Medicare Physician Payment Innovation Act of 2013 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to revise requirements for payments for physician's services to eliminate the sustainable growth rate system from the formula for determination of the fee schedules for such services.
Sets at 0.0 the 2014 update to the single conversion factor in such formula.
Establishes updates for separate primary care and other service categories beginning January 1, 2015, as well as separate conversion factors and separate updates through 2018 for each service category.
Directs the Secretary, through the Center for Medicare and Medicaid Innovation, to: (1) expand testing of each innovative payment and service delivery model in at least three geographic regions; and (2) include analysis of average implementation costs, per physician, in evaluations of models in phase 1 testing.
Specifies as such a model, subject to testing, payment for outpatient therapy services and speech language pathology services on the basis of a treatment session, an episode of care, or other bundled payment methodology as a model to be tested during phase 1 testing.
Directs the Comptroller General to study the evaluations of each model tested.
Directs the Secretary to release to the public a comprehensive list of such health care delivery models identified as likely to: (1) reduce spending without reducing quality of care, or (2) improve the quality of patient care without increasing spending.
Requires the Secretary to inform physicians, nurse practitioners, group practices, and institutions employing Medicare part B (Supplementary Medical Insurance) providers on how best to transition to alternative health care delivery and payment models aimed at improving the coordination, quality, and efficiency of health care.
Freezes the physician fee schedule for 2019 by requiring 0.0 updates to the relevant conversion factors.
Directs the Secretary to: (1) contract and agree with regional extension centers to provide guidance and assistance on how physicians may transition to implementation of alternative health care delivery models identified as represernting best practices; and (2) make certain funding available to the Office of the National Coordinator for Health Care Technology to award grants and incentive payments under a competitive process to regional extension centers and other qualified entities for such activities.
Requires the Office to: (1) establish a process for the competitive selection of regional extension centers (and other qualified entities) in the third quarter of 2015, and (2) authorize the initial distribution of funds to such centers and entities.
Prescribes updates to conversion factors for 2020-2023, but freezes them again beginning in 2024.
Requires the Secretary to consider certain factors in determining the growth rates to be recognized beginning with 2020 for alternative payment and delivery models.
Directs the Secretary to report to Congress on the impact on spending and on access to services under Medicare resulting from changes to the Medicare delivery and payments systems, including those made by this Act.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 574 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 574
To amend part B of title XVIII of the Social Security Act to reform
Medicare payment for physicians' services by eliminating the
sustainable growth rate system and providing incentives for the
adoption of innovative payment and delivery models to improve quality
and efficiency.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 6, 2013
Ms. Schwartz (for herself, Mr. Heck of Nevada, Mr. Blumenauer, Mrs.
Christensen, Mr. Carney, Mr. Courtney, Mr. Polis, Mr. Fattah, and Ms.
Castor of Florida) introduced the following bill; which was referred to
the Committee on Energy and Commerce, and in addition to the Committee
on Ways and Means, 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 part B of title XVIII of the Social Security Act to reform
Medicare payment for physicians' services by eliminating the
sustainable growth rate system and providing incentives for the
adoption of innovative payment and delivery models to improve quality
and efficiency.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; PURPOSE.
(a) Short Title.--This Act may be cited as the ``Medicare Physician
Payment Innovation Act of 2013''.
(b) Purpose.--The purpose of this Act is to reform the system of
Medicare payment for physicians' services--
(1) by ending the application of the sustainable growth
rate (SGR) system;
(2) to stabilize payments for 2014;
(3) to promote the rapid development and implementation of
alternative improved payment and delivery models that
incentivize high quality, high-value care; and
(4) to provide continuing incentives for adoption of such
alternative payment and delivery models by physicians and other
providers.
SEC. 2. MEDICARE PHYSICIAN PAYMENT REFORM.
(a) Repeal of SGR Payment Methodology.--Section 1848 of the Social
Security Act (42 U.S.C. 1395w-4) is amended--
(1) in subsection (d)--
(A) in paragraph (1)(A), by inserting ``or a
subsequent paragraph'' after ``paragraph (4)''; and
(B) in paragraph (4)--
(i) in the heading, by striking ``years
beginning with 2001'' and inserting ``2001,
2002, and 2003''; and
(ii) in subparagraph (A), by striking ``a
year beginning with 2001'' and inserting
``2001, 2002, and 2003''; and
(2) in subsection (f)--
(A) in paragraph (1)(B), by inserting ``through
2013'' after ``of such succeeding year''; and
(B) in paragraph (2), by inserting ``and ending
with 2013'' after ``beginning with 2000''.
(b) Stabilizing 2014 Payment Rates at Current Level.--
(1) In general.--Subsection (d) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4), as amended by section
601 of the American Taxpayer Relief Act of 2012 (Public Law
112-240), is amended by adding at the end the following new
paragraph:
``(15) Update for 2014.--In lieu of the update to the
single conversion factor established in paragraph (1)(C) that
would otherwise apply for 2014, the update to the single
conversion factor shall be 0 percent for 2014.''.
(2) Technical amendment.--Effective for years beginning
with 2014, subparagraph (C)(i) of paragraph (7) of section
1848(m) of the Social Security Act (42 U.S.C. 1395w-
4(m)(7)(C)(i); relating to additional incentive payment) is
amended by inserting ``, the program of Osteopathic Continuous
Certification of the American Osteopathic Association,'' after
``Specialties Maintenance of Certification program''.
(c) Establishment of Differential Updates Beginning With 2015 To
Promote Access to Primary Care Services.--
(1) Establishment of service categories.--Subsection (j) of
section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is
amended by adding at the end the following new paragraphs:
``(5) Service categories.--
``(A) In general.--For services furnished on or
after January 1, 2015, each of the following categories
of services shall be treated as a separate `service
category':
``(i) Primary care.--Primary care services
(as defined in subparagraph (B)) furnished by a
qualifying practitioner.
``(ii) Other services.--Other physicians'
services.
``(B) Primary care services.--In this subsection,
the term `primary care services' means services
identified, as of April 1, 2013, with the following
HCPCS codes (and as subsequently modified by the
Secretary):
``(i) Office and outpatient visits.--99201
through 99215.
``(ii) Hospital observational services.--
99217 through 99220.
``(iii) Hospital inpatient visits
services.--99221 through 99239.
``(iv) Nursing home, domiciliary, rest home
or custodial care visits.--99304 through 99340.
``(v) Home service visits.--99341 through
99350.
``(vi) Welcome to medicare visit.--G0402.
``(vii) Annual wellness visits.--G0438 and
G0439.
``(C) Inclusion of preventive services.--Such term
also includes preventive services described in section
1861(ddd)(3) and additional preventive services
described in section 1861(ddd)(1).
``(D) Inclusion of additional services.--Such term
also includes services, such as care coordination
services, telemedicine services, non-face-to-face care
management services, preparation and supervision of
long-term care plans, home care plan oversight
services, and similar services that the Secretary
identifies, by regulation, as being similar to the
services described in subparagraph (B) or (C).
``(6) Qualifying practitioner.--The term `qualifying
practitioner' means, with respect to the furnishing of primary
care services, an individual--
``(A) for whom primary care services has accounted
for at least 60 percent of the allowed charges under
this part (not counting any such charges attributable
to in-office clinical laboratory services) in a prior
period as determined by the Secretary; or
``(B) who does not have claims under this part
during such a prior period and whom the Secretary
determines is likely to meet the requirement of
subparagraph (A) for the subsequent period.''.
(2) Establishment of separate conversion factors for each
service category.--Section 1848(d)(1) of the Social Security
Act (42 U.S.C. 1395w-4(d)(1)), as amended by subsection
(a)(1)(A), is further amended--
(A) in subparagraph (A)--
(i) by designating the sentence beginning
``The conversion factor'' as clause (i) with
the heading ``Application of single conversion
factor.--'' and with appropriate indentation;
(ii) by striking ``The conversion factor''
and inserting ``Subject to clause (ii), the
conversion factor''; and
(iii) by adding at the end the following
new clause:
``(ii) Application of multiple conversion
factors beginning with 2015.--
``(I) In general.--In applying
clause (i) for each year beginning with
2015, separate conversion factors shall
be established for each service
category of physicians' services (as
defined in subsection (j)(5)(A)) and
any reference in this section to a
conversion factor for such years shall
be deemed a reference to the conversion
factor for each of such categories.
``(II) Initial conversion
factors.--Such factors for 2015 shall
be based upon the single conversion
factor for the previous year multiplied
by the update established under
paragraph (16) for such category for
2015.
``(III) Updating of conversion
factors.--Such factor for a service
category for a subsequent year shall be
based upon the conversion factor for
such category for the previous year and
adjusted by the update established for
such category under paragraph (16) or a
subsequent paragraph for the year
involved.''; and
(B) in subparagraph (D), by striking ``other
physicians' services'' and inserting ``for physicians'
services in the service category described in
subsection (j)(5)(A)(ii))''.
(3) Establishment of separate updates for conversion
factors for each service category.--Section 1848(d) of the
Social Security Act (42 U.S.C. 1395w-4(d)), as amended by
subsection (b), is amended by adding at the end the following
new paragraph:
``(16) Updates by service category beginning with 2015;
updates for 2015 through 2018.--In applying paragraph (4) for
each year beginning with 2015, the following rules apply:
``(A) Application of separate update adjustments
for each service category.--Pursuant to paragraph
(1)(A)(ii)(I), for each year beginning with 2014, the
update shall be made to the conversion factor for each
service category (as defined in subsection (j)(5)(A)).
``(B) Updates for 2015 through 2018.--The updates
for 2015, 2016, 2017, and 2018 for the conversion
factor for the services category described in--
``(i) subsection (j)(5)(A)(i) shall be 2.5
percent; and
``(ii) subsection (j)(5)(A)(ii) shall be
0.5 percent.''.
(d) Promoting Testing and Evaluation of New Payment and Delivery
Models (Phase I).--
(1) Expansion of testing in multiple geographic regions.--
Section 1115A(a)(5) of the Social Security Act (42 U.S.C.
1315a(a)(5)) is amended by inserting before the period at the
end the following: ``, but shall (to the maximum extent
feasible) including testing of each such model in geographic
areas in at least 3 regions''.
(2) Inclusion of physician implementation costs in
evaluations.--Section 1115A(b)(4)(A) of the Social Security Act
(42 U.S.C. 1315a(b)(4)(A)) is amended--
(A) by striking ``and'' at the end of clause (i);
(B) by striking the period at the end of clause
(ii) and inserting ``; and''; and
(C) by adding at the end the following new clause:
``(iii) the average cost, per physician, of
implementation of the model with respect to
physicians' services.''.
(3) Accelerating testing and evaluation process.--Section
1115A(b) of the Social Security Act (42 U.S.C. 1315a(b)) is
amended by adding at the end the following new paragraph:
``(5) Timing.--The Secretary, acting through the CMI, shall
conduct activities under this subsection in such a timely
manner so that evaluations of initial models can be initially
completed so that physicians and other providers can begin to
transition to implementation of such models with respect to
services for which payment is made under section 1848 beginning
not later than January 1, 2018.''.
(4) Involvement of provider groups in selection of
models.--Section 1115A(b)(4) of such Act is amended by adding
at the end the following subparagraph:
``(D) Involvement of provider groups in model
selection.--The Secretary shall consult and work
closely with physician and other provider groups in the
selection of models under this subsection and
subsection (c).''.
(5) Use of other models.--Section 1115A of such Act is
further amended--
(A) by adding at the end of subsection (b)(2)(B)
the following new clause:
``(xxi) Providing payment for outpatient
therapy services and speech language pathology
services on the basis of a treatment session,
an episode of care, or other bundled payment
methodology that takes into account varying
levels of severity and complexity of patient
diagnoses, conditions, and comorbidities and
the varying intensity of services needed for
effective treatment of patients.''; and
(B) in subsection (c), in the matter preceding
paragraph (1), by--
(i) striking ``or'' after ``tested under
subsection (b)'' and inserting a comma; and
(ii) by inserting ``, or other model
(including a model that was not tested under
subsection (b))'' after ``section 1866C''.
(6) GAO review and study.--The Comptroller General of the
United States shall conduct a study of the evaluations made
under subsection (b) of section 1115A of the Social Security
Act, as amended by this section. Such study shall include an
analysis of the alternative payment and delivery models
identified under such section for payment for physicians'
services (and other services) under the Medicare program. Not
later than April 1, 2017, the Comptroller General shall submit
a report to Congress on such study and shall include in the
report such recommendations as the Comptroller General deems
appropriate for--
(A) changes in the development and implementation
process under such section; and
(B) alternative payment and delivery models
identified under such section as being appropriate for
expansion under subsection (c) of such section.
(7) Publication of list of successful models.--Beginning on
October 1, 2017, and each year thereafter, the Secretary of
Health and Human Services shall publicly release a
comprehensive list of such health care delivery and payment
models identified, under section 1115A of the Social Security
Act or otherwise, as meeting (or likely to meet) the
requirements of subsection (c)(1) of such section. Such list
shall include at least 4 health care delivery and payment
models and may include models not tested under subsection (b)
of such section.
(8) Considerations.--The Comptroller General in making
recommendations under paragraph (6) and the Secretary in
releasing the list of models under paragraph (7) shall take
into account variations among providers in size, specialty mix,
case mix, and patient demographics, as well as regional health
care infrastructure variations and variations in cost of living
among areas, and shall specifically consider appropriate
variations that take into account the special circumstances of
providers in rural and other underserved areas.
(e) Implementation of Payment and Delivery Model Options (Phase
II).--
(1) In general.--Based on the report of the Comptroller
General under subsection (d)(4) and not later than October 1,
2017, the Secretary of Health and Human Services shall provide
information to physicians (and nurse practitioners and other
providers for which payment is determined based on the fee
schedule under section 1848 of the Social Security Act) or
group practices and institutions employing Medicare part B
providers on how best to transition to alternative health care
delivery and payment models that are aimed at improving the
coordination, quality and efficiency of health care, including
those developed under section 1115A or 1866E of the Social
Security Act (42 U.S.C. 1315a, 1395cc-5).
(2) Increasing flexibility in implementation.--Section
1115A(c) of the Social Security Act (42 U.S.C. 1315a(c)), as
amended by subsection (c)(5), is further amended, in the matter
preceding paragraph (1), by inserting, after ``through
rulemaking'', the following: ``(which may include the issuance
of interim final rules) or through publication of a directive
or other guidance''.
(3) Timing.--Section 1115A of such Act is further amended
by adding at the end the following: ``The Secretary shall seek
to effect such expansion to the maximum extent feasible so that
physicians (and other providers paid in amounts determined
based on the fee schedule under section 1848) may begin to
transition to implementation of such models beginning not later
than January 1, 2018.''.
(f) Transition During 2019.--
(1) Freeze in fee schedule for 2019.--Subsection (d) of
section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (b) and (c)(3), is amended by adding at
the end the following new paragraph:
``(17) Update for 2019.--The update to both of the
conversion factors for 2019 shall be 0 percent.''.
(2) Expanded assistance through regional extension centers
and other qualified entities.--Section 1115A(d) of the Social
Security Act (42 U.S.C. 1315a(d)) is amended by adding at the
end the following new paragraph:
``(4) Assistance in implementation.--
``(A) In general.--Using funds available under
subsection (f)(1) and consistent with this paragraph,
the Secretary shall enter into contracts and agreements
with regional extension centers, in coordination with
the National Coordinator for Health Information
Technology, and other appropriate entities to provide
guidance and assistance on how physicians (and other
providers paid in amounts determined based on the fee
schedule under section 1848) may transition to
implementation of alternative health care delivery
models identified as representing best practices under
this section.
``(B) Dedicated funding.--
``(i) In general.--Of the amounts available
under subsection (f)(1)(B), the Secretary shall
make $720,000,000 available to the Office of
the National Coordinator for Health Information
Technology for the awarding of grants and
incentive payments under a competitive process
to regional extension centers (receiving
funding under section 3012(c) of the Public
Health Service Act) and other qualified
entities for activities described in
subparagraph (A). Such grants and payments
shall not be available for assistance after
December 31, 2019.
``(ii) Process.--Under clause (i), the
Office shall--
``(I) establish a competitive
selection process for the selection of
regional extension centers (and other
qualified entities) in the third
quarter of 2015; and
``(II) provide for the initial
distribution of funds to such centers
and entities by January 1, 2016.
``(iii) Collaboration.--The Center shall
collaborate with the Office in providing
direction to such centers and entities in
conducting activities under this paragraph,
including the development of performance
benchmarks based on provider participation and
progress toward integration.
``(iv) Priority.--The grants and incentive
payments under this subparagraph shall be
directed to target assistance to solo and small
specialty practices as well as community health
centers and similar providers of primary care
services.''.
(g) Continuing Incentives for Providing High-Quality, High-Value
Care.--
(1) Fee schedule adjustments.--Subsection (d) of section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended
by subsections (b), (c)(3), and (f), is amended by adding at
the end the following:
``(18) Updates for 2020 through 2023.--
``(A) In general.--Except as provided in this
paragraph, the update to each of the conversion
factors--
``(i) for 2020 shall be minus 2 percent;
``(ii) for 2021 shall be minus 3 percent;
``(iii) for 2022 shall be minus 4 percent;
and
``(iv) for 2023 shall be minus 5 percent.
``(B) Treatment of services paid using alternative
payment and delivery models.--In the case of
physicians' services for which payment is covered under
an alternative payment and delivery model, such as
those implemented under section 1115A, subparagraph (A)
does not apply.
``(C) General exemption.--The Secretary shall, by
regulation, exempt a provider from the application of
the negative payment update specified in subparagraph
(A) for a year if the Secretary determines that--
``(i) the provider--
``(I) is a meaningful EHR user (as
determined under subsection (o)(2) with
respect to the year); and
``(II) meets the qualifications
under subparagraph (B) of subsection
(m)(7) (relating to additional
incentive payments) for an additional
incentive payment under subparagraph
(A) of such subsection (which includes
satisfactory participation in the
quality reporting system and
participation in an approved
Maintenance of Certification program);
``(ii) the payment modifier for the
provider under subsection (p), which is based
upon the performance of the provider on
measures of quality of care furnished compared
to cost and which is expressed as a percentage
of payment, is within the top 25 percent of
such payment modifiers for providers within the
same fee schedule area, as determined by the
Secretary; or
``(iii) in the case of outpatient therapy
services, the provider of such services adheres
to a comprehensive list of cost, quality, and
outcome measures as demonstrated by--
``(I) participation in a certified
registry;
``(II) if applicable, participation
in the physician quality reporting
system under subsection (k);
``(III) use of an approved patient
assessment tool;
``(IV) current certification as a
physical therapist clinical specialist
by the American Physical Therapy
Association (APTA), an occupational
therapist by the American Occupational
Therapy Association, or as an
audiologist or a speech-language
pathologist by the American Speech-
Language-Hearing Association; or
``(V) compliance with comparable
functional measures reporting
requirements as recognized by the
Secretary.
``(D) Case-by-case hardship exemption.--The
Secretary may, on a case-by-case basis, exempt a
provider from the application of the negative payment
update specified in subparagraph (A) for a year if the
Secretary determines, subject to annual renewal, that
because of limitations in the nature of a medical
practice, limitations in the number of Medicare
beneficiaries that may be served by the provider, or
other special circumstances, imposing a financial
disincentive under such subparagraph for failure to
adopt an alternative payment and delivery model
referred to in subparagraph (B) would result in a
significant hardship to the provider.
``(19) Updates beginning with 2024.--
``(A) In general.--The update to both of the
conversion factors for each year beginning with 2024
shall be 0 percent.
``(B) Treatment of services paid using alternative
payment and delivery models.--In the case of
physicians' services for which payment is covered under
an alternative payment and delivery model, such as
those implemented under section 1115A, subparagraph (A)
does not apply.''.
(2) Considerations in promulgating growth rates for
alternative payment and delivery models.--
(A) In general.--In determining the growth rates to
be recognized beginning with 2020 for alternative
payment and delivery models under the Medicare program
that cover physicians' services, such as those
implemented under section 1115A of the Social Security
Act, the Secretary of Health and Human Services shall
consider (among other factors) the following:
(i) Ensuring access to primary care and
specialty services, including participation of
primary care practitioners and specialists and
newly graduating practitioners.
(ii) Restraining spending growth.
(iii) Ensuring access to services for
vulnerable populations.
(B) Limitations.--In no case shall the growth
factor determined under this paragraph for a year--
(i) be less than 1 percent; or
(ii) be greater than the percentage
increase in the MEI (as defined in section
1842(i)(3) of the Social Security Act, 42
U.S.C. 1395u(i)(3)) for such year.
(C) Application of congressional review act.--
Chapter 8 of title 5, United States Code, applies with
respect to the promulgation of a growth factor under
this paragraph for a year.
(h) Impact Report.--Not later than January 1, 2023, the Secretary
of Health and Human Services shall submit to Congress a report on the
impact on spending and on access to services under title XVIII of the
Social Security Act, including under part A of such title, resulting
from changes to Medicare delivery and payment systems, including under
the amendments made by this section.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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 Committee on Ways and Means, 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 Health.
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