SGR Repeal and Medicare Provider Payment Modernization Act of 2014 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to: (1) end and remove sustainable growth rate (SGR) methodology from the determination of annual conversion factors in the formula for payment for physicians' services; (2) establish an update to the single conversion factor for 2014 through 2018 of 0.5%, (3) freeze the update to the single conversion factor at 0.00% for 2019 through 2023, and (4) establish an update of 1% for health professionals participating in alternative payment models (APMs) and an update of 0.5% for all other health professionals after 2023.
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 rate of increase) of items and services for which Medicare payment is made, and (2) total utilization and expenditures (and their rate of increase) under Medicare parts A (Hospital Insurance), B (Supplementary Medical Insurance), and D (Voluntary Prescription Drug Benefit Program).
Directs MEDPAC to report to Congress on: (1) the payment update for professional services applied under Medicare for 2014 through 2018, (2) the effect of such update on the efficiency, economy, and quality of care provided under such program, (3) the effect of such update on ensuring a sufficient number of providers to maintain access to care by Medicare beneficiaries, and (4) recommendations for any future payment updates for professional services under such program to ensure adequate access to care is maintained for Medicare beneficiaries
Revises and consolidates components of the three specified existing performance incentive programs into a merit-based incentive payment system (MIPS) the Secretary of Health and Human Services (HHS) is directed to establish, under which MIPS-eligible professionals (excluding most Alternative Payment Model [APM] participants) receive annual payment increases or decreases based on their performance. Applies the MIPS program to payments for items and services furnished on or after January 1, 2018.
Requires specified incentive payments to be made to eligible partial qualifying APM participants.
Directs the Secretary to make available on the Physician Compare website of the Centers for Medicare & Medicaid Services (CMS) certain information, including information regarding the performance of MIPS-eligible professionals.
Requires the Comptroller General (GAO) to evaluate the MIPS program.
Requires GAO to submit to Congress a report that: (1) compares the similarities and differences in the use of quality measures under the original Medicare fee-for-service programs, the Medicare Advantage (MA) program under Medicare part C (Medicare+Choice), selected state Medicaid programs, and private payer arrangements; and (2) make recommendations on how to reduce the administrative burden involved in applying such quality measures.
Directs GAO to report to Congress on: (1) whether entities that pool financial risk for physician services can play a role in supporting physician practices in assuming financial risk for treatment of patients, and (2) the transition to an APM of professionals in rural areas, health professional shortage areas, or medically underserved areas.
Establishes the Payment Model Technical Advisory Committee to make recommendations to the Secretary on physician-focused payment models.
Requires the Secretary to study: (1) the application of federal fraud prevention laws related to APMs; (2) the effect of individuals' socioeconomic status on quality and resource use outcome measures for individuals under Medicare; and (3) the impact of risk factors, race, health literacy, limited English proficiency (LEP), and patient activation, on quality and resource use outcome measures under Medicare.
Directs the Secretary to: (1) post on the CMS Internet website a draft plan for the development of quality measures to assess professionals, (2) establish new Healthcare Common Procedure Coding System (HCPCS) codes for chronic care management services, and (3) conduct an education and outreach campaign to inform professionals who furnish items and services under Medicare part B and Medicare part B enrollees of the benefits of chronic care management services.
Authorizes the Secretary to: (1) collect and use information on the resources directly or indirectly related to physicians' services in the determination of relative values under the Medicare physician fee schedule; and (2) establish or adjust practice expense relative values using cost, charge, or other data from suppliers or service providers.
Revises and expands factors for identification of potentially misvalued codes. Sets an annual target for relative value adjustments for misvalued services. Phases-in of significant relative value unit (RVU) reductions.
Directs GAO to study the processes used by the Relative Value Scale Update Committee (RUC) to make recommendations to the Secretary regarding relative values for specific services under the Medicare physician fee schedule.
Makes Metropolitan Statistical Areas in California fee schedule areas for Medicare payments.
Directs the Secretary to: (1) establish a program to promote the use of appropriate use criteria for certain imaging services furnished by ordering professionals and furnishing professionals, and (2) make publicly available on the CMS Physician Compare website specified information with respect to eligible professionals.
Expands the kinds and uses of data available to qualified entities for quality improvement activities.
Directs the Secretary to provide Medicare data to qualified clinical data registries to facilitate quality improvement or patient safety.
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) report to Congress 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.
Declares it a national objective to achieve widespread exchange of health information through interoperable certified electronic health record (EHR) technology nationwide by December 31, 2017, as a consequence of a significant federal investment in the implementation of health information technology through the Medicare and Medicaid EHR programs.
Directs the Secretary to study the feasibility of establishing mechanisms that includes aggregated results of surveys of meaningful EHR users on the functionality of certified EHR products to enable such users to compare directly the functionality and other features of such products.
Requires GAO studies on the use of telehealth under federal programs and on remote patient monitoring services.
Amends the Balanced Budget and Emergency Deficit Control Act of 1985 (Gramm-Rudman-Hollings Act) with respect to savings from Overseas Contingency Operations/Global War on Terrorism (OCO/GWOT).
Establishes caps on any amount of OCO/GWOT budget authority subject to sequestration for FY2016-FY2021.
Declares that any amount of OCO/GWOT budget authority for FY2016-FY2021 in excess of such established levels shall be counted in determining whether a breach has occurred in the security category and the nonsecurity category on a proportional basis to the total spending for overseas contingency operation in the security category and the nonsecurity category.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4209 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 4209
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate and improve Medicare payments for physicians
and other professionals, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 12, 2014
Mr. Tierney introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Ways and Means, the Judiciary, and the Budget, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to repeal the Medicare
sustainable growth rate and improve Medicare payments for physicians
and other professionals, 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 ``SGR Repeal and
Medicare Provider Payment Modernization Act of 2014''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Repealing the sustainable growth rate (SGR) and improving
Medicare payment for physicians' services.
Sec. 3. Priorities and funding for measure development.
Sec. 4. Encouraging care management for individuals with chronic care
needs.
Sec. 5. 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 availability of Medicare data.
Sec. 9. Reducing administrative burden and other provisions.
Sec. 10. Savings from overseas contingency and related activities.
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), in the matter
preceding subparagraph (A), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for april through december of 2014,
2015, and subsequent years.--Subsection (d) of section 1848 of
the Social Security Act (42 U.S.C. 1395w-4) is amended by
striking paragraph (15) and inserting the following new
paragraphs:
``(15) Update for 2014 through 2018.--The update to the
single conversion factor established in paragraph (1)(C) for
2014 and each subsequent year through 2018 shall be 0.5
percent.
``(16) Update for 2019 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
2019 and each subsequent year 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, 1.0 percent; and
``(B) for other items and services, 0.5 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.
(C) Report on update to physicians' services under
medicare.--Not later than July 1, 2018, the Medicare
Payment Advisory Commission shall submit to Congress a
report on--
(i) the payment update for professional
services applied under the Medicare program
under title XVIII of the Social Security Act
for the period of years 2014 through 2018;
(ii) the effect of such update on the
efficiency, economy, and quality of care
provided under such program;
(iii) the effect of such update on ensuring
a sufficient number of providers to maintain
access to care by Medicare beneficiaries; and
(iv) recommendations for any future payment
updates for professional services under such
program to ensure adequate access to care is
maintained for Medicare beneficiaries.
(b) Consolidation of Certain Current Law Performance Programs With
New Merit-Based Incentive Payment System.--
(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
2017'';
(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 mips.--Section 1848(o)(2) of the Social Security
Act (42 U.S.C. 1395w-4(o)(2)) is amended--
(i) in subparagraph (A), in the matter
preceding clause (i)--
(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 mips.--
With respect to 2018 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
MIPS eligible professional (as defined in subsection
(q)(1)(C)) for such year is a meaningful EHR user under
this paragraph for the performance period under
subsection (q) for such year.''.
(2) Quality reporting.--
(A) Sunsetting separate quality 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 2017'';
and
(ii) in clause (ii)(II), by striking ``and
each subsequent year''.
(B) Continuation of quality measures and processes
for mips.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended--
(i) in subsection (k), by adding at the end
the following new paragraph:
``(9) Continued application for purposes of mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
provisions of this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''; and
(ii) in subsection (m)--
(I) by redesignating 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 mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
processes under this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS
eligible professionals (as defined in subsection
(q)(1)(C)) for the year involved.''.
(3) Value-based payments.--
(A) Sunsetting separate value-based payments.--
Clause (iii) of section 1848(p)(4)(B) of the Social
Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to
read as follows:
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished on or after January 1, 2015, but
before January 1, 2018, 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,
2018.''.
(B) Continuation of value-based payment modifier
measures for mips.--Section 1848(p) of the Social
Security Act (42 U.S.C. 1395w-4(p)) is amended--
(i) in paragraph (2), by adding at the end
the following new subparagraph:
``(C) Continued application for purposes of mips.--
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 2018 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Merit-Based Incentive Payment System.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended by adding at the end the
following new subsection:
``(q) Merit-Based Incentive Payment System.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional Merit-based
Incentive Payment System (in this subsection referred
to as the `MIPS') under which the Secretary shall--
``(i) develop a methodology for assessing
the total performance of each MIPS 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 MIPS eligible professional for a
performance period for a year to determine and
apply a MIPS adjustment factor (and, as
applicable, an additional MIPS adjustment
factor) under paragraph (6) to the professional
for the year.
``(B) Program implementation.--The MIPS shall apply
to payments for items and services furnished on or
after January 1, 2018.
``(C) MIPS eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `MIPS eligible professional' means--
``(I) for the first and second
years for which the MIPS applies to
payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)), a physician assistant, nurse
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
a group that includes such
professionals; and
``(II) for the third year for which
the MIPS applies to payments (and for
the performance period for such third
year) and for each succeeding year (and
for the performance period for each
such year), the professionals described
in subclause (I) and such other
eligible professionals (as defined in
subsection (k)(3)(B)) as specified by
the Secretary and a group that includes
such professionals.
``(ii) Exclusions.--For purposes of clause
(i), the term `MIPS eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B)) who--
``(I) is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) 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 MIPS;
or
``(III) 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 2018 and
2019, the reference in subparagraph (A)
of such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2020 and
2021--
``(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 2022 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 a low-
volume threshold to apply for purposes of
clause (ii)(III), which may include one or more
or a combination of the following:
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the eligible
professional for the performance period
involved.
``(II) The minimum number (as
determined by the Secretary) of items
and services furnished to individuals
enrolled under this part by such
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
MIPS 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 MIPS eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a MIPS adjustment factor (or
additional MIPS adjustment factor) under
paragraph (6) apply to such individual for such
year.
``(vii) Partial qualifying apm participant
clarifications.--
``(I) Treatment as mips eligible
professional.--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 MIPS,
such eligible professional is
considered to be a MIPS eligible
professional with respect to such year.
``(II) Not eligible for qualifying
apm participant payments.--In no case
shall an eligible professional who is a
partial qualifying APM participant,
with respect to a year, be considered a
qualifying APM participant (as defined
in paragraph (2) of section 1833(z))
for such year or be eligible for the
additional payment under paragraph (1)
of such section for such year.
``(D) Application to group practices.--
``(i) In general.--Under the MIPS:
``(I) Quality performance
category.--The Secretary shall
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for MIPS 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 MIPS 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 range of items and
services furnished by the MIPS eligible
professionals in the group practice involved.
``(iii) Clarification.--MIPS eligible
professionals electing to be a virtual group
under paragraph (5)(I) shall not be considered
MIPS eligible professionals in a group practice
for purposes of applying this subparagraph.
``(E) Use of registries.--Under the MIPS, the
Secretary shall encourage the use of qualified clinical
data registries pursuant to subsection (m)(3)(E) in
carrying out this 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.
``(G) Accounting for risk factors.--
``(i) Risk factors.--Taking into account
the relevant studies conducted and
recommendations made in reports under section
2(f)(1) of the SGR Repeal and Medicare Provider
Payment Modernization Act of 2014, 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 MIPS.
``(ii) Accounting for other factors in
payment adjustments.--Taking into account the
studies conducted and recommendations made in
reports under section 2(f)(1) of the SGR Repeal
and Medicare Provider Payment Modernization Act
of 2014 and other information as appropriate,
the Secretary shall account for identified
factors with an effect on quality and resource
use outcome measures when determining payment
adjustments, composite performance scores,
scores for performance categories, or scores
for measures or activities under the MIPS.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the MIPS, 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 included in the final measures
list published under subparagraph (D)(i) for
such year and the list of quality measures
described in subparagraph (D)(vi) used by
qualified clinical data registries under
subsection (m)(3)(E).
``(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 drugs under part D.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities (as defined in
subparagraph (C)(v)(III)) under subcategories
specified by the Secretary for such period,
which shall include at least the following:
``(I) The subcategory of expanded
practice access, 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 assessment
and training, and using shared
decision-making mechanisms.
``(V) The subcategory of patient
safety and practice assessment, such as
through use of clinical or surgical
checklists and practice assessments
related to maintaining certification.
``(VI) The subcategory of
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
15 or fewer 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
the 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,
such as measures for inpatient hospitals, for
purposes of the performance categories
described in clauses (i) and (ii) of
subparagraph (A). For purposes of the previous
sentence, the Secretary may not use measures
for hospital outpatient departments, except in
the case of emergency physicians.
``(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) Application of measures and
activities to non-patient-facing
professionals.--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 furnish 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 MIPS
eligible professionals of such
professional types or subcategories,
alternative measures or activities that
fulfill 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.
``(v) Clinical practice improvement
activities.--
``(I) Request for information.--In
initially applying subparagraph
(B)(iii), the Secretary shall use a
request for information to solicit
recommendations from stakeholders to
identify activities described in such
subparagraph and specifying criteria
for such activities.
``(II) 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--
``(aa) identifying
activities described in
subparagraph (B)(iii);
``(bb) specifying criteria
for such activities; and
``(cc) determining whether
a MIPS eligible professional
meets such criteria.
``(III) Clinical practice
improvement activities defined.--For
purposes of this subsection, 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) Annual list of quality measures available for
mips assessment.--
``(i) In general.--Under the MIPS, the
Secretary, through notice and comment
rulemaking and subject to the succeeding
clauses of this subparagraph, shall, with
respect to the performance period for a year,
establish an annual final list of quality
measures from which MIPS eligible professionals
may choose for purposes of assessment under
this subsection for such performance period.
Pursuant to the previous sentence, the
Secretary shall--
``(I) not later than November 1 of
the year prior to the first day of the
first performance period under the
MIPS, establish and publish in the
Federal Register a final list of
quality measures; and
``(II) not later than November 1 of
the year prior to the first day of each
subsequent performance period, update
the final list of quality measures from
the previous year (and publish such
updated final list in the Federal
Register), by--
``(aa) removing from such
list, as appropriate, quality
measures, which may include the
removal of measures that are no
longer meaningful (such as
measures that are topped out);
``(bb) adding to such list,
as appropriate, new quality
measures; and
``(cc) determining whether
or not quality measures on such
list that have undergone
substantive changes should be
included in the updated list.
``(ii) Call for quality measures.--
``(I) In general.--Eligible
professional organizations and other
relevant stakeholders shall be
requested to identify and submit
quality measures to be considered for
selection under this subparagraph in
the annual list of quality measures
published under clause (i) and to
identify and submit updates to the
measures on such list. For purposes of
the previous sentence, measures may be
submitted regardless of whether such
measures were previously published in a
proposed rule or endorsed by an entity
with a contract under section 1890(a).
``(II) Eligible professional
organization defined.--In this
subparagraph, the term `eligible
professional organization' means a
professional organization as defined by
nationally recognized multispecialty
boards of certification or equivalent
certification boards.
``(iii) Requirements.--In selecting quality
measures for inclusion in the annual final list
under clause (i), the Secretary shall--
``(I) provide that, to the extent
practicable, all quality domains (as
defined in subsection (s)(1)(B)) are
addressed by such measures; and
``(II) ensure that such selection
is consistent with the process for
selection of measures under subsections
(k), (m), and (p)(2).
``(iv) Peer review.--Before including a new
measure or a measure described in clause
(i)(II)(cc) in the final list of measures
published under clause (i) for a year, the
Secretary shall submit for publication in
applicable specialty-appropriate peer-reviewed
journals such measure and the method for
developing and selecting such measure,
including clinical and other data supporting
such measure.
``(v) Measures for inclusion.--The final
list of quality measures published under clause
(i) shall include, as applicable, measures
under subsections (k), (m), and (p)(2),
including quality measures from among--
``(I) measures endorsed by a
consensus-based entity;
``(II) measures developed under
subsection (s); and
``(III) measures submitted under
clause (ii)(I).
Any measure selected for inclusion in such list
that is not endorsed by a consensus-based
entity shall have a focus that is evidence-
based.
``(vi) Exception for qualified clinical
data registry measures.--Measures used by a
qualified clinical data registry under
subsection (m)(3)(E) shall not be subject to
the requirements under clauses (i), (iv), and
(v). The Secretary shall publish the list of
measures used by such qualified clinical data
registries on the Internet website of the
Centers for Medicare & Medicaid Services.
``(vii) Exception for existing quality
measures.--Any quality measure specified by the
Secretary under subsection (k) or (m),
including under subsection (m)(3)(E), and any
measure of quality of care established under
subsection (p)(2) for the reporting period
under the respective subsection beginning
before the first performance period under the
MIPS--
``(I) shall not be subject to the
requirements under clause (i) (except
under items (aa) and (cc) of subclause
(II) of such clause) or to the
requirement under clause (iv); and
``(II) shall be included in the
final list of quality measures
published under clause (i) unless
removed under clause (i)(II)(aa).
``(viii) Consultation with relevant
eligible professional organizations and other
relevant stakeholders.--Relevant eligible
professional organizations and other relevant
stakeholders, including State and national
medical societies, shall be consulted in
carrying out this subparagraph.
``(ix) Optional application.--The process
under section 1890A is not required to apply to
the selection of measures under this
subparagraph.
``(3) Performance standards.--
``(A) Establishment.--Under the MIPS, 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 consider the following:
``(i) Historical performance standards.
``(ii) Improvement.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with 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 taking into account,
as available and applicable, paragraph (1)(G), the
Secretary shall develop a methodology for assessing the
total performance of each MIPS eligible professional
according to performance standards under paragraph (3)
with respect to applicable measures and 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
(using a scoring scale of 0 to 100) for each such
professional for the performance period for such year.
In this subsection such a composite assessment for such
a professional with respect to a performance period
shall be referred to as the `composite performance
score' for such professional for such performance
period.
``(B) 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 MIPS 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 and qualified clinical data
registries for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage MIPS 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 qualified
clinical data registries; and
``(II) with respect to a
performance period, with respect to a
year, for which a MIPS eligible
professional reports such measures
through the use of such EHR technology,
treat such professional as satisfying
the clinical quality measures reporting
requirement described in subsection
(o)(2)(A)(iii) for such year.
``(C) Clinical practice improvement activities
performance score.--
``(i) Rule for accreditation.--A MIPS
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 MIPS eligible professional in an alternative
payment model (as defined in section
1833(z)(3)(C)) with respect to a performance
period shall earn such eligible professional a
minimum score of one-half of the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
performance period.
``(iii) Subcategories.--A MIPS eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) or participate in an alternative
payment model in order to achieve the highest
potential score for the performance category
described in paragraph (2)(A)(iii).
``(D) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the
MIPS applies, in addition to the achievement of
a MIPS eligible professional, if data
sufficient to measure improvement is available,
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 MIPS applies, under the methodology
developed under subparagraph (A), the Secretary
may assign a higher scoring weight under
subparagraph (F) with respect to the
achievement of a MIPS eligible professional
than with respect to any improvement of such
professional applied under clause (i) with
respect to a measure, activity, or category
described in paragraph (2).
``(E) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
subparagraph (F)(i) and clauses (ii) and (iii),
the composite performance score shall be
determined as follows:
``(I) Quality.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A). In
applying the previous sentence,
the Secretary shall, as
feasible, encourage the
application of outcome measures
within such category.
``(bb) First 2 years.--For
the first and second years for
which the MIPS applies to
payments, the percentage
applicable under item (aa)
shall be increased in a manner
such that the total percentage
points of the increase under
this item for the respective
year equals the total number of
percentage points by which the
percentage applied under
subclause (II)(bb) for the
respective year is less than 30
percent.
``(II) Resource use.--
``(aa) In general.--Subject
to item (bb), thirty percent of
such score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(bb) First 2 years.--For
the first year for which the
MIPS applies to payments, not
more than 10 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A). For
the second year for which the
MIPS applies to payments, not
more than 15 percent of such
score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(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, subject to subclauses (I)(bb) and
(II)(bb) of clause (i), the percentages
applicable under one or more of subclauses (I),
(II), and (III) of clause (i) for such year
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.
``(F) Certain flexibility for weighting performance
categories, measures, and activities.--Under the
methodology under subparagraph (A), if there are not
sufficient measures and clinical practice improvement
activities applicable and available to each type of
eligible professional involved, the Secretary shall
assign different scoring weights (including a weight of
0)--
``(i) which may vary from the scoring
weights specified in subparagraph (E), for each
performance category based on the extent to
which the category is applicable to the type of
eligible professional involved; and
``(ii) for each measure and activity
specified under paragraph (2)(B) with respect
to each such category based on the extent to
which the measure or activity is applicable and
available to the type of eligible professional
involved.
``(G) 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.
``(H) Inclusion of quality measure data from other
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 MIPS
eligible professionals with respect to items and
services furnished to individuals who are not
individuals entitled to benefits under part A or
enrolled under part B.
``(I) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of MIPS
eligible professionals electing to be a virtual
group under clause (ii) with respect to a
performance period for a year, for purposes of
applying the methodology under subparagraph
(A)--
``(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
MIPS 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
MIPS eligible professional or a group practice
consisting of not more than 10 MIPS eligible
professionals to elect, with respect to a
performance period for a year, for such
individual MIPS eligible professional or all
such MIPS eligible professionals in such group
practice, respectively, to be a virtual group
under this subparagraph with at least one other
such individual MIPS eligible professional or
group practice making such an election. Such a
virtual group may be based on geographic areas
or on provider specialties defined by
nationally recognized multispecialty boards of
certification or equivalent certification
boards and such other eligible professional
groupings in order to capture classifications
of providers across eligible professional
organizations and other practice areas or
categories.
``(iii) Requirements.--The process under
clause (ii)--
``(I) shall provide that an
election under such clause, with
respect to a performance period, shall
be made before or during the beginning
of such performance period and may not
be changed during such performance
period;
``(II) shall provide that a
practice described in such clause, and
each MIPS eligible professional in such
practice, may elect to be in no more
than one virtual group for a
performance period; and
``(III) may provide that a virtual
group may be combined at the tax
identification number level.
``(6) MIPS payments.--
``(A) MIPS adjustment factor.--Taking into account
paragraph (1)(G), the Secretary shall specify a MIPS
adjustment factor for each MIPS eligible professional
for a year. Such MIPS adjustment factor for a MIPS
eligible professional for a year shall be in the form
of a percent and shall be determined--
``(i) by comparing the composite
performance score of the eligible professional
for such year to the performance threshold
established under subparagraph (D)(i) for such
year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year result in differential payments under this
paragraph reflecting that--
``(I) MIPS eligible professionals
with composite performance scores for
such year at or above such performance
threshold for such year receive zero or
positive incentive payment adjustment
factors for such year in accordance
with clause (iii), with such
professionals having higher composite
performance scores receiving higher
adjustment factors; and
``(II) MIPS eligible professionals
with composite performance scores for
such year below such performance
threshold for such year receive
negative payment adjustment factors for
such year in accordance with clause
(iv), with such professionals having
lower composite performance scores
receiving lower adjustment factors;
``(iii) in a manner such that MIPS eligible
professionals with composite scores described
in clause (ii)(I) for such year, subject to
clauses (i) and (ii) of subparagraph (F),
receive a zero or positive adjustment factor on
a linear sliding scale such that an adjustment
factor of 0 percent is assigned for a score at
the performance threshold and an adjustment
factor of the applicable percent specified in
subparagraph (B) is assigned for a score of
100; and
``(iv) in a manner such that--
``(I) subject to subclause (II),
MIPS eligible professionals with
composite performance scores described
in clause (ii)(II) for such year
receive a negative payment adjustment
factor on a linear sliding scale such
that an adjustment factor of 0 percent
is assigned for a score at the
performance threshold and an adjustment
factor of the negative of the
applicable percent specified in
subparagraph (B) is assigned for a
score of 0; and
``(II) MIPS eligible professionals
with composite performance scores that
are equal to or greater than 0, but not
greater than \1/4\ of the performance
threshold specified under subparagraph
(D)(i) for such year, receive a
negative payment adjustment factor that
is equal to the negative of the
applicable percent specified in
subparagraph (B) for such year.
``(B) Applicable percent defined.--For purposes of
this paragraph, the term `applicable percent' means--
``(i) for 2018, 4 percent;
``(ii) for 2019, 5 percent;
``(iii) for 2020, 7 percent; and
``(iv) for 2021 and subsequent years, 9
percent.
``(C) Additional mips adjustment factors for
exceptional performance.--
``(i) In general.--In the case of a MIPS
eligible professional with a composite
performance score for a year at or above the
additional performance threshold under
subparagraph (D)(ii) for such year, in addition
to the MIPS adjustment factor under
subparagraph (A) for the eligible professional
for such year, subject to the availability of
funds under clause (ii), the Secretary shall
specify an additional positive MIPS adjustment
factor for such professional and year. Such
additional MIPS adjustment factors shall be
determined by the Secretary in a manner such
that professionals having higher composite
performance scores above the additional
performance threshold receive higher additional
MIPS adjustment factors.
``(ii) Additional funding pool.--For 2018
and each subsequent year through 2023, there is
appropriated from the Federal Supplementary
Medical Insurance Trust Fund $500,000,000 for
MIPS payments under this paragraph resulting
from the application of the additional MIPS
adjustment factors under clause (i).
``(D) Establishment of performance thresholds.--
``(i) Performance threshold.--For each year
of the MIPS, the Secretary shall compute a
performance threshold with respect to which the
composite performance score of MIPS eligible
professionals shall be compared for purposes of
determining adjustment factors under
subparagraph (A) that are positive, negative,
and zero. Such performance threshold for a year
shall be the mean or median (as selected by the
Secretary) of the composite performance scores
for all MIPS eligible professionals with
respect to a prior period specified by the
Secretary. The Secretary may reassess the
selection under the previous sentence every 3
years.
``(ii) Additional performance threshold for
exceptional performance.--In addition to the
performance threshold under clause (i), for
each year of the MIPS, the Secretary shall
compute an additional performance threshold for
purposes of determining the additional MIPS
adjustment factors under subparagraph (C)(i).
For each such year, the Secretary shall apply
either of the following methods for computing
such additional performance threshold for such
a year:
``(I) The threshold shall be the
score that is equal to the 25th
percentile of the range of possible
composite performance scores above the
performance threshold with respect to
the prior period described in clause
(i).
``(II) The threshold shall be the
score that is equal to the 25th
percentile of the actual composite
performance scores for MIPS eligible
professionals with composite
performance scores at or above the
performance threshold with respect to
the prior period described in clause
(i).
``(iii) Special rule for initial 2 years.--
With respect to each of the first two years to
which the MIPS applies, the Secretary shall,
prior to the performance period for such years,
establish a performance threshold for purposes
of determining MIPS adjustment factors under
subparagraph (A) and a threshold for purposes
of determining additional MIPS adjustment
factors under subparagraph (C)(i). Each such
performance threshold shall--
``(I) be based on a period prior to
such performance periods; and
``(II) take into account--
``(aa) data available with
respect to performance on
measures and activities that
may be used under the
performance categories under
subparagraph (2)(B); and
``(bb) other factors
determined appropriate by the
Secretary.
``(E) Application of mips adjustment factors.--In
the case of items and services furnished by a MIPS
eligible professional during a year (beginning with
2018), the amount otherwise paid under this part with
respect to such items and services and MIPS eligible
professional for such year, shall be multiplied by--
``(i) 1, plus
``(ii) the sum of--
``(I) the MIPS adjustment factor
determined under subparagraph (A)
divided by 100, and
``(II) as applicable, the
additional MIPS adjustment factor
determined under subparagraph (C)(i)
divided by 100.
``(F) Aggregate application of mips adjustment
factors.--
``(i) Application of scaling factor.--
``(I) In general.--With respect to
positive MIPS adjustment factors under
subparagraph (A)(ii)(I) for eligible
professionals whose composite
performance score is above the
performance threshold under
subparagraph (D)(i) for such year,
subject to subclause (II), the
Secretary shall increase or decrease
such adjustment factors by a scaling
factor in order to ensure that the
budget neutrality requirement of clause
(ii) is met.
``(II) Scaling factor limit.--In no
case may be the scaling factor applied
under this clause exceed 3.0.
``(ii) Budget neutrality requirement.--
``(I) In general.--Subject to
clause (iii), the Secretary shall
ensure that the estimated amount
described in subclause (II) for a year
is equal to the estimated amount
described in subclause (III) for such
year.
``(II) Aggregate increases.--The
amount described in this subclause is
the estimated increase in the aggregate
allowed charges resulting from the
application of positive MIPS adjustment
factors under subparagraph (A) (after
application of the scaling factor
described in clause (i)) to MIPS
eligible professionals whose composite
performance score for a year is above
the performance threshold under
subparagraph (D)(i) for such year.
``(III) Aggregate decreases.--The
amount described in this subclause is
the estimated decrease in the aggregate
allowed charges resulting from the
application of negative MIPS adjustment
factors under subparagraph (A) to MIPS
eligible professionals whose composite
performance score for a year is below
the performance threshold under
subparagraph (D)(i) for such year.
``(iii) Exceptions.--
``(I) In the case that all MIPS
eligible professionals receive
composite performance scores for a year
that are below the performance
threshold under subparagraph (D)(i) for
such year, the negative MIPS adjustment
factors under subparagraph (A) shall
apply with respect to such MIPS
eligible professionals and the budget
neutrality requirement of clause (ii)
shall not apply for such year.
``(II) In the case that, with
respect to a year, the application of
clause (i) results in a scaling factor
equal to the maximum scaling factor
specified in clause (i)(II), such
scaling factor shall apply and the
budget neutrality requirement of clause
(ii) shall not apply for such year.
``(iv) Additional incentive payment
adjustments.--In specifying the MIPS additional
adjustment factors under subparagraph (C)(i)
for each applicable MIPS eligible professional
for a year, the Secretary shall ensure that the
estimated increase in payments under this part
resulting from the application of such
additional adjustment factors for MIPS eligible
professionals in a year shall be equal (as
estimated by the Secretary) to the additional
funding pool amount for such year under
subparagraph (C)(ii).
``(7) Announcement of result of adjustments.--Under the
MIPS, the Secretary shall, not later than 30 days prior to
January 1 of the year involved, make available to MIPS eligible
professionals the MIPS adjustment factor (and, as applicable,
the additional MIPS adjustment factor) under paragraph (6)
applicable to the eligible professional for items and services
furnished by the professional for such year. The Secretary may
include such information in the confidential feedback under
paragraph (12).
``(8) No effect in subsequent years.--The MIPS adjustment
factors and additional MIPS adjustment factors under paragraph
(6) shall apply only with respect to the year involved, and the
Secretary shall not take into account such adjustment factors
in making payments to a MIPS eligible professional under this
part in a subsequent year.
``(9) Public reporting.--
``(A) In general.--The Secretary shall, in an
easily understandable format, make available on the
Physician Compare Internet website of the Centers for
Medicare & Medicaid Services the following:
``(i) Information regarding the performance
of MIPS eligible professionals under the MIPS,
which--
``(I) shall include the composite
score for each such MIPS eligible
professional and the performance of
each such MIPS eligible professional
with respect to each performance
category; and
``(II) may include the performance
of each such MIPS 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 MIPS, including
the range of composite scores for all MIPS eligible
professionals and the range of the performance of all
MIPS eligible professionals with respect to each
performance category.
``(10) Consultation.--The Secretary shall consult with
stakeholders in carrying out the MIPS, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (6) and regarding the use of qualified clinical data
registries. Such consultation shall include the use of a
request for information or other mechanisms determined
appropriate.
``(11) 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
MIPS eligible professionals in practices of 15 or fewer
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
such Act), and medically underserved areas, and
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.--
``(i) In general.--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 $40,000,000 for each of
fiscal years 2015 through 2019. Amounts
transferred under this subparagraph for a
fiscal year shall be available until expended.
``(ii) Technical assistance.--Of the
amounts transferred pursuant to clause (i) for
each of fiscal years 2015 through 2019, not
less than $10,000,000 shall be made available
for each such year for technical assistance to
small practices in health professional shortage
areas (as so designated) and medically
underserved areas.
``(12) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2016,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to MIPS eligible professionals
on the performance of such
professionals 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. With
respect to the performance category described
in paragraph (2)(A)(i), 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 based on performance on
quality measures reported through the use of
such registries. With respect to any other
performance category described in paragraph
(2)(A), the Secretary shall encourage provision
of feedback through qualified clinical data
registries as described in subsection
(m)(3)(E).
``(iii) Use of data.--For purposes of
clause (i), the Secretary may use data, with
respect to a MIPS eligible 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, 2017,
the Secretary shall make available to each MIPS
eligible professional information, with respect
to individuals who are patients of such MIPS
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 may be made available under
the previous sentence to such MIPS eligible
professionals by mechanisms determined
appropriate by the Secretary, which may include
use of a web-based portal. Such information may
be made available in accordance with the same
or similar terms as data are made available to
accountable care organizations participating in
the shared savings program under section 1899,
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 MIPS 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), such as 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 data, such as
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).
``(13) Review.--
``(A) Targeted review.--The Secretary shall
establish a process under which a MIPS eligible
professional may seek an informal review of the
calculation of the MIPS 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 (6) with respect to a year (other
than with respect to the calculation of such eligible
professional's MIPS adjustment factor for such year or
additional MIPS adjustment factor for such year) after
the factors determined in subparagraph (A) and
subparagraph (C) of such paragraph have been determined
for such year.
``(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 MIPS adjustment factor under
paragraph (6)(A) and the amount of the
additional MIPS adjustment factor under
paragraph (6)(C)(i) and the determination of
such amounts.
``(ii) The establishment of the performance
standards under paragraph (3) and the
performance period under paragraph (4).
``(iii) The identification of measures and
activities specified under paragraph (2)(B) and
information made public or posted on the
Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under
paragraph (9).
``(iv) The methodology developed under
paragraph (5) that is used to 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 mips.--Not
later than October 1, 2019, and October 1, 2022, the
Comptroller General of the United States shall submit
to Congress a report evaluating the eligible
professional Merit-based Incentive Payment System 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
composite performance scores and MIPS
adjustment factors (and additional MIPS
adjustment factors) for MIPS eligible
professionals (as defined in subsection
(q)(1)(c) of such section) under such program,
and patterns relating to such scores and
adjustment factors, including based on type of
provider, practice size, geographic location,
and patient mix;
(ii) provide recommendations for improving
such program;
(iii) evaluate the impact of technical
assistance funding under section 1848(q)(11) of
the Social Security Act, as added by paragraph
(1), on the ability of professionals to improve
within such program or successfully transition
to an alternative payment model (as defined in
section 1833(z)(3) of the Social Security Act,
as added by subsection (e)), with priority for
such evaluation given to practices located in
rural areas, health professional shortage areas
(as designated in section 332(a)(1)(a) of the
Public Health Service Act), and medically
underserved areas; and
(iv) provide recommendations for optimizing
the use of such technical assistance funds.
(B) Study to examine alignment of quality measures
used in public and private programs.--
(i) In general.--Not later than 18 months
after the date of the enactment of this Act,
the Comptroller General of the United States
shall submit to Congress a report that--
(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,
selected State Medicaid programs under
title XIX of such Act, and private
payer arrangements; and
(II) makes recommendations on how
to reduce the administrative burden
involved in applying such quality
measures.
(ii) Requirements.--The report under clause
(i) shall--
(I) consider those measures
applicable to individuals entitled to,
or enrolled for, benefits under such
part A, or enrolled under such part B
and individuals under the age of 65;
and
(II) focus on those measures that
comprise the most significant component
of the quality performance category of
the eligible professional MIPS
incentive program under subsection (q)
of section 1848 of the Social Security
Act (42 U.S.C. 1395w-4), as added by
paragraph (1).
(C) Study on role of independent risk managers.--
Not later than January 1, 2016, the Comptroller General
of the United States shall submit to Congress a report
examining whether entities that pool financial risk for
physician practices, such as independent risk managers,
can play a role in supporting physician practices,
particularly small physician practices, in assuming
financial risk for the treatment of patients. Such
report shall examine barriers that small physician
practices currently face in assuming financial risk for
treating patients, the types of risk management
entities that could assist physician practices in
participating in two-sided risk payment models, and how
such entities could assist with risk management and
with quality improvement activities. Such report shall
also include an analysis of any existing legal barriers
to such arrangements.
(D) Study to examine rural and health professional
shortage area alternative payment models.--Not later
than October 1, 2020, and October 1, 2022, the
Comptroller General of the United States shall submit
to Congress a report that examines the transition of
professionals in rural areas, health professional
shortage areas (as designated in section 332(a)(1)(A)
of the Public Health Service Act), or medically
underserved areas to an alternative payment model (as
defined in section 1833(z)(3) of the Social Security
Act, as added by subsection (e)). Such report shall
make recommendations for removing administrative
barriers to practices, including small practices
consisting of 15 or fewer professionals, in rural
areas, health professional shortage areas, and
medically underserved areas to participation in such
models.
(3) Funding for implementation.--For purposes of
implementing the provisions of and the amendments made by this
section, the Secretary of Health and Human Services shall
provide for the transfer of $80,000,000 from the Supplementary
Medical Insurance Trust Fund established under 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 2018. 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 2015 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
2014''; and
(B) by inserting ``and, for reporting periods
occurring in 2015 and subsequent years, the Secretary
may establish'' following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under mips.--Section 1848(n) of the Social Security Act (42
U.S.C. 1395w-4(n)) is amended by adding at the end the
following new paragraph:
``(11) Reports ending with 2016.--Reports under the Program
shall not be provided after December 31, 2016. See subsection
(q)(12) for reports under the eligible professionals Merit-
based Incentive Payment System.''.
(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)(B)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Increasing transparency of physician focused payment
models.--Section 1868 of the Social Security Act (42 U.S.C.
1395ee) is amended by adding at the end the following new
subsection:
``(c) Physician Focused Payment Models.--
``(1) Technical advisory committee.--
``(A) Establishment.--There is established an ad
hoc committee to be known as the `Payment Model
Technical Advisory Committee' (referred to in this
subsection as the `Committee').
``(B) Membership.--
``(i) Number and appointment.--The
Committee shall be composed of 11 members
appointed by the Comptroller General of the
United States.
``(ii) Qualifications.--The membership of
the Committee shall include individuals with
national recognition for their expertise in
payment models and related delivery of care. No
more than 5 members of the Committee shall be
providers of services or suppliers, or
representatives of providers of services or
suppliers.
``(iii) Prohibition on federal
employment.--A member of the Committee shall
not be an employee of the Federal Government.
``(iv) Ethics disclosure.--The Comptroller
General shall establish a system for public
disclosure by members of the Committee of
financial and other potential conflicts of
interest relating to such members. Members of
the Committee shall be treated as employees of
Congress for purposes of applying title I of
the Ethics in Government Act of 1978 (Public
Law 95-521).
``(v) Date of initial appointments.--The
initial appointments of members of the
Committee shall be made by not later than 180
days after the date of enactment of this
subsection.
``(C) Term; vacancies.--
``(i) Term.--The terms of members of the
Committee shall be for 3 years except that the
Comptroller General shall designate staggered
terms for the members first appointed.
``(ii) Vacancies.--Any member appointed to
fill a vacancy occurring before the expiration
of the term for which the member's predecessor
was appointed shall be appointed only for the
remainder of that term. A member may serve
after the expiration of that member's term
until a successor has taken office. A vacancy
in the Committee shall be filled in the manner
in which the original appointment was made.
``(D) Duties.--The Committee shall meet, as needed,
to provide comments and recommendations to the
Secretary, as described in paragraph (2)(C), on
physician-focused payment models.
``(E) Compensation of members.--
``(i) In general.--Except as provided in
clause (ii), a member of the Committee shall
serve without compensation.
``(ii) Travel expenses.--A member of the
Committee shall be allowed travel expenses,
including per diem in lieu of subsistence, at
rates authorized for an employee of an agency
under subchapter I of chapter 57 of title 5,
United States Code, while away from the home or
regular place of business of the member in the
performance of the duties of the Committee.
``(F) Operational and technical support.--
``(i) In general.--The Assistant Secretary
for Planning and Evaluation shall provide
technical and operational support for the
Committee, which may be by use of a contractor.
The Office of the Actuary of the Centers for
Medicare & Medicaid Services shall provide to
the Committee actuarial assistance as needed.
``(ii) Funding.--The Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, such amounts as are
necessary to carry out clause (i) (not to
exceed $5,000,000) for fiscal year 2014 and
each subsequent fiscal year. Any amounts
transferred under the preceding sentence for a
fiscal year shall remain available until
expended.
``(G) Application.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply
to the Committee.
``(2) Criteria and process for submission and review of
physician-focused payment models.--
``(A) Criteria for assessing physician-focused
payment models.--
``(i) Rulemaking.--Not later than November
1, 2015, the Secretary shall, through notice
and comment rulemaking, following a request for
information, establish criteria for physician-
focused payment models, including models for
specialist physicians, that could be used by
the Committee for making comments and
recommendations pursuant to paragraph (1)(D).
``(ii) MedPAC submission of comments.--
During the comment period for the proposed rule
described in clause (i), the Medicare Payment
Advisory Commission may submit comments to the
Secretary on the proposed criteria under such
clause.
``(iii) Updating.--The Secretary may update
the criteria established under this
subparagraph through rulemaking.
``(B) Stakeholder submission of physician focused
payment models.--On an ongoing basis, individuals and
stakeholder entities may submit to the Committee
proposals for physician-focused payment models that
such individuals and entities believe meet the criteria
described in subparagraph (A).
``(C) TAC review of models submitted.--The
Committee shall, on a periodic basis, review models
submitted under subparagraph (B), prepare comments and
recommendations regarding whether such models meet the
criteria described in subparagraph (A), and submit such
comments and recommendations to the Secretary.
``(D) Secretary review and response.--The Secretary
shall review the comments and recommendations submitted
by the Committee under subparagraph (C) and post a
detailed response to such comments and recommendations
on the Internet website of the Centers for Medicare &
Medicaid Services.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to impact the development or testing of
models under this title or titles XI, XIX, or XXI.''.
(2) Incentive payments for participation in eligible
alternative payment models.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the 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 2018 and ending with 2023 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) 2018 and 2019.--With respect to 2018 and
2019, 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) 2020 and 2021.--With respect to 2020 and
2021, 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, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title),
meet the requirement described in
clause (iii)(I) with respect to
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 (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(C) Beginning in 2022.--With respect to 2022 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, and other
than payments made under title
XIX in a State in which no
medical home or alternative
payment model is available
under the State program under
that title),
meet the requirement described in
clause (iii)(I) with respect to
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 (AA) bears more
than nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures; or (BB) is a
medical home (with respect to
beneficiaries under title XIX)
that meets criteria comparable
to medical homes expanded under
section 1115A(c).
``(3) 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) The shared savings program 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).
``(4) 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.''.
(3) 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.''.
(4) 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 15 or
fewer professionals.
``(xxiii) Focusing on risk-based models for
small physician practices which may involve
two-sided risk and prospective patient
assignment, and which examine risk-adjusted
decreases in mortality rates, hospital
readmissions rates, and other relevant and
appropriate clinical measures.
``(xxiv) Focusing primarily on title XIX,
working in conjunction with the Center for
Medicaid and CHIP Services.''; 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''.
(5) Construction regarding telehealth services.--Nothing in
the provisions of, or amendments made by, this Act shall be
construed as precluding an alternative payment model or a
qualifying APM participant (as those terms are defined in
section 1833(z) of the Social Security Act, as added by
paragraph (1)) from furnishing a telehealth service for which
payment is not made under section 1834(m) of the Social
Security Act (42 U.S.C. 1395m(m)).
(6) Integrating medicare advantage alternative payment
models.--Not later than July 1, 2015, the Secretary of Health
and Human Services shall submit to Congress a study that
examines the feasibility of integrating alternative payment
models in the Medicare Advantage payment system. The study
shall include the feasibility of including a value-based
modifier and whether such modifier should be budget neutral.
(7) Study and report on fraud related to alternative
payment models under the medicare program.--
(A) Study.--The Secretary of Health and Human
Services, in consultation with the Inspector General of
the Department of Health and Human Services, shall
conduct a study that--
(i) examines the applicability of the
Federal fraud prevention laws to items and
services furnished under title XVIII of the
Social Security Act for which payment is made
under an alternative payment model (as defined
in section 1833(z)(3)(C) of such Act (42 U.S.C.
1395l(z)(3)(C)));
(ii) identifies aspects of such alternative
payment models that are vulnerable to
fraudulent activity; and
(iii) examines the implications of waivers
to such laws granted in support of such
alternative payment models, including under any
potential expansion of such models.
(B) Report.--Not later than 2 years after the date
of the enactment of this Act, the Secretary shall
submit to Congress a report containing the results of
the study conducted under subparagraph (A). 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.
(f) 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 Merit-based Incentive
Payment System 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 Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act 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, as the Secretary determines appropriate,
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 provisions of title XVIII of the
Social Security Act that are similar to the eligible
professional Merit-based Incentive Payment System under
section 1848(q) 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) and other
information as appropriate, the Secretary
shall, as the Secretary determines appropriate,
account for identified factors with an effect
on quality and resource use outcome measures
when determining payment adjustment mechanisms
under provisions of title XVIII of the Social
Security Act that are similar to the eligible
professional Merit-based Incentive Payment
System under section 1848(q) 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 Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act to the
Secretary to carry out this paragraph and the
application of this paragraph to the Merit-based
Incentive Payment System under section 1848(q) of such
Act $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 Merit-based Incentive Payment System under section
1848(q) of the Social Security Act and, as the Secretary
determines appropriate, other similar provisions of title XVIII
of such Act.
(g) 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 care episode groups and patient condition
groups, the Secretary shall undertake the steps
described in the succeeding provisions of this
paragraph.
``(B) Public availability of existing efforts to
design an episode grouper.--Not later than 120 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) care episode groups; and
``(ii) 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 care episode groups
and patient condition groups, which
account for a target of an estimated
\2/3\ 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 180
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 180 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 2017), 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 270 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 180 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 2017), 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, 2017, 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
charges 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 charges (such as
subtotals for categories of items and services)
and measures of utilization of items and
services (such as frequency of specific items
and services and the ratio of specific items
and services among 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) Implementation.--To the extent that the Secretary
contracts with an entity to carry out any part of the
provisions of this subsection, the Secretary may not contract
with an entity or an entity with a subcontract if the entity or
subcontracting entity currently makes recommendations to the
Secretary on relative values for services under the fee
schedule for physicians' services under this section.
``(7) Limitation.--There shall be no 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).
``(8) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(9) 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 a certified registered nurse anesthetist
(as defined in section 1861(bb)(2)); and
``(ii) beginning January 1, 2018, such
other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(10) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this subsection.''.
SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (g) of section 2, is further amended by
inserting at the end the following new subsection:
``(s) Priorities and Funding for Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--Not later
than January 1, 2015, 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 (as defined in paragraph
(5)). Under such plan the Secretary shall--
``(i) address how measures used by private
payers and integrated delivery systems could be
incorporated under title XVIII;
``(ii) describe how coordination, to the
extent possible, will occur across
organizations developing such measures; and
``(iii) take into account how clinical best
practices and clinical practice guidelines
should be used in the development of quality
measures.
``(B) Quality domains.--For purposes of this
subsection, the term `quality domains' means at least
the following domains:
``(i) Clinical care.
``(ii) Safety.
``(iii) Care coordination.
``(iv) Patient and caregiver experience.
``(v) Population health and prevention.
``(C) Consideration.--In developing the draft plan
under this paragraph, the Secretary shall consider--
``(i) gap analyses conducted by the entity
with a contract under section 1890(a) or other
contractors or entities;
``(ii) whether measures are applicable
across health care settings;
``(iii) clinical practice improvement
activities submitted under subsection
(q)(2)(C)(iv) for identifying possible areas
for future measure development and identifying
existing gaps with respect to such measures;
and
``(iv) the quality domains applied under
this subsection.
``(D) Priorities.--In developing the draft plan
under this paragraph, the Secretary shall give priority
to the following types of measures:
``(i) Outcome measures, including 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.
``(E) Stakeholder input.--The Secretary shall
accept through March 1, 2015, comments on the draft
plan posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(F) Final measure development plan.--Not later
than May 1, 2015, taking into account the comments
received under this subparagraph, the Secretary shall
finalize the plan and post on the Internet website of
the Centers for Medicare & Medicaid Services an
operational plan for the development of quality
measures for use under the applicable provisions. Such
plan shall be updated as appropriate.
``(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 in accordance with the plan under paragraph
(1) quality measures for application under the
applicable provisions. Such entities shall include
organizations with quality measure development
expertise.
``(B) Prioritization.--
``(i) In general.--In entering into
contracts or other arrangements under
subparagraph (A), the Secretary shall give
priority to the development of the types of
measures described in paragraph (1)(D).
``(ii) Consideration.--In selecting
measures for development under this subsection,
the Secretary shall consider--
``(I) whether such measures would
be electronically specified; and
``(II) clinical practice guidelines
to the extent that such guidelines
exist.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than May 1, 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 subparagraph (A) shall include the following:
``(i) A description of the Secretary's
efforts to implement this paragraph.
``(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) 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.
``(v) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to paragraph (1),
the Secretary shall seek stakeholder input with respect to--
``(A) the identification of gaps where no quality
measures exist, particularly with respect to the types
of measures described in paragraph (1)(D);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) Definition of applicable provisions.--In this
subsection, the term `applicable provisions' means the
following provisions:
``(A) Subsection (q)(2)(B)(i).
``(B) Section 1833(z)(2)(C).
``(6) Funding.--For purposes of carrying out this
subsection, the Secretary shall provide for the transfer, from
the Federal Supplementary Medical Insurance Trust Fund under
section 1841, of $15,000,000 to the Centers for Medicare &
Medicaid Services Program Management Account for each of fiscal
years 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.
(a) In General.--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.''.
(b) Education and Outreach.--
(1) Campaign.--
(A) In general.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct an education and outreach
campaign to inform professionals who furnish items and
services under part B of title XVIII of the Social
Security Act and individuals enrolled under such part
of the benefits of chronic care management services
described in section 1848(b)(8) of the Social Security
Act, as added by subsection (a), and encourage such
individuals with chronic care needs to receive such
services.
(B) Requirements.--Such campaign shall--
(i) be directed by the Office of Rural
Health Policy of the Department of Health and
Human Services and the Office of Minority
Health of the Centers for Medicare & Medicaid
Services; and
(ii) focus on encouraging participation by
underserved rural populations and racial and
ethnic minority populations.
(2) Report.--
(A) In general.--Not later than December 31, 2017,
the Secretary shall submit to Congress a report on the
use of chronic care management services described in
such section 1848(b)(8) by individuals living in rural
areas and by racial and ethnic minority populations.
Such report shall--
(i) identify barriers to receiving chronic
care management services; and
(ii) make recommendations for increasing
the appropriate use of chronic care 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''.
(i) Disclosure of Data Used To Establish Multiple Procedure Payment
Reduction Policy.--The Secretary of Health and Human Services shall
make publicly available the information 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. 6. PROMOTING EVIDENCE-BASED CARE.
(a) 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, only developed or endorsed by national
professional medical specialty societies or other
provider-led entities, 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 provider-led 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 only from
among appropriate use criteria developed or endorsed by
national professional medical specialty societies or
other provider-led 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) are scientifically valid and
evidence based; and
``(iii) are based on studies that are
published and reviewable by stakeholders.
``(C) Revisions.--The Secretary shall review, on an
annual basis, the specified applicable appropriate use
criteria to determine if there is a need to update or
revise (as appropriate) such specification of
applicable appropriate use criteria and make such
updates or revisions through rulemaking.
``(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 permit 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 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, health
care technology experts, 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 identify on an annual basis 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 an annual basis, no more
than five percent of the total number of 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) Process.--The Secretary shall establish a
process for determining when an outlier ordering
professional is no longer an outlier ordering
professional.
``(E) 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) Appropriate use criteria in prior
authorization.--In applying prior authorization under
subparagraph (A), the Secretary shall utilize only the
applicable appropriate use criteria specified under
this subsection.
``(C) 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.
``(7) Construction.--Nothing in this subsection shall be
construed as granting the Secretary the authority to develop or
initiate the development of clinical practice guidelines or
appropriate use criteria.''.
(b) 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).''.
(c) Report on Experience of Imaging Appropriate Use Criteria
Program.--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 includes a description of the extent to which
appropriate use criteria could be used for other services under part B
of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.),
such as radiation therapy and clinical diagnostic laboratory services.
SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION ON
PHYSICIANS' SERVICES.
(a) In General.--The Secretary shall make publicly available on
Physician Compare the information described in subsection (b) with
respect to eligible professionals.
(b) Information Described.--The following information, with respect
to an eligible professional, is described in this subsection:
(1) Information on the number of services furnished by the
eligible professional under part B of title XVIII of the Social
Security Act (42 U.S.C. 1395j et seq.), which may include
information on the most frequent services furnished or
groupings of services.
(2) Information on submitted charges and payments for
services under such part.
(3) 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
section shall be searchable by at least the following:
(1) The specialty or type of the eligible professional.
(2) Characteristics of the services furnished, such as
volume or groupings of services.
(3) The location of the eligible professional.
(d) Disclosure.--The information made available under this section
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.--
(1) Initial implementation.--Physician Compare shall
include the information described in subsection (b)--
(A) with respect to physicians, by not later than
July 1, 2015; and
(B) with respect to other eligible professionals,
by not later than July 1, 2016.
(2) Annual updating.--The information made available under
this section 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 section prior to
such information being made public.
(g) Definitions.--In this section:
(1) Eligible professional; physician; secretary.--The terms
``eligible professional'', ``physician'', and ``Secretary''
have the meaning given such terms in section 10331(i) of Public
Law 111-148.
(2) Physician compare.--The term ``Physician Compare''
means the Physician Compare Internet website of the Centers for
Medicare & Medicaid Services (or a successor website).
SEC. 8. EXPANDING AVAILABILITY OF MEDICARE DATA.
(a) Expanding Uses of Medicare Data by Qualified Entities.--
(1) Additional analyses.--
(A) In general.--Subject to subparagraph (B), to
the extent consistent with applicable information,
privacy, security, and disclosure laws (including
paragraph (3)), notwithstanding paragraph (4)(B) of
section 1874(e) of the Social Security Act (42 U.S.C.
1395kk(e)) and the second sentence of paragraph (4)(D)
of such section, beginning July 1, 2015, a qualified
entity may use the combined data described in paragraph
(4)(B)(iii) of such section received by such entity
under such section, and information derived from the
evaluation described in such paragraph (4)(D), to
conduct additional non-public analyses (as determined
appropriate by the Secretary) and provide or sell such
analyses to authorized users 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).
(B) Limitations with respect to analyses.--
(i) Employers.--Any analyses provided or
sold under subparagraph (A) to an employer
described in paragraph (9)(A)(iii) may only be
used by such employer for purposes of providing
health insurance to employees and retirees of
the employer.
(ii) Health insurance issuers.--A qualified
entity may not provide or sell an analysis to a
health insurance issuer described in paragraph
(9)(A)(iv) unless the issuer is providing the
qualified entity with data under section
1874(e)(4)(B)(iii) of the Social Security Act
(42 U.S.C. 1395kk(e)(4)(B)(iii)).
(2) Access to certain data.--
(A) Access.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws (including paragraph (3)),
notwithstanding paragraph (4)(B) of section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)) and the
second sentence of paragraph (4)(D) of such section,
beginning July 1, 2015, a qualified entity may--
(i) provide or sell the combined data
described in paragraph (4)(B)(iii) of such
section to authorized users described in
clauses (i), (ii), and (v) of paragraph (9)(A)
for non-public use, including for the purposes
described in subparagraph (B); or
(ii) subject to subparagraph (C), provide
Medicare claims data to authorized users
described in clauses (i), (ii), and (v), of
paragraph (9)(A) for non-public use, including
for the purposes described in subparagraph (B).
(B) Purposes described.--The purposes described in
this subparagraph are assisting providers of services
and suppliers in developing and participating in
quality and patient care improvement activities,
including developing new models of care.
(C) Medicare claims data must be provided at no
cost.--A qualified entity may not charge a fee for
providing the data under subparagraph (A)(ii).
(3) Protection of information.--
(A) In general.--Except as provided in subparagraph
(B), an analysis or data that is provided or sold under
paragraph (1) or (2) shall not contain information that
individually identifies a patient.
(B) Information on patients of the provider of
services or supplier.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, an analysis or data that is provided
or sold to a provider of services or supplier under
paragraph (1) or (2) may contain information that
individually identifies a patient of such provider or
supplier, including with respect to items and services
furnished to the patient by other providers of services
or suppliers.
(C) Prohibition on using analyses or data for
marketing purposes.--An authorized user shall not use
an analysis or data provided or sold under paragraph
(1) or (2) for marketing purposes.
(4) Data use agreement.--A qualified entity and an
authorized user described in clauses (i), (ii), and (v) of
paragraph (9)(A) shall enter into an agreement regarding the
use of any data that the qualified entity is providing or
selling to the authorized user under paragraph (2). Such
agreement shall describe the requirements for privacy and
security of the data and, as determined appropriate by the
Secretary, any prohibitions on using such data to link to other
individually identifiable sources of information. If the
authorized user is not a covered entity under the rules
promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, the agreement shall identify the
relevant regulations, as determined by the Secretary, that the
user shall comply with as if it were acting in the capacity of
such a covered entity.
(5) No redisclosure of analyses or data.--
(A) In general.--Except as provided in subparagraph
(B), an authorized user that is provided or sold an
analysis or data under paragraph (1) or (2) shall not
redisclose or make public such analysis or data or any
analysis using such data.
(B) Permitted redisclosure.--A provider of services
or supplier that is provided or sold an analysis or
data under paragraph (1) or (2) may, as determined by
the Secretary, redisclose such analysis or data for the
purposes of performance improvement and care
coordination activities but shall not make public such
analysis or data or any analysis using such data.
(6) Opportunity for providers of services and suppliers to
review.--Prior to a qualified entity providing or selling an
analysis to an authorized user under paragraph (1), 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 such
provider or supplier with the opportunity to appeal and correct
errors in the manner described in section 1874(e)(4)(C)(ii) of
the Social Security Act (42 U.S.C. 1395kk(e)(4)(C)(ii)).
(7) Assessment for a breach.--
(A) In general.--In the case of a breach of a data
use agreement under this section or section 1874(e) of
the Social Security Act (42 U.S.C. 1395kk(e)), the
Secretary shall impose an assessment on the qualified
entity both in the case of--
(i) an agreement between the Secretary and
a qualified entity; and
(ii) an agreement between a qualified
entity and an authorized user.
(B) Assessment.--The assessment under subparagraph
(A) shall be an amount up to $100 for each individual
entitled to, or enrolled for, benefits under part A of
title XVIII of the Social Security Act or enrolled for
benefits under part B of such title--
(i) in the case of an agreement described
in subparagraph (A)(i), for whom the Secretary
provided data on to the qualified entity under
paragraph (2); and
(ii) in the case of an agreement described
in subparagraph (A)(ii), for whom the qualified
entity provided data on to the authorized user
under paragraph (2).
(C) Deposit of amounts collected.--Any amounts
collected pursuant to this paragraph shall be deposited
in Federal Supplementary Medical Insurance Trust Fund
under section 1841 of the Social Security Act (42
U.S.C. 1395t).
(8) Annual reports.--Any qualified entity that provides or
sells an analysis or data under paragraph (1) or (2) shall
annually submit to the Secretary a report that includes--
(A) a summary of the analyses provided or sold,
including the number of such analyses, the number of
purchasers of such analyses, and the total amount of
fees received for such analyses;
(B) a description of the topics and purposes of
such analyses;
(C) information on the entities who received the
data under paragraph (2), the uses of the data, and the
total amount of fees received for providing, selling,
or sharing the data; and
(D) other information determined appropriate by the
Secretary.
(9) Definitions.--In this subsection and subsection (b):
(A) Authorized user.--The term ``authorized user''
means the following:
(i) A provider of services.
(ii) A supplier.
(iii) 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).
(v) A medical society or hospital
association.
(vi) Any entity not described in clauses
(i) through (v) that is approved by the
Secretary (other than an employer or health
insurance issuer not described in clauses (iii)
and (iv), respectively, as determined by the
Secretary).
(B) Provider of services.--The term ``provider of
services'' has the meaning given such term in section
1861(u) of the Social Security Act (42 U.S.C.
1395x(u)).
(C) Qualified entity.--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)).
(D) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the
meaning given such term in section 1861(d) of the
Social Security Act (42 U.S.C. 1395x(d)).
(b) Access to Medicare Data by Qualified Clinical Data Registries
To Facilitate Quality Improvement.--
(1) Access.--
(A) In general.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2015, the Secretary
shall, at the request of a qualified clinical data
registry under section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)), provide the
data described in subparagraph (B) (in a form and
manner determined to be appropriate) to such qualified
clinical data registry for purposes of linking such
data with clinical outcomes data and performing risk-
adjusted, scientifically valid analyses and research to
support quality improvement or patient safety, provided
that any public reporting of such analyses or research
that identifies a provider of services or supplier
shall only be conducted with the opportunity of such
provider or supplier to appeal and correct errors in
the manner described in subsection (a)(6).
(B) Data described.--The data described in this
subparagraph is--
(i) claims data under the Medicare program
under title XVIII of the Social Security Act;
and
(ii) if the Secretary determines
appropriate, claims data under the Medicaid
program under title XIX of such Act and the
State Children's Health Insurance Program under
title XXI of such Act.
(2) Fee.--Data described in paragraph (1)(B) shall be
provided to a qualified clinical data registry under paragraph
(1) at a fee equal to the cost of providing such data. Any fee
collected pursuant to the preceding sentence shall be deposited
in the Centers for Medicare & Medicaid Services Program
Management Account.
(c) Expansion of Data Available to Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
(1) in the subsection heading, by striking ``Medicare'';
and
(2) in paragraph (3)--
(A) by inserting after the first sentence the
following new sentence: ``Beginning July 1, 2015, 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.
(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, 2015,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2015, 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) 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;
(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.
(c) 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 and
Medicaid EHR incentive programs, Congress declares it a
national objective to achieve widespread exchange of
health information through interoperable certified EHR
technology nationwide by December 31, 2017.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term
``widespread interoperability'' means
interoperability between certified EHR
technology systems employed by meaningful EHR
users under the Medicare and Medicaid EHR
incentive programs and other clinicians and
health care providers on a nationwide basis.
(ii) Interoperability.--The term
``interoperability'' means the ability of two
or more health information systems or
components to exchange clinical and other
information and to use the information that has
been exchanged using common standards as to
provide access to longitudinal information for
health care providers in order to facilitate
coordinated care and improved patient outcomes.
(C) Establishment of metrics.--Not later than July
1, 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 not being
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)
that the professional has not knowingly and willfully
taken any action to limit or restrict the 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) that the
hospital has not knowingly and willfully taken any
action to limit or restrict the compatibility or
interoperability of the certified EHR technology''.
(C) Effective date.--The amendments made by this
subsection shall apply to meaningful EHR users as of
the date that is one year 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 mechanisms 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 of, and
resources needed to develop and maintain, 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 user'' has the
meaning given such term under the Medicare EHR
incentive programs.
(C) The term ``Medicare and Medicaid EHR incentive
programs'' means--
(i) in the case of the Medicare program
under title XVIII of the Social Security Act,
the incentive programs under section
1814(l)(3), section 1848(o), subsections (l)
and (m) of section 1853, and section 1886(n) of
the Social Security Act (42 U.S.C. 1395f(l)(3),
1395w-4(o), 1395w-23, 1395ww(n)); and
(ii) in the case of the Medicaid program
under title XIX of such Act, the incentive
program under subsections (a)(3)(F) and (t) of
section 1903 of such Act (42 U.S.C. 1396b).
(D) The term ``Secretary'' means the Secretary of
Health and Human Services.
(d) GAO Studies and Reports on the Use of Telehealth Under Federal
Programs and on Remote Patient Monitoring Services.--
(1) Study on telehealth services.--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) Study on remote patient monitoring services.--
(A) In general.--The Comptroller General of the
United States shall conduct a study--
(i) of the dissemination of remote patient
monitoring technology in the private health
insurance market;
(ii) of the financial incentives in the
private health insurance market relating to
adoption of such technology;
(iii) of the barriers to adoption of such
services under the Medicare program under title
XVIII of the Social Security Act;
(iv) that evaluates the patients,
conditions, and clinical circumstances that
could most benefit from remote patient
monitoring services; and
(v) that evaluates the challenges related
to establishing appropriate valuation for
remote patient monitoring services under the
Medicare physician fee schedule under section
1848 of the Social Security Act (42 U.S.C.
1395w-4) in order to accurately reflect the
resources involved in furnishing such services.
(B) Definitions.--For purposes of this paragraph:
(i) Remote patient monitoring services.--
The term ``remote patient monitoring services''
means services furnished through remote patient
monitoring technology.
(ii) Remote patient monitoring
technology.--The term ``remote patient
monitoring technology'' means a coordinated
system that uses one or more home-based or
mobile monitoring devices that automatically
transmit vital sign data or information on
activities of daily living and may include
responses to assessment questions collected on
the devices wirelessly or through a
telecommunications connection to a server that
complies with the Federal regulations
(concerning the privacy of individually
identifiable health information) promulgated
under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996, as
part of an established plan of care for that
patient that includes the review and
interpretation of that data by a health care
professional.
(3) Reports.--Not later than 24 months after the date of
the enactment of this Act, the Comptroller General shall submit
to Congress--
(A) a report containing the results of the study
conducted under paragraph (1); and
(B) a report containing the results of the study
conducted under paragraph (2).
A report required under this paragraph shall be submitted
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate. The Comptroller General may submit one report
containing the results described in subparagraphs (A) and (B)
and the recommendations described in the previous sentence.
(e) Rule of Construction Regarding Healthcare Provider Standards of
Care.--
(1) Maintenance of state standards.--The development,
recognition, or implementation of any guideline or other
standard under any Federal health care provision shall not be
construed--
(A) 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; or
(B) to preempt any standard of care or duty of
care, owed by a health care provider to a patient, duly
established under State or common law.
(2) Definitions.--For purposes of this subsection:
(A) Federal health care provision.--The term
``Federal health care provision'' means any provision
of the Patient Protection and Affordable Care Act
(Public Law 111-148), title I or subtitle B of title II
of the Health Care and Education Reconciliation Act of
2010 (Public Law 111-152), or title XVIII or XIX of the
Social Security Act.
(B) Health care provider.--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) Medical malpractice or medical product
liability action or claim.--The term ``medical
malpractice or medical product 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) State.--The term ``State'' includes the
District of Columbia, Puerto Rico, and any other
commonwealth, possession, or territory of the United
States.
(3) Preservation of state law.--No provision of the Patient
Protection and Affordable Care Act (Public Law 111-148), title
I or subtitle B of title II of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), or title XVIII
or XIX of the Social Security Act shall be construed to preempt
any State or common law governing medical professional or
medical product liability actions or claims.
SEC. 10. SAVINGS FROM OVERSEAS CONTINGENCY AND RELATED ACTIVITIES.
(a) In General.--Section 251 of the Balanced Budget and Emergency
Deficit Control Act of 1985 (2 U.S.C. 901) is amended--
(1) in subsection (b)(2)(A)(ii), by inserting ``for fiscal
years 2012 through 2015,'' before ``the Congress''; and
(2) by adding at the end the following:
``(E) Overseas contingency operations/global war on
terrorism.--If, for fiscal years 2016 through 2021,
appropriations for discretionary accounts are enacted
that Congress designates for Overseas Contingency
Operations/Global War on Terrorism in statute on an
account by account basis and the President subsequently
so designates, the adjustment for the fiscal year shall
be the total of such appropriations for the fiscal year
in discretionary accounts designated as being for
Overseas Contingency Operations/Global War on
Terrorism, but not to exceed--
``(i) For fiscal year 2016, $29,946,000,000
in budget authority.
``(ii) For fiscal year 2017,
$29,946,000,000 in budget authority.
``(iii) For fiscal year 2018,
$29,946,000,000 in budget authority.
``(iv) For fiscal year 2019,
$29,946,000,000 in budget authority.
``(v) For fiscal year 2020, $29,946,000,000
in budget authority.
``(vi) For fiscal year 2021,
$29,946,000,000 in budget authority.''.
(b) Breach.--Section 251(a)(2) of such Act (2 U.S.C. 901(a)(2)) is
amended to read as follows:
``(2) Eliminating a breach.--
``(A) In general.--Each non-exempt account within a
category shall be reduced by a dollar amount calculated
by multiplying the enacted level of sequestrable
budgetary resources in that account by the uniform
percentage necessary to eliminate a breach within that
category.
``(B) Overseas contingencies.--Any amount of budget
authority for Overseas Contingency Operations/Global
War on Terrorism for fiscal years 2016 through 2021 in
excess of the levels set in subsection 251(b)(2)(E)
shall be counted in determining whether a breach has
occurred in the security category and the nonsecurity
category on a proportional basis to the total spending
for overseas contingency operations in the security
category and the nonsecurity category.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, the Judiciary, and the Budget, 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, the Judiciary, and the Budget, 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, the Judiciary, and the Budget, 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, the Judiciary, and the Budget, 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.
Referred to the Subcommittee on the Constitution and Civil Justice.
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