following
provisions:
``(I) Subsection (q)(2)(B)(i).
``(II) Section 1833(z)(2)(C).
``(B) Stakeholder input.--The Secretary shall
accept through December 1, 2014, comments on the draft
plan posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(C) Operational measure development plan.--Not
later than February 1, 2015, taking into account the
comments received under subparagraph (B), the Secretary
shall post on the Internet website of the Centers for
Medicare & Medicaid Services an operational plan for
the development of quality measures for use under
subsection (q)(2)(A)(i).
``(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, improving, updating, or
expanding quality measures for application under the
applicable provisions. Such entities may include
physician specialty societies and other practitioner
organizations.
``(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)(A)(iii).
``(ii) Consideration.--In selecting
measures for development under this subsection,
the Secretary shall consider whether such
measures would be electronically specified.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than February 1, 2016,
and annually thereafter, the Secretary shall post on
the Internet website of the Centers for Medicare &
Medicaid Services a report on the progress made in
developing quality measures for application under the
applicable provisions.
``(B) Requirements.--Each report submitted pursuant
to paragraph (1) shall include the following:
``(i) A description of the Secretary's
efforts to implement this subsection.
``(ii) With respect to the measures
developed 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;
``(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
development 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) An update on the progress in
developing the types of measures described in
paragraph (1)(A)(iii), including a description
of issues affecting such progress.
``(v) A list of quality topics and concepts
that are being considered for development of
measures and the rationale for the selection of
topics and concepts including their
relationship to gap analyses.
``(vi) A description of any updates to the
plan under paragraph (1) (including newly
identified gaps and the status of previously
identified gaps) and the inventory of measures
applicable under the applicable provisions.
``(vii) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to measures
applicable under the applicable provisions, 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)(A)(iii);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) 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 2014 through 2018. Amounts transferred under this
paragraph shall remain available through the end of fiscal year
2021.''.
SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS.
Section 1848(b) of the Social Security 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 by an applicable provider (as
defined in subparagraph (B)) for individuals with
chronic care needs the Secretary shall--
``(i) establish one or more HCPCS codes for
chronic care management services for such
individuals; and
``(ii) subject to subparagraph (D), make
payment (as the Secretary determines to be
appropriate) under this section for such
management services furnished on or after
January 1, 2015, by an applicable provider.
``(B) Applicable provider defined.--For purposes of
this paragraph, the term `applicable provider' means a
physician (as defined in section 1861(r)(1)), physician
assistant or nurse practitioner (as defined in section
1861(aa)(5)(A)), or clinical nurse specialist (as
defined in section 1861(aa)(5)(B)) who furnishes
services as part of a patient-centered medical home or
a comparable specialty practice that--
``(i) is recognized as such a medical home
or comparable specialty practice by an
organization that is recognized by the
Secretary for purposes of such recognition as
such a medical home or practice; or
``(ii) meets such other comparable
qualifications as the Secretary determines to
be appropriate.
``(C) Budget neutrality.--The budget neutrality
provision under subsection (c)(2)(B)(ii)(II) shall
apply in establishing the payment under subparagraph
(A)(ii).
``(D) Policies relating to payment.--In carrying
out this paragraph, with respect to chronic care
management services, the Secretary shall--
``(i) make payment to only one applicable
provider for such services furnished to an
individual during a period;
``(ii) not make payment under subparagraph
(A) if such payment would be duplicative of
payment that is otherwise made under this title
for such services (such as in the case of
hospice care or home health services); and
``(iii) not require that an annual wellness
visit (as defined in section 1861(hhh)) or an
initial preventive physical examination (as
defined in section 1861(ww)) be furnished as a
condition of payment for such management
services.''.
SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN FEE
SCHEDULE.
(a) Authority To Collect and Use Information on Physicians'
Services in the Determination of Relative Values.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraph:
``(M) Authority to collect and use information on
physicians' services in the determination of relative
values.--
``(i) Collection of information.--
Notwithstanding any other provision of law, the
Secretary may collect or obtain information on
the resources directly or indirectly related to
furnishing services for which payment is made
under the fee schedule established under
subsection (b). Such information may be
collected or obtained from any eligible
professional or any other source.
``(ii) Use of information.--Notwithstanding
any other provision of law, subject to clause
(v), the Secretary may (as the Secretary
determines appropriate) use information
collected or obtained pursuant to clause (i) in
the determination of relative values for
services under this section.
``(iii) Types of information.--The types of
information described in clauses (i) and (ii)
may, at the Secretary's discretion, include any
or all of the following:
``(I) Time involved in furnishing
services.
``(II) Amounts and types of
practice expense inputs involved with
furnishing services.
``(III) Prices (net of any
discounts) for practice expense inputs,
which may include paid invoice prices
or other documentation or records.
``(IV) Overhead and accounting
information for practices of physicians
and other suppliers.
``(V) Any other element that would
improve the valuation of services under
this section.
``(iv) Information collection mechanisms.--
Information may be collected or obtained
pursuant to this subparagraph from any or all
of the following:
``(I) Surveys of physicians, other
suppliers, providers of services,
manufacturers, and vendors.
``(II) Surgical logs, billing
systems, or other practice or facility
records.
``(III) Electronic health records.
``(IV) Any other mechanism
determined appropriate by the
Secretary.
``(v) Transparency of use of information.--
``(I) In general.--Subject to
subclauses (II) and (III), if the
Secretary uses information collected or
obtained under this subparagraph in the
determination of relative values under
this subsection, the Secretary shall
disclose the information source and
discuss the use of such information in
such determination of relative values
through notice and comment rulemaking.
``(II) Thresholds for use.--The
Secretary may establish thresholds in
order to use such information,
including the exclusion of information
collected or obtained from eligible
professionals who use very high
resources (as determined by the
Secretary) in furnishing a service.
``(III) Disclosure of
information.--The Secretary shall make
aggregate information available under
this subparagraph but shall not
disclose information in a form or
manner that identifies an eligible
professional or a group practice, or
information collected or obtained
pursuant to a nondisclosure agreement.
``(vi) Incentive to participate.--The
Secretary may provide for such payments under
this part to an eligible professional that
submits such solicited information under this
subparagraph as the Secretary determines
appropriate in order to compensate such
eligible professional for such submission. Such
payments shall be provided in a form and manner
specified by the Secretary.
``(vii) Administration.--Chapter 35 of
title 44, United States Code, shall not apply
to information collected or obtained under this
subparagraph.
``(viii) Definition of eligible
professional.--In this subparagraph, the term
`eligible professional' has the meaning given
such term in subsection (k)(3)(B).
``(ix) Funding.--For purposes of carrying
out this subparagraph, in addition to funds
otherwise appropriated, the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, of $2,000,000 to the
Centers for Medicare & Medicaid Services
Program Management Account for each fiscal year
beginning with fiscal year 2014. Amounts
transferred under the preceding sentence for a
fiscal year shall be available until
expended.''.
(2) Limitation on review.--Section 1848(i)(1) of the Social
Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the collection and use of information in the
determination of relative values under subsection
(c)(2)(M).''.
(b) Authority for Alternative Approaches To Establishing Practice
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by
adding at the end the following new subparagraph:
``(N) Authority for alternative approaches to
establishing practice expense relative values.--The
Secretary may establish or adjust practice expense
relative values under this subsection using cost,
charge, or other data from suppliers or providers of
services, including information collected or obtained
under subparagraph (M).''.
(c) Revised and Expanded Identification of Potentially Misvalued
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued codes pursuant to clause
(i)(I), the Secretary shall examine codes (and
families of codes as appropriate) based on any
or all of the following criteria:
``(I) Codes that have experienced
the fastest growth.
``(II) Codes that have experienced
substantial changes in practice
expenses.
``(III) Codes that describe new
technologies or services within an
appropriate time period (such as 3
years) after the relative values are
initially established for such codes.
``(IV) Codes which are multiple
codes that are frequently billed in
conjunction with furnishing a single
service.
``(V) Codes with low relative
values, particularly those that are
often billed multiple times for a
single treatment.
``(VI) Codes that have not been
subject to review since implementation
of the fee schedule.
``(VII) Codes that account for the
majority of spending under the
physician fee schedule.
``(VIII) Codes for services that
have experienced a substantial change
in the hospital length of stay or
procedure time.
``(IX) Codes for which there may be
a change in the typical site of service
since the code was last valued.
``(X) Codes for which there is a
significant difference in payment for
the same service between different
sites of service.
``(XI) Codes for which there may be
anomalies in relative values within a
family of codes.
``(XII) Codes for services where
there may be efficiencies when a
service is furnished at the same time
as other services.
``(XIII) Codes with high intra-
service work per unit of time.
``(XIV) Codes with high practice
expense relative value units.
``(XV) Codes with high cost
supplies.
``(XVI) Codes as determined
appropriate by the Secretary.''.
(d) Target for Relative Value Adjustments for Misvalued Services.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a)
and (b), is amended by adding at the end the following new
subparagraph:
``(O) Target for relative value adjustments for
misvalued services.--With respect to fee schedules
established for each of 2015 through 2018, the
following shall apply:
``(i) Determination of net reduction in
expenditures.--For each year, the Secretary
shall determine the estimated net reduction in
expenditures under the fee schedule under this
section with respect to the year as a result of
adjustments to the relative values established
under this paragraph for misvalued codes.
``(ii) Budget neutral redistribution of
funds if target met and counting overages
towards the target for the succeeding year.--If
the estimated net reduction in expenditures
determined under clause (i) for the year is
equal to or greater than the target for the
year--
``(I) reduced expenditures
attributable to such adjustments shall
be redistributed for the year in a
budget neutral manner in accordance
with subparagraph (B)(ii)(II); and
``(II) the amount by which such
reduced expenditures exceeds the target
for the year shall be treated as a
reduction in expenditures described in
clause (i) for the succeeding year, for
purposes of determining whether the
target has or has not been met under
this subparagraph with respect to that
year.
``(iii) Exemption from budget neutrality if
target not met.--If the estimated net reduction
in expenditures determined under clause (i) for
the year is less than the target for the year,
reduced expenditures in an amount equal to the
target recapture amount shall not be taken into
account in applying subparagraph (B)(ii)(II)
with respect to fee schedules beginning with
2015.
``(iv) Target recapture amount.--For
purposes of clause (iii), the target recapture
amount is, with respect to a year, an amount
equal to the difference between--
``(I) the target for the year; and
``(II) the estimated net reduction
in expenditures determined under clause
(i) for the year.
``(v) Target.--For purposes of this
subparagraph, with respect to a year, the
target is calculated as 0.5 percent of the
estimated amount of expenditures under the fee
schedule under this section for the year.''.
(2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended
by adding at the end the following new subclause:
``(VIII) Reductions for misvalued
services if target not met.--Effective
for fee schedules beginning with 2015,
reduced expenditures attributable to
the application of the target recapture
amount described in subparagraph
(O)(iii).''.
(e) Phase-in of Significant Relative Value Unit (RVU) Reductions.--
(1) In general.--Section 1848(c) of the Social Security Act
(42 U.S.C. 1395w-4(c)) is amended by adding at the end the
following new paragraph:
``(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for fee schedules established beginning
with 2015, if the total relative value units for a service for
a year would otherwise be decreased by an estimated amount
equal to or greater than 20 percent as compared to the total
relative value units for the previous year, the applicable
adjustments in work, practice expense, and malpractice relative
value units shall be phased-in over a 2-year period.''.
(2) Conforming amendments.--Section 1848(c)(2) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(ii)(I), by striking
``subclause (II)'' and inserting ``subclause (II) and
paragraph (7)''; and
(B) in subparagraph (K)(iii)(VI)--
(i) by striking ``provisions of
subparagraph (B)(ii)(II)'' and inserting
``provisions of subparagraph (B)(ii)(II) and
paragraph (7)''; and
(ii) by striking ``under subparagraph
(B)(ii)(II)'' and inserting ``under
subparagraph (B)(ii)(I)''.
(f) Authority To Smooth Relative Values Within Groups of
Services.--Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(C)) is amended--
(1) in each of clauses (i) and (iii), by striking ``the
service'' and inserting ``the service or group of services''
each place it appears; and
(2) in the first sentence of clause (ii), by inserting ``or
group of services'' before the period.
(g) GAO Study and Report on Relative Value Scale Update
Committee.--
(1) Study.--The Comptroller General of the United States
(in this subsection referred to as the ``Comptroller General'')
shall conduct a study of the processes used by the Relative
Value Scale Update Committee (RUC) to provide recommendations
to the Secretary of Health and Human Services regarding
relative values for specific services under the Medicare
physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w-4).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1).
(h) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and notwithstanding the
previous provisions of this subsection, for services
furnished on or after January 1, 2017, the fee schedule
areas used for payment under this section applicable to
California shall be the following:
``(i) Each Metropolitan Statistical Area
(each in this paragraph referred to as an
`MSA'), as defined by the Director of the
Office of Management and Budget as of December
31 of the previous year, shall be a fee
schedule area.
``(ii) All areas not included in an MSA
shall be treated as a single rest-of-State fee
schedule area.
``(B) Transition for msas previously in rest-of-
state payment locality or in locality 3.--
``(i) In general.--For services furnished
in California during a year beginning with 2017
and ending with 2021 in an MSA in a transition
area (as defined in subparagraph (D)), subject
to subparagraph (C), the geographic index
values to be applied under this subsection for
such year shall be equal to the sum of the
following:
``(I) Current law component.--The
old weighting factor (described in
clause (ii)) for such year multiplied
by the geographic index values under
this subsection for the fee schedule
area that included such MSA that would
have applied in such area (as estimated
by the Secretary) if this paragraph did
not apply.
``(II) MSA-based component.--The
MSA-based weighting factor (described
in clause (iii)) for such year
multiplied by the geographic index
values computed for the fee schedule
area under subparagraph (A) for the
year (determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The
MSA-based weighting factor described in this
clause for a year is 1 minus the old weighting
factor under clause (ii) for that year.
``(C) Hold harmless.--For services furnished in a
transition area in California during a year beginning
with 2017, the geographic index values to be applied
under this subsection for such year shall not be less
than the corresponding geographic index values that
would have applied in such transition area (as
estimated by the Secretary) if this paragraph did not
apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
``(E) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2017, for
California, any reference in this section to a fee
schedule area shall be deemed a reference to a fee
schedule area established in accordance with this
paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(D), the
term''.
SEC. 6. PROMOTING EVIDENCE-BASED CARE.
(a) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
(1) In general.--Section 1834 of the Social Security Act
(42 U.S.C. 1395m) is amended by adding at the end the following
new subsection:
``(p) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
``(1) Program established.--
``(A) In general.--The Secretary shall establish a
program to promote the use of appropriate use criteria
(as defined in subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C)) furnished in
an applicable setting (as defined in subparagraph (D))
by ordering professionals and furnishing professionals
(as defined in subparagraphs (E) and (F),
respectively).
``(B) Appropriate use criteria defined.--In this
subsection, the term `appropriate use criteria' means
criteria to assist ordering professionals and
furnishing professionals in making the most appropriate
treatment decision for a specific clinical condition.
To the extent feasible, such criteria shall be
evidence-based.
``(C) Applicable imaging service defined.--In this
subsection, the term `applicable imaging service' means
an advanced diagnostic imaging service (as defined in
subsection (e)(1)(B)) for which the Secretary
determines--
``(i) one or more applicable appropriate
use criteria specified under paragraph (2)
apply;
``(ii) there are one or more qualified
clinical decision support mechanisms listed
under paragraph (3)(C); and
``(iii) one or more of such mechanisms is
available free of charge.
``(D) Applicable setting defined.--In this
subsection, the term `applicable setting' means a
physician's office, a hospital outpatient department
(including an emergency department), an ambulatory
surgical center, and any other outpatient setting
determined appropriate by the Secretary.
``(E) Ordering professional defined.--In this
subsection, the term `ordering professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
orders an applicable imaging service for an individual.
``(F) Furnishing professional defined.--In this
subsection, the term `furnishing professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
furnishes an applicable imaging service for an
individual.
``(2) Establishment of applicable appropriate use
criteria.--
``(A) In general.--Not later than November 15,
2015, the Secretary shall through rulemaking, and in
consultation with physicians, practitioners, and other
stakeholders, specify applicable appropriate use
criteria for applicable imaging services from among
appropriate use criteria developed or endorsed by
national professional medical specialty societies or
other entities.
``(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph (A), the
Secretary shall take into account whether the
criteria--
``(i) have stakeholder consensus;
``(ii) have been determined to be
scientifically valid and are evidence based;
and
``(iii) are in the public domain.
``(C) Revisions.--The Secretary shall periodically
update and revise (as appropriate) such specification
of applicable appropriate use criteria.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criteria
applies with respect to an applicable imaging service,
the Secretary shall specify one or more applicable
appropriate use criteria under this paragraph for the
service.
``(3) Mechanisms for consultation with applicable
appropriate use criteria.--
``(A) Identification of mechanisms to consult with
applicable appropriate use criteria.--
``(i) In general.--The Secretary shall
specify one or more qualified clinical decision
support mechanisms that could be used by
ordering professionals to consult with
applicable appropriate use criteria for
applicable imaging services.
``(ii) Consultation.--The Secretary shall
consult with physicians, practitioners, and
other stakeholders in specifying mechanisms
under this paragraph.
``(iii) Inclusion of certain mechanisms.--
Mechanisms specified under this paragraph may
include any or all of the following that meet
the requirements described in subparagraph
(B)(ii):
``(I) Use of clinical decision
support modules in certified EHR
technology (as defined in section
1848(o)(4)).
``(II) Use of private sector
clinical decision support mechanisms
that are independent from certified EHR
technology, which may include use of
clinical decision support mechanisms
available from medical specialty
organizations.
``(III) Use of a clinical decision
support mechanism established by the
Secretary.
``(B) Qualified clinical decision support
mechanisms.--
``(i) In general.--For purposes of this
subsection, a qualified clinical decision
support mechanism is a mechanism that the
Secretary determines meets the requirements
described in clause (ii).
``(ii) Requirements.--The requirements
described in this clause are the following:
``(I) The mechanism makes available
to the ordering professional applicable
appropriate use criteria specified
under paragraph (2) and the supporting
documentation for the applicable
imaging service ordered.
``(II) In the case where there are
more than one applicable appropriate
use criteria specified under such
paragraph for an applicable imaging
service, the mechanism indicates the
criteria that it uses for the service.
``(III) The mechanism determines
the extent to which an applicable
imaging service ordered is consistent
with the applicable appropriate use
criteria so specified.
``(IV) The mechanism generates and
provides to the ordering professional a
certification or documentation that
documents that the qualified clinical
decision support mechanism was
consulted by the ordering professional.
``(V) The mechanism is updated on a
timely basis to reflect revisions to
the specification of applicable
appropriate use criteria under such
paragraph.
``(VI) The mechanism meets privacy
and security standards under applicable
provisions of law.
``(VII) The mechanism performs such
other functions as specified by the
Secretary, which may include a
requirement to provide aggregate
feedback to the ordering professional.
``(C) List of mechanisms for consultation with
applicable appropriate use criteria.--
``(i) Initial list.--Not later than April
1, 2016, the Secretary shall publish a list of
mechanisms specified under this paragraph.
``(ii) Periodic updating of list.--The
Secretary shall periodically update the list of
qualified clinical decision support mechanisms
specified under this paragraph.
``(4) Consultation with applicable appropriate use
criteria.--
``(A) Consultation by ordering professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
ordered by an ordering professional that would be
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), an ordering professional shall--
``(i) consult with a qualified decision
support mechanism listed under paragraph
(3)(C); and
``(ii) provide to the furnishing
professional the information described in
clauses (i) through (iii) of subparagraph (B).
``(B) Reporting by furnishing professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), payment for such service may only be
made if the claim for the service includes the
following:
``(i) Information about which qualified
clinical decision support mechanism was
consulted by the ordering professional for the
service.
``(ii) Information regarding--
``(I) whether the service ordered
would adhere to the applicable
appropriate use criteria specified
under paragraph (2);
``(II) whether the service ordered
would not adhere to such criteria; or
``(III) whether such criteria was
not applicable to the service ordered.
``(iii) The national provider identifier of
the ordering professional (if different from
the furnishing professional).
``(C) Exceptions.--The provisions of subparagraphs
(A) and (B) and paragraph (6)(A) shall not apply to the
following:
``(i) Emergency services.--An applicable
imaging service ordered for an individual with
an emergency medical condition (as defined in
section 1867(e)(1)).
``(ii) Inpatient services.--An applicable
imaging service ordered for an inpatient and
for which payment is made under part A.
``(iii) Alternative payment models.--An
applicable imaging service ordered by an
ordering professional with respect to an
individual attributed to an alternative payment
model (as defined in section 1833(z)(3)(C)).
``(iv) Significant hardship.--An applicable
imaging service ordered by an ordering
professional who the Secretary may, on a case-
by-case basis, exempt from the application of
such provisions if the Secretary determines,
subject to annual renewal, that consultation
with applicable appropriate use criteria would
result in a significant hardship, such as in
the case of a professional who practices in a
rural area without sufficient Internet access.
``(D) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means
the following:
``(i) The physician fee schedule
established under section 1848(b).
``(ii) The prospective payment system for
hospital outpatient department services under
section 1833(t).
``(iii) The ambulatory surgical center
payment systems under section 1833(i).
``(5) Identification of outlier ordering professionals.--
``(A) In general.--With respect to applicable
imaging services furnished beginning with 2017, the
Secretary shall determine, on a periodic basis (which
may be annually), ordering professionals who are
outlier ordering professionals.
``(B) Outlier ordering professionals.--The
determination of an outlier ordering professional
shall--
``(i) be based on low adherence to
applicable appropriate use criteria specified
under paragraph (2), which may be based on
comparison to other ordering professionals; and
``(ii) include data for ordering
professionals for whom prior authorization
under paragraph (6)(A) applies.
``(C) Use of two years of data.--The Secretary
shall use two years of data to identify outlier
ordering professionals under this paragraph.
``(D) Consultation with stakeholders.--The
Secretary shall consult with physicians, practitioners
and other stakeholders in developing methods to
identify outlier ordering professionals under this
paragraph.
``(6) Prior authorization for ordering professionals who
are outliers.--
``(A) In general.--Beginning January 1, 2020,
subject to paragraph (4)(C), with respect to services
furnished during a year, the Secretary shall, for a
period determined appropriate by the Secretary, apply
prior authorization for applicable imaging services
that are ordered by an outlier ordering professional
identified under paragraph (5).
``(B) Funding.--For purposes of carrying out this
paragraph, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $5,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2019
through 2021. Amounts transferred under the preceding
sentence shall remain available until expended.''.
(2) Conforming amendment.--Section 1833(t)(16) of the
Social Security Act (42 U.S.C. 1395l(t)(16)) is amended by
adding at the end the following new subparagraph:
``(E) Application of appropriate use criteria for
certain imaging services.--For provisions relating to
the application of appropriate use criteria for certain
imaging services, see section 1834(p).''.
(b) Establishment of Appropriate Use Program for Other Part B
Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m),
as amended by subsection (a), is amended by adding at the end the
following new subsection:
``(q) Establishment of Appropriate Use Program for Other Part B
Services.--
``(1) Establishment.--
``(A) In general.--The Secretary may establish an
appropriate use program for services under this part
(other than applicable imaging services under
subsection (p)) using a process similar to the process
under such subsection.
``(B) Requirements.--In determining whether to
establish a program under subparagraph (A), the
Secretary shall take into consideration--
``(i) the implementation of appropriate use
criteria for applicable imaging services under
subsection (p); and
``(ii) the report under paragraph (2).
``(C) Input from stakeholders in advance of
rulemaking.--Before issuing a notice of proposed
rulemaking to establish a program under subparagraph
(A), the Secretary shall issue an advance notice of
proposed rulemaking.
``(2) Report on experience of imaging appropriate use
criteria program.--Not later than 18 months after the date of
the enactment of this subsection, the Comptroller General of
the United States shall submit to Congress a report that
includes a description of the extent to which appropriate use
criteria could be used for other services under this part, such
as radiation therapy and clinical diagnostic laboratory
services.''.
SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION ON
PHYSICIANS' SERVICES.
(a) Transferring Freestanding Physician Compare Provision to the
Social Security Act.--
(1) In general.--Section 10331 of Public Law 111-148 is
transferred and redesignated as subsection (t) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsections (c) and (h) of section 2 and by section 3.
(2) Conforming redesignations.--Section 1848(t) of the
Social Security Act (42 U.S.C. 1395w-4(t)), as transferred and
redesignated by paragraph (1), is further amended--
(A) by striking the subsection heading and
inserting the following new subsection heading:
``Public Reporting of Performance and Other Information
on Physician Compare.--'';
(B) by redesignating subsections (a) through (i) as
paragraphs (1) through (9), respectively, and indenting
appropriately;
(C) in paragraph (1), as redesignated by
subparagraph (B)--
(i) by redesignating paragraphs (1) and (2)
as subparagraphs (A) and (B), respectively, and
indenting appropriately;
(ii) in subparagraph (B), as redesignated
by clause (i), by redesignating subparagraphs
(A) through (G) as clauses (i) through (vii),
respectively, and indenting appropriately;
(D) in paragraph (2), as redesignated by
subparagraph (B), by redesignating paragraphs (1)
through (7) as subparagraphs (A) through (G),
respectively, and indenting appropriately; and
(E) in paragraph (9), as redesignated by
subparagraph (B), by redesignating paragraphs (1)
through (4) as subparagraphs (A) through (D),
respectively, and indenting appropriately.
(3) Conforming amendments.--Section 1848(t) of the Social
Security Act (42 U.S.C. 1395w-4(t)), as amended by paragraph
(2), is further amended--
(A) in paragraph (1)--
(i) in subparagraph (A)--
(I) by striking ``the Medicare
program under section 1866(j) of the
Social Security Act (42 U.S.C.
1395cc(j))'' and inserting ``the
program under this title under section
1866(j)''; and
(II) by striking ``of such Act (42
U.S.C. 1395w-4)''; and
(ii) in subparagraph (B), in the matter
preceding clause (i)--
(I) by striking ``subsection (c)''
and inserting ``paragraph (3)'';
(II) by striking ``the Medicare
program under such section 1866(j)''
and inserting ``the program under this
title under section 1866(j)''; and
(III) by striking ``this section''
and inserting ``this subsection'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph
(A), by striking ``subsection (a)(2)'' and
inserting ``paragraph (1)(B)'';
(ii) in subparagraph (D), by striking ``the
Medicare program'' and inserting ``the program
under this title''; and
(iii) in each of subparagraphs (F) and (G),
by striking ``this section'' and inserting
``this subsection'';
(C) in paragraph (3), by striking ``this section''
and inserting ``this subsection'';
(D) in paragraph (4)--
(i) by striking ``of the Social Security
Act, as added by section 3014 of this Act'';
and
(ii) by striking ``this section'' and
inserting ``this subsection'';
(E) in paragraph (5)--
(i) by striking ``this subsection (a)(2)''
and inserting ``paragraph (1)(B)''; and
(ii) by striking ``(Public Law 110-275)'';
(F) in paragraph (6), by striking ``subsection
(a)(1)'' and inserting ``paragraph (1)(A)'';
(G) in paragraph (7)--
(i) by striking ``subsection (f)'' and
inserting ``paragraph (6)''; and
(ii) by striking ``title XVIII of the
Social Security Act'' and inserting ``this
title'';
(H) in paragraph (8)--
(i) by striking ``subparagraphs (A) through
(G) of subsection (a)(2)'' and inserting
``clauses (i) through (vii) of paragraph
(1)(B)'';
(ii) by striking ``title XVIII of the
Social Security Act'' and inserting ``this
title''; and
(iii) by striking ``such title'' and
inserting ``this title''; and
(I) in paragraph (9)--
(i) in the matter preceding subparagraph
(A), by striking ``this section'' and inserting
``this subsection'';
(ii) in subparagraph (A), by striking ``of
the Social Security Act (42 U.S.C. 1395w-4)'';
(iii) in subparagraph (B), by striking ``of
such Act (42 U.S.C. 1395x(r))'';
(iv) in subparagraph (C), by striking
``subsection (a)(1)'' and inserting ``paragraph
(1)(A)''; and
(v) by striking subparagraph (D).
(b) Public Availability of Medicare Data.--Section 1848(t) of the
Social Security Act (42 U.S.C. 1395w-4(t)), as amended by subsection
(a), is further amended--
(1) by redesignating paragraph (9) as paragraph (10);
(2) by inserting after paragraph (8) the following new
paragraph:
``(9) Public availability of eligible professional claims
data.--
``(A) In general.--The Secretary shall make
publicly available on Physician Compare the information
described in subparagraph (B) with respect to eligible
professionals.
``(B) Information described.--The following
information, with respect to an eligible professional,
is described in this subparagraph:
``(i) Information on the number of services
furnished by the eligible professional, which
may include information on the most frequent
services furnished or groupings of services.
``(ii) Information on submitted charges and
payments for services under this part.
``(iii) A unique identifier for the
eligible professional that is available to the
public, such as a national provider identifier.
``(C) Searchability.--The information made
available under this paragraph shall be searchable by
at least the following:
``(i) The specialty or type of the eligible
professional.
``(ii) Characteristics of the services
furnished, such as volume or groupings of
services.
``(iii) The location of the eligible
professional.
``(D) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(E) Implementation.--
``(i) Initial implementation.--Physician
Compare shall include the information described
in subparagraph (B)--
``(I) with respect to physicians,
by not later than July 1, 2015; and
``(II) with respect to other
eligible professionals, by not later
than July 1, 2016.
``(ii) Annual updating.--The information
made available under this paragraph shall be
updated on Physician Compare not less
frequently than on an annual basis.
``(F) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for an eligible professional to review, and
submit corrections for, the information to be made
public with respect to the eligible professional under
this paragraph prior to such information being made
public.''; and
(3) in paragraph (10)(C), as redesignated by paragraph (1),
by inserting ``(or a successor website)'' before the period at
the end.
SEC. 8. EXPANDING CLAIMS DATA AVAILABILITY TO IMPROVE CARE.
(a) Expansion of Uses of Claims Data by Qualified Entities.--
Section 1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is
amended by adding at the end the following new paragraph:
``(5) Expansion of uses of claims data by qualified
entities.--
``(A) Expansion.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2014,
notwithstanding paragraph (4)(B) (other than clause
(iii) of such paragraph) and the second sentence of
paragraph (4)(D), a qualified entity may, as determined
appropriate by the Secretary, do any or all of the
following:
``(i)(I) Use the combined data described in
paragraph (4)(B)(iii) to conduct analyses,
other than for reports described in paragraph
(4), for entities described in subparagraph (B)
for non-public uses, as determined appropriate
by the Secretary, such as for the purposes
described in subclause (II).
``(II) The purposes described in this
subclause are assisting providers of services
and suppliers in developing and participating
in quality and patient care improvement
activities (including developing new models of
care), population health management, and
disease monitoring, and the purposes described
in subparagraph (C).
``(ii) Provide or sell such analyses to
entities described in subparagraph (B).
``(iii) Provide entities described in
clauses (i), (ii), (v), and (vi) of
subparagraph (B) with access to the combined
data described in paragraph (4)(B)(iii) through
a qualified data enclave (as defined in
subparagraph (F)) that is maintained by the
qualified entity in order for entities
described in such clauses to conduct analyses
for non-public uses, such as for the purposes
described in clause (i)(II).
``(B) Entities described.--For the purpose of
subparagraph (A) clauses (i) and (ii), the entities
described in this subparagraph are the following:
``(i) A provider of services.
``(ii) A supplier.
``(iii) Subject to subparagraph (C), an
employer (as defined in section 3(5) of the
Employee Retirement Insurance Security Act of
1974).
``(iv) A health insurance issuer (as
defined in section 2791 of the Public Health
Service Act) that provides data under paragraph
(4)(B)(iii).
``(v) A medical society or hospital
association.
``(vi) Other entities approved by the
Secretary (other than an employer (as so
defined) and a health insurance issuer (as so
defined)).
``(C) Limitation with respect to employers.--Any
analyses provided or sold under this paragraph to an
employer (as so defined) may only be used by such
employer for purposes of providing health insurance to
employees and retirees of the employer.
``(D) Protection of patient identification.--
``(i) In general.--Except as provided in
clause (ii), an analysis provided or sold under
this paragraph shall not contain information
that individually identifies a patient.
``(ii) Information on patients of the
provider of services or supplier.--An analysis
that is provided or sold under this paragraph
to a provider of services or supplier may
contain data that individually identifies a
patient of such provider or supplier but only
with respect to items and services furnished by
such provider or supplier to such patient.
``(iii) Opportunity for providers of
services and suppliers to review.--Prior to a
qualified entity providing or selling an
analysis under this paragraph to an entity
described in subparagraph (B), to the extent
that such analysis would individually identify
a provider of services or supplier who is not
being provided or sold such analysis, such
qualified entity shall provide an opportunity
for such provider or supplier to review and
submit corrections to such analysis.
``(E) No redisclosure.--An entity described in
subparagraph (B) that is provided or sold an analysis
under this paragraph shall not redisclose or make
public such an analysis.
``(F) Requirements for a qualified data enclave.--
``(i) Definition.--For purposes of this
paragraph, the term `qualified data enclave'
means a data enclave that the Secretary
determines meets the following:
``(I) The data enclave is a web-
based portal or comparable mechanism.
``(II) Subject to the requirements
described in clause (ii) and such other
requirements as the Secretary may
specify, the data enclave is capable of
providing access to the combined data
described in subparagraph (A)(iii).
``(ii) Enclave access requirements.--The
requirements described in this clause are the
following:
``(I) A qualified data enclave
shall preclude any entity that obtains
access to the data from removing or
extracting the data from such enclave.
``(II) Subject to the succeeding
sentence, the enclave shall preclude
access to data that individually
identifies a patient, including data on
the patient's name and date of birth
and such other data as the Secretary
shall specify. Such data enclave may
provide providers of services and
suppliers with access to such
individually identifiable patient data
but only with respect to items and
services furnished by such provider or
supplier to such patient.
``(III) Access to data in the
enclave shall not be provided to any
entity unless the qualified entity and
the entity have entered into a data use
agreement, the terms of which contain
the requirements of this paragraph and
such other terms the Secretary may
specify.
``(G) Annual reports.--Any qualified entity that
provides or sells analyses pursuant to subparagraph
(A)(ii) or provides access to a qualified data enclave
pursuant to subparagraph (A)(iii) shall annually submit
to the Secretary a report that includes--
``(i) 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;
``(ii) a description of the topics and
purposes of such analyses;
``(iii) information on the entities who
obtained access to the qualified data enclave,
the uses of the data, and the total amount of
fees received for providing such access; and
``(iv) other information determined
appropriate by the Secretary.''.
(b) 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: ``Effective July 1, 2014, 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 titles for one or more specified
geographic areas and time periods requested by a
qualified entity.''; and
(B) in the last sentence, by inserting ``or under
titles XIX or XXI'' before the period at the end.
(c) Access to Medicare Data by Qualified Clinical Data Registries
to Facilitate Quality Improvement.--Section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)) is amended by adding at the
end the following new clause:
``(vi) Access to medicare data to
facilitate quality improvement.--
``(I) In general.--To the extent
consistent with applicable information,
privacy, security, and disclosure laws,
and subject to other requirements as
the Secretary may specify, beginning
July 1, 2014, the Secretary shall, if
requested by a qualified clinical data
registry under this subparagraph,
subject to subclauses (II) and (III),
provide data as described in section
1874(e)(3) (in a form and manner
determined to be appropriate) to such
registry for purposes of linking such
data with clinical data and performing
analyses and research to support
quality improvement or patient safety.
``(II) Protection.--A qualified
clinical data registry may not publicly
report any data made available under
subclause (I) (or any analyses or
research described in such subclause)
that individually identifies a provider
of services, supplier, or individual
unless the registry obtains the consent
of such provider, supplier, or
individual prior to such reporting.
``(III) Fee.--The data described in
subclause (I) shall be made available
to qualified clinical data registries
at a fee equal to the cost of making
such data available. Any fee collected
pursuant to the preceding sentence
shall be deposited in the Centers for
Medicare & Medicaid Services Program
Management Account.''.
(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--
(1) by inserting ``, for periods prior to July 1, 2014,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2014, into the Centers for
Medicare & Medicaid Services Program Management Account''.
SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER PROVISIONS.
(a) Medicare Physician and Practitioner Opt-out to Private
Contract.--
(1) Indefinite, continuing automatic extension 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 striking
``during the 2-year period beginning on the
date the affidavit is signed'' and inserting
``during the applicable 2-year period (as
defined in subparagraph (D))'';
(ii) in subparagraph (C), by striking
``during the 2-year period described in
subparagraph (B)(ii)'' and inserting ``during
the applicable 2-year period''; and
(iii) by adding at the end the following
new subparagraph:
``(D) Applicable 2-year periods for effectiveness
of affidavits.--In this subsection, the term
`applicable 2-year period' means, with respect to an
affidavit of a physician or practitioner under
subparagraph (B), the 2-year period beginning on the
date the affidavit is signed and includes each
subsequent 2-year period unless the physician or
practitioner involved provides notice to the Secretary
(in a form and manner specified by the Secretary), 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 application of the affidavit for
such subsequent 2-year period.''.
(B) Effective date.--The amendments made by
subparagraph (A) shall apply to affidavits 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 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 affidavit 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, 2015, 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 physicians 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 subparagraph (A) shall
include at least the following 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, relative to when
they first entered practice and with respect to
applicable 2-year periods.
``(v) The proportion of such physicians and
practitioners who billed for emergency or
urgent care services.''.
(b) Medicare Non-participating Physicians Demonstration Project.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish and implement a demonstration project (in this
section referred to as the ``demonstration project'') under
title XVIII of the Social Security Act to provide that payments
for services under such title furnished by non-participating
physicians (as defined in section 1861(r)(1) of the Social
Security Act (42 U.S.C. 1395x(r)(1))) to individuals entitled
to benefits under part A or enrolled under part B of such title
are paid directly to such physicians. The Secretary shall carry
out the demonstration project in a geographic area that is a
statistically significant area no larger than a State.
(2) Advance notice to physicians.--The Secretary shall, in
a timely manner and prior to the beginning of the year in which
payment will be made under the demonstration project, notify
physicians in the geographic area described in paragraph (1) of
the option to participate in the demonstration project.
(3) Timetable for implementation.--
(A) Demonstration start date.--The demonstration
project shall apply with respect to services furnished
beginning on January 1, 2015.
(B) 1-year duration.--The Secretary shall implement
the demonstration project such that payments are made
under such demonstration project for a period of 1
year.
(4) Report.--Not later than 18 months after the date of the
conclusion of the demonstration project, the Secretary shall
submit to Congress a report analyzing the impact of the
demonstration project. Such report shall include an analysis of
the impact, if any, of the demonstration project upon the--
(A) percentage and number of physicians who choose
not to participate under title XVIII of the Social
Security Act and a comparison of such percentage and
number to the previous year;
(B) percentage of claims submitted by and payments
made to physicians in the demonstration that are
unassigned and a comparison of unassigned claims and
payments by non-participating physicians in the
previous year;
(C) percentage and number of the physicians in the
demonstration by specialty designation; and
(D) access to services for which payment is made
under such title for individuals entitled to benefits
under part A or enrolled under part B of such title.
(5) Beneficiary notice.--
(A) Notice by secretary to beneficiaries.--The
Secretary shall notify individuals entitled to benefits
under part A or enrolled under part B of title XVIII of
the Social Security Act in the geographic area in which
the demonstration project is conducted of the
implications of physician participation in the
demonstration project.
(B) Notice by physicians to patients.--A physician
who elects to participate in the demonstration project
shall notify individuals to whom the physician
furnishes services for which payment will be provided
under the demonstration project of such election. Such
notification shall be provided prior to the provision
of service and include a notification, with respect to
each such individual, that--
(i) the right of the individual to payment
is being reassigned to the physician;
(ii) payment for services furnished by the
physician to such individual will be made
directly to the physician; and
(iii) the individual is responsible for the
remaining amount, which may be higher than
would be the case if the physician participated
in the Medicare program.
(c) 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 consultation 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 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 arrangements, or other
relationships; and
(2) describe how the recommendations address
accountability, transparency, and quality, including how best
to limit inducements to stint on care, discharge 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 Social Security Act.
(d) Promoting Interoperability of Electronic Health Record
Systems.--
(1) Recommendations for achieving widespread ehr
interoperability.--
(A) Objective.--As a consequence of a significant
Federal investment in the implementation of health
information technology through the Medicare EHR
incentive programs, Congress declares it a national
objective to achieve widespread and nationwide exchange
of health information through interoperable certified
EHR technology by December 31, 2019.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term
``widespread interoperability'' means
nationwide interoperability between certified
EHR technology systems employed by meaningful
EHR users under the Medicare EHR incentive
programs and other clinicians and health care
providers.
(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 longitudinal information for
health care providers in order to facilitate
coordinated care and improved patient outcomes.
(C) Establishment of metrics.--Not later than
December 31, 2015, and in consultation with
stakeholders, the Secretary shall establish metrics to
be used to determine if and to the extent that the
objective described in subparagraph (A) has been
achieved.
(D) Recommendations if objective not achieved.--If
the Secretary of Health and Human Services determines
that the objective described in subparagraph (A) has
not been achieved by December 31, 2017, then the
Secretary shall submit to Congress a report, by not
later than December 31, 2018, that identifies barriers
to such objective and recommends actions that the
Federal Government can take to achieve such objective.
Such recommended actions may include recommendations--
(i) to adjust payments for meaningful EHR
users under the Medicare EHR incentive
programs; and
(ii) for criteria for decertifying
certified EHR technology products.
(2) Preventing blocking the sharing of information.--
(A) For meaningful ehr professionals.--Section
1848(o)(2)(A)(ii) of the Social 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
professional demonstrates (through a process specified
by the Secretary, such as the use of an attestation
similar to that required in the health information
technology donation safe harbor established under
regulations under section 1128B(b)(3)(E)) that the
professional has not and will not take any deliberate
action to limit or restrict the use, compatibility, or
interoperability of the certified EHR technology''.
(B) For meaningful ehr hospitals.--Section
1886(n)(3)(A)(ii) of the Social 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 process specified by the
Secretary, such as the use of an attestation referred
to in section 1848(o)(2)(A)(ii)) that the hospital has
not and will not take any deliberate action to limit or
restrict the use, compatibility, or interoperability of
the certified EHR technology''.
(C) Effective date.--The amendments made by this
subsection shall apply to meaningful EHR users as of
the date that is 6 months after the date of the
enactment of this Act.
(3) Study and report on the feasibility of establishing a
website to compare certified ehr technology products.--
(A) Study.--The Secretary shall conduct a study to
examine the feasibility of establishing a website (in
this subsection referred to as the ``website'') that
includes aggregated results of surveys of meaningful
EHR users on the functionality of certified EHR
technology products to enable such users to directly
compare the functionality and other features of such
products. Such information may be made available
through contracts with physician, hospital, or other
organizations that maintain such comparative
information.
(B) Report.--Not later than 1 year after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report on the website. The report
shall include information on the benefits and resources
of such a website.
(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 hospital'' means an
eligible hospital (as defined in section 1886(n)(6)(A)
of the Social Security Act (42 U.S.C. 1395ww(n)(6)(A))
that is a meaningful EHR user.
(C) The term ``meaningful EHR professional'' means
an eligible professional (as defined in section
1848(o)(5)(C) of the Social Security Act (42 U.S.C.
1395w-4(o)(5)(C)) who is a meaningful EHR user.
(D) The term ``meaningful EHR user'' has the
meaning given such term under the Medicare EHR
incentive programs.
(E) The term ``Medicare EHR incentive programs''
means the incentive programs under section 1848(o),
subsections (l) and (m) of section 1853, and section
1886(n) of the Social Security Act (42 U.S.C. 1395w-
4(o), 1395w-23, 1395ww(n)).
(F) The term ``Secretary'' means the Secretary of
Health and Human Services.
(e) GAO Study and Report on the Use of Telehealth Under Federal
Programs.--
(1) Study.--The Comptroller General of the United States
shall conduct 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 Security 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 professional licensure,
changing technology, privacy and security,
infrastructure requirements, and varying needs across
urban and rural areas.
(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 Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(D) How the Centers for Medicare & Medicaid
Services conducts oversight of payments made under the
Medicare program under such title XVIII to providers
for telehealth services.
(2) Report.--Not later than 24 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(f) Rule of Construction Regarding Health Care Provider Standards
of Care.--
(1) In general.--The development, recognition, or
implementation of any guideline or other standard under any
Federal health care provision shall not be construed to
establish the standard of care or duty of care owed by a health
care provider to a patient in any medical malpractice or
medical product liability action or claim.
(2) Definitions.--For purposes of this subsection:
(A) The term ``Federal health care provision''
means any provision of the Patient Protection and
Affordable Care Act (Public Law 111-148), title I and
subtitle B of title III of the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-
152), and titles XVIII and XIX of the Social Security
Act.
(B) The term ``health care provider'' means any
individual or entity--
(i) licensed, registered, or certified
under Federal or State laws or regulations to
provide health care services; or
(ii) required to be so licensed,
registered, or certified but that is exempted
by other statute or regulation.
(C) The term ``medical malpractice or medical
liability action or claim'' means a medical malpractice
action or claim (as defined in section 431(7) of the
Health Care Quality Improvement 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 or section 351 of the
Public Health Service Act).
(D) The term ``State'' includes the District of
Columbia, Puerto Rico, and any other commonwealth,
possession, or territory of the United States.
(3) No preemption.--No provision of the Patient Protection
and Affordable Care Act (Public Law 111-148), title I or
subtitle B of title III of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), or title XVIII
or XIX of the Social Security Act shall be construed to preempt
any State or common law governing medical professional or
medical product liability actions or claims.
Union Calendar No. 283
113th CONGRESS
2d Session
H. R. 2810
[Report No. 113-257, Parts I and II]
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to reform the
sustainable growth rate and Medicare payment for physicians' services,
and for other purposes.
_______________________________________________________________________
March 14, 2014
Reported from the Committee on Ways and Means with an amendment,
committed to the Committee of the Whole House on the State of the
Union, and ordered to be printed