SGR Repeal and Medicare Beneficiary Access Act of 2013 - (Sec. 2) Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act (SSA) to: (1) end with 2013 the current formula for an update to the single conversion factor in the formula for payment for physicians' services, (2) end and remove sustainable growth rate (SGR) methodology from the determination of such annual conversion factors, (3) prescribe an update to the single conversion factor for 2014-2016 of 0.5%, (4) freeze the update to the single conversion factor at 0.00% for 2017-2023, and (5) establish for 2024 and subsequent years an update of 2% for health professionals participating in alternative payment models (APMs) and an update of 1% for all other health professionals.
Directs the Medicare Payment Advisory Commission (MEDPAC) to report to Congress on the relationship between: (1) physician and other health professional utilization and expenditures (and their rates of increase) on items and services for which Medicare payment is made, and (2) total utilization and expenditures (and the rate of increase of such utilization and expenditures) under Medicare parts A (Hospital Insurance), B, and D (Voluntary Prescription Drug Benefit Program).
Directs the Secretary of Health and Human Services (HHS) to establish a value-based performance (VBP) incentive program by consolidating (with certain revisions) the existing: (1) electronic health record (EHR) meaningful use incentive program, (2) quality reporting program, and (3) value-based payment program.
Requires VBP-eligible professionals (excluding most APM participants) to receive annual payment increases or decreases based on their performance.
Defines VBP-eligible professional as: (1) a physician, a physician assistant, nurse practitioner, clinical nurse specialist, and a certified registered nurse anesthetist during the VBP program's first two years, and (2) also other eligible professionals specified by the Secretary for succeeding years.
Excludes from treatment as a VBP eligible professional any eligible professional who is: (1) a qualifying APM participant; (2) a partial qualifying APM participant for the most recent period for which data are available and who, for the performance period with respect to that year, does not report on applicable measures and activities a VBP professional is required to report; or (3) does not exceed, for that performance period, a specified low-volume threshold measurement.
Qualifies for VBP incentive payments a partial qualifying APM participant who reports on applicable measures and activities a VBP professional is required to report.
Prescribes requirements for: (1) application of the VBP program to group practices; and (2) measures and activities under the performance categories of quality, resource use, clinical practice improvement, and meaningful use of EHR technology.
Requires the Secretary to: (1) establish performance standards for the VBP program, taking into account historical performance standards, improvement rates, and the opportunity for continued improvement; and (2) develop a methodology for assessing the total performance of each VBP eligible professional according to such standards with respect to applicable measures and activities for each performance category, leading to a composite performance score for each professional for each performance period.
Prescribes requirements for creation of a performance funding pool from which all VBP program incentives payments shall be made. Makes such a funding pool consist of the total amount of specified gradual reductions to the otherwise applicable physician fee schedule for the years 2017-2021 and following years.
Prescribes a formula for the calculation of VBP program incentive payments, beginning with 2017, subject to criteria for budget neutrality as well as a process for informal review of the calculation of an individual professional's VBP program incentive payment adjustment factor for a year.
Directs the Secretary to enter into contracts or agreements with appropriate entities (such as quality improvement organizations, regional extension centers, or regional health collaboratives) to offer guidance and assistance about performance categories or transition to an APM to MIPS-eligible professionals in practices of 15 or fewer professionals (with priority given to such practices located in rural areas, health professional shortage areas, medically underserved areas, and practices with low composite performance scores).
Requires the Secretary to make available to each VBP eligible professional timely (such as quarterly) confidential feedback and other information to improve performance.
Requires the Comptroller General (GAO) to: (1) evaluate the VBP program; and (2) report on the similarities and differences in the use of quality measures under the original Medicare fee-for-service program, the Medicare Advantage program under Medicare part C, and private payer arrangements, and make recommendations on how to reduce the administrative burden involved in applying such quality measures.
Prescribes incentive payments for participation in eligible APMs between 2017 and 2022, consisting of an additional 5% of the current-year payment amount for the covered professional services for the preceding year.
Directs the Secretary to study: (1) the applicability of federal fraud prevention laws to items and services furnished under Medicare for which payment is made under an APM, (2) aspects of such APMs that are vulnerable to fraudulent activity, and (3) the implication of waivers to such laws granted in support of such APMs.
Directs the Secretary to study: (1) the effect of individuals' socioeconomic status on quality and resource use outcome measures for individuals under the Medicare program, and (2) the impact of certain risk factors on such quality and resource use outcome measures.
Directs the Secretary, taking account of such studies, to: (1) estimate how an individual's health status and other risk factors affect quality and resource use outcome measures and, as feasible, to incorporate information from quality and resource use outcome measurement into the eligible professional VBP incentive program; and (2) account for other identified factors with an effect on quality and resource use outcome measures when determining payment adjustments under the VBP incentive program.
Directs the Secretary to develop and report to Congress on a strategic plan for collecting or otherwise assessing data on race and ethnicity for purposes of carrying out the eligible professional VBP incentive program.
Directs the Secretary to take certain steps, including development of care episode and patient condition groups as well as proposed classification codes, in order to involve the physician, practitioner, and other stakeholder communities in enhancing the infrastructure for resource use measurement for VBP, APM, and other purposes.
(Sec. 3) Directs the Secretary to develop and post on the Internet website of the Centers for Medicare and Medicaid Services (CMS) a draft plan as well as an operational plan, taking stakeholder comments on the draft plan into account, for the development of quality measures.
Directs the Secretary to enter into contracts or other arrangements with entities, which may include physician specialty societies and other practitioner organizations, for the purpose of developing, improving, updating, or expanding such quality measures.
Requires the Secretary to transfer $15 million from the Federal Supplemental Medical Insurance Trust Fund to the CMS Program Management Account for each of FY2014-2018.
(Sec. 4) Requires the Secretary to: (1) establish one or more Healthcare Common Procedure Coding System (HCPCS) codes for chronic care management services for patients with chronic care needs, and (2) make payments for any such services furnished by an applicable provider.
(Sec. 5) Authorizes the Secretary to: (1) collect or obtain information from any eligible professional or any other source on the resources directly or indirectly related to furnishing services paid for under the Medicare fee schedule, and (2) use such information to determine relative values for those services.
Authorizes the Secretary to establish or adjust practice expense relative values using cost, charge, or other data from suppliers or service providers, including any such collected or obtained information.
Expands the list of codes the Secretary must examine to identify services that may be misvalued, including codes: (1) that account for the majority of spending under the physician fee schedule, (2) that have experienced a substantial change in the hospital length of stay or procedure time, (3) for which there is a significant difference in payment for the same service between different sites of service, (4) with high intra-service work per unit of time, (5) with high practice expense relative value units (RVUs), and (6) with high cost supplies.
Sets at 0.5% of the estimated amount of fee schedule expenditures in 2015-2018 the annual target (estimated net reduction in expenditures under the fee schedule) with respect to relative value adjustments for misvalued services.
Declares that, for fee schedules beginning with 2015, if the RVUs for a service for a year would otherwise be decreased by an estimated 20% or more as compared to the total RVUs for the previous year, the applicable adjustments in work, practice expense, and malpractice RVUs must be phased-in over a two-year period.
Directs GAO to study the processes used by the Relative Value Scale Update Committee (RUC) (of the American Medical Association) to make recommendations to the Secretary regarding relative values for specific services.
Requires the use on or after January 1, 2017, of metropolitan statistical areas (MSAs) as fee schedule areas in California, with all areas not included in an MSA to be treated as a single rest-of-state fee schedule area.
Prescribes a formula for the geographic index values applied to the physicians fee schedule for MSAs previously in the rest-of-payment locality or in locality 3.
(Sec. 6) Directs the Secretary to: (1) establish a program to promote the use of appropriate use criteria for certain advanced diagnostic imaging services furnished by ordering and furnishing professionals, and (2) specify applicable appropriate use criteria for imaging services from among appropriate use criteria developed or endorsed by national professional medical specialty societies or other entities.
Directs the Secretary to: (1) determine, on a periodic basis, outlier ordering professionals; (2) apply prior authorization for applicable imaging services ordered by an outlier ordering professional; (3) establish an appropriate use program for other Medicare part B services; and (4) make publicly available on the Physician Compare website specified information with respect to an eligible professional.
(Sec. 8) Expands the kinds (including standardized extracts) and uses of claims data available to qualified entities for quality improvement activities, including analysis of data for non-public uses as well as their provision or sale (subject to certain conditions) to physicians, other professionals, providers, medical societies, and hospital associations and certain other entities.
Directs the Secretary to provide Medicare claims data to requesting qualified clinical data registries to link it with clinical data and perform analyses and research to support quality improvement or patient safety.
Restricts access to claims data through a qualified data enclave only (a web-based portal or comparable mechanism) from which data cannot be extracted. Requires any data or analyses to have no individually identifiable data about a particular patient, with specified exceptions.
Requires any fees charged for making standardized extracts of claims data available to qualified entities to be deposited into the CMS Program Management Account (currently, into the Federal Supplementary Medical Insurance Trust Fund).
(Sec. 9) Permits continuing automatic extensions of a Medicare physician and practitioner election to opt-out of the Medicare physician payment system into private contracts.
Directs the Secretary to: (1) make publicly available through an appropriate publicly accessible website information on the number and characteristics of opt-out physicians and practitioners, and (2) establish a demonstration project to make sure that Medicare payments for services furnished by non-participating physicians to individuals entitled to benefits under part A or enrolled under part B are paid directly to such physicians.
Directs the Secretary to make recommendations to Congress to amend existing fraud and abuse law to permit gainsharing or similar arrangements between physicians and hospitals that improve care while reducing waste and increasing efficiency.
Declares it a national objective to achieve widespread and nationwide exchange of health information through interoperable certified EHR technology by December 31, 2019, as a consequence of a significant federal investment in the implementation of health information technology through the Medicare EHR incentive programs.
Directs the Secretary to study the feasibility of establishing a website to compare certified EHR technology products.
Requires a GAO study on the use of telehealth under federal programs.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2810 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 2810
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
_______________________________________________________________________
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 such 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 that is recognized by the
American Board of Medical Specialties, American
Osteopathic Association, American Board of Physician
Specialties, or an equivalent certification board.
``(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 the American
Board of Medical Specialties 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 update 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, 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
evaluation, including through the demonstration program
under subsection (e), and approval under subsection
(f);
``(D) applicable Alternative Payment Models are
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.--As soon as
practicable, but not later than one year after the date
of the enactment of this section, the Secretary shall
enter into the first contract under subparagraph (A).
``(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) In general.--Under the process under
subsection (b), the APM contracting entity shall at
least annually recommend to the Secretary--
``(i) based on the criteria described in
subparagraph (B), Alternative Payment Models
submitted under subsection (c) to be evaluated
through a demonstration program under
subsection (e); and
``(ii) based on the criteria described in
subparagraph (C), Alternative Payment Models
submitted under subsection (c) for purposes of
implementation under subsection (f), without
evaluation through such a demonstration
program.
Such a recommendation may be made with respect to a
model for which a waiver would be required under
paragraph (2).
``(B) Criteria for recommending models for
demonstration.--The APM contracting entity shall make a
recommendation under subparagraph (A)(i), with respect
to an Alternative Payment Model, only if the entity
determines that the model satisfies each of the
following criteria:
``(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 (v).
``(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 meaningful
evaluation.
``(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 meaningful
evaluation.
``(iii) Such model, including if 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 implementation of such model as
an eligible APM under this section is
expected--
``(I) to reduce spending under this
title without reducing the quality of
care; or
``(II) improve the quality of
patient care without increasing
spending.
``(v) The proposal for such model
demonstrates--
``(I) the potential to successfully
manage the cost of furnishing items and
services under this title so as to not
result in expenditures under this title
for individuals participating under
such APM being greater than
expenditures under this title for such
individuals if the APM were not
implemented;
``(II) the ability to maintain or
improve the overall patient care; and
``(III) the ability to maintain or
improve the quality of care provided to
individuals enrolled under this part
who participate under such mode.
``(vi) The model provides for a payment
arrangement--
``(I) covering at least items and
services furnished under this part by
eligible professionals participating in
the model;
``(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.--The APM
contracting entity may make a recommendation under
subparagraph (A)(ii), with respect to an Alternative
Payment Model, only if the entity determines that the
model has already been evaluated for a sufficient
enough period and through such evaluation the model was
shown--
``(i) to have satisfied the criteria
described in each of clauses (i), (ii), (iii),
and (vi) of subparagraph (B);
``(ii) to demonstrate each of the abilities
described in clause (v) of such subparagraph;
and
``(iii)(I) to reduce spending under this
title without reducing the quality of care; or
``(II) improve the quality of patient care
without increasing spending.
``(D) Transparency and disclosures.--
``(i) Disclosures.--Not later than 90 days
after receipt of a submission of a model under
subsection (c) by an entity, the APM
contracting entity shall submit to the
Secretary and such entity 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), 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)(ii), 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 (C).
For any year beginning with 2015 that the APM
contracting does not recommend any models under
subparagraph (A), the entity shall instead
satisfy this clause by submitting to the
Secretary and making publicly available an
explanation for not having any such
recommendations.
``(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 in order for such
model to be evaluated under the demonstration program
(if described in clause (i) of such paragraph).
``(B) Approval.--Not later than 90 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 provided
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 entities 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 (3). The duration of a
demonstration program under this subsection, with respect to
such a model, shall be 3 years (or a shorter period, taking
into account the applicable recommendation under subsection
(d)(1)(A)(i)).
``(2) Approval by secretary of models for demonstration.--
Not later than 90 days after the date of receipt of a
recommendation under subsection (d)(1)(A)(i), with respect to
an Alternative Payment Model, the Secretary shall approve such
model for a demonstration program under this subsection only if
the Secretary determines the model satisfies the criteria
described in subsection (d)(1)(B). The Secretary shall
periodically make a available a list of such models so
approved.
``(3) Participating entities.--To participate under a
demonstration program under this subsection, with respect to an
Alternative Payment Model, a physician, practitioner, or other
supplier shall enter into a contract with the Administrator of
the Centers for Medicare & Medicaid Services under this
subsection. For purposes of this section, such a physician,
practitioner, or supplier who so participates under such an
Alternative Payment Model shall be referred to as a
`participating APM provider'.
``(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 entities 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
entities 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 program
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, $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 transferred 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 entities 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 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) In general.--Not later than the applicable date under
paragraph (2), the Secretary shall, implement an Alternative
Payment Model recommended under subsection (d)(1)(A)(ii) or
(e)(4)(E)(ii)(I) as an eligible APM only if--
``(A) 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;
``(B) the Chief Actuary of the Centers for Medicare
& Medicaid Services certifies that such model would
reduce (or would not result in any increase in) program
spending under this title; and
``(C) the Secretary determines that such model
would not deny or limit the coverage or provision of
benefits under this title for applicable individuals.
Not later than 90 days after the date of issuance of a proposed
rule, with respect to an Alternative Payment Model, the
Medicare Payment Advisory Commission shall submit comments to
Congress and the Secretary evaluating 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.
``(2) Applicable date.--For purposes of paragraph (1), the
applicable date under this paragraph--
``(A) for an Alternative Payment Model recommended
under subsection (d)(1)(A)(ii) is 90 days after the
date of submission of such recommendation; and
``(B) for an Alternative Payment Model recommended
under subsection (e)(4)(E)(ii)(I) is 90 days after the
date of submission of such recommendation
``(3) 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.
``(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''.
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 the second sentence of paragraph
(4)(D) of section 1874(e) of the Social Security Act (42 U.S.C.
1395kk(e)), 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
analyses (as determined appropriate by the Secretary of Health
and Human Services) that such entity may provide or sell to
providers of services and suppliers (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 for non-public use (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, in order 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 analysis and research to support
quality improvement.
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 physician (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
physician, make payment (as the Secretary
determines to be appropriate) under the fee
schedule under this section using such HCPCS
codes.
``(B) Applicable physician defined.--For purposes
of this paragraph, the term `applicable physician'
means a physician (as defined in section 1861(r)(1))
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 physician payment.--In
carrying out this paragraph, the Secretary shall only
make payment to a single applicable physician 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
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
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), as of such date, 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.
(b) 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:
``(8) 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.--With respect to fee schedules established
for 2016, 2017, and 2018, 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 net 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 to result in such a net reduction
for such year.''.
(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).''.
(c) 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.
<all>
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.
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.
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.
Referred to the Subcommittee on Health.
Committee Consideration and Mark-up Session Held.
Committee Consideration and Mark-up Session Held.
Ordered to be Reported (Amended) by the Yeas and Nays: 51 - 0.
Referred to the Subcommittee on the Constitution and Civil Justice.
Reported (Amended) by the Committee on Energy and Commerce. H. Rept. 113-257, Part I.
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Reported (Amended) by the Committee on Energy and Commerce. H. Rept. 113-257, Part I.
Committee on Judiciary discharged.
Committee on Judiciary discharged.
House Committee on Ways and Means Granted an extension for further consideration ending not later than Dec. 2, 2013.
House Committee on Ways and Means Granted an extension for further consideration ending not later than Jan. 10, 2014.
Committee Consideration and Mark-up Session Held.
Ordered to be Reported in the Nature of a Substitute (Amended) by the Yeas and Nays: 39 - 0.
House Committee on Ways and Means Granted an extension for further consideration ending not later than March 14, 2014.
Reported (Amended) by the Committee on Ways and Means. H. Rept. 113-257, Part II.
Reported (Amended) by the Committee on Ways and Means. H. Rept. 113-257, Part II.
Placed on the Union Calendar, Calendar No. 283.