[House Report 113-257]
[From the U.S. Government Publishing Office]
113th Congress Rept. 113-257
HOUSE OF REPRESENTATIVES
2d Session Part 2
======================================================================
SGR REPEAL AND MEDICARE BENEFICIARY ACCESS ACT OF 2013
_______
March 14, 2014.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Camp, from the Committee on Ways and Means, submitted the following
R E P O R T
[To accompany H.R. 2810]
[Including cost estimate of the Congressional Budget Office]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 2810) to amend title XVIII of the Social Security
Act to reform the sustainable growth rate and Medicare payment
for physicians' services, and for other purposes, having
considered the same, report favorably thereon with an amendment
and recommend that the bill as amended do pass.
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``SGR Repeal and
Medicare Beneficiary Access Act of 2013''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Repealing the sustainable growth rate (SGR) and improving
medicare payment for physicians' services.
Sec. 3. Priorities and funding for quality measure development.
Sec. 4. Encouraging care management for individuals with chronic care
needs.
Sec. 5. Ensuring accurate valuation of services under the physician fee
schedule.
Sec. 6. Promoting evidence-based care.
Sec. 7. Empowering beneficiary choices through access to information on
physicians' services.
Sec. 8. Expanding claims data availability to improve care.
Sec. 9. Reducing administrative burden and other provisions.
SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING
MEDICARE PAYMENT FOR PHYSICIANS' SERVICES.
(a) Stabilizing Fee Updates.--
(1) Repeal of sgr payment methodology.--Section 1848 of the
Social Security Act (42 U.S.C. 1395w-4) is amended--
(A) in subsection (d)--
(i) in paragraph (1)(A), by inserting ``or a
subsequent paragraph'' after ``paragraph (4)'';
and
(ii) in paragraph (4)--
(I) in the heading, by inserting
``and ending with 2013'' after ``years
beginning with 2001''; and
(II) in subparagraph (A), by
inserting ``and ending with 2013''
after ``a year beginning with 2001'';
and
(B) in subsection (f)--
(i) in paragraph (1)(B), by inserting
``through 2013'' after ``of each succeeding
year''; and
(ii) in paragraph (2), by inserting ``and
ending with 2013'' after ``beginning with
2000''.
(2) Update of rates for 2014 and subsequent years.--
Subsection (d) of section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended by adding at the end the following
new paragraphs:
``(15) Update for 2014 through 2016.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2014 through 2016 shall be 0.5 percent.
``(16) Update for 2017 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
each of 2017 through 2023 shall be zero percent.
``(17) Update for 2024 and subsequent years.--The update to
the single conversion factor established in paragraph (1)(C)
for 2024 and each subsequent year shall be--
``(A) for items and services furnished by a
qualifying APM participant (as defined in section
1833(z)(2)) for such year, 2 percent; and
``(B) for other items and services, 1 percent.''.
(3) MedPAC reports.--
(A) Initial report.--Not later than July 1, 2016, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the relationship between--
(i) physician and other health professional
utilization and expenditures (and the rate of
increase of such utilization and expenditures)
of items and services for which payment is made
under section 1848 of the Social Security Act
(42 U.S.C. 1395w-4); and
(ii) total utilization and expenditures (and
the rate of increase of such utilization and
expenditures) under parts A, B, and D of title
XVIII of such Act.
Such report shall include a methodology to describe
such relationship and the impact of changes in such
physician and other health professional practice and
service ordering patterns on total utilization and
expenditures under parts A, B, and D of such title.
(B) Final report.--Not later than July 1, 2020, the
Medicare Payment Advisory Commission shall submit to
Congress a report on the relationship described in
subparagraph (A), including the results determined from
applying the methodology included in the report
submitted under such subparagraph.
(b) Consolidation of Certain Current Law Performance Programs With
New Value-based Performance Incentive Program.--
(1) EHR meaningful use incentive program.--
(A) Sunsetting separate meaningful use payment
adjustments.--Section 1848(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended--
(i) in clause (i), by striking ``or any
subsequent payment year'' and inserting ``or
2016'';
(ii) in clause (ii)--
(I) in the matter preceding subclause
(I), by striking ``Subject to clause
(iii), for'' and inserting ``For'';
(II) in subclause (I), by adding at
the end ``and'';
(III) in subclause (II), by striking
``; and'' and inserting a period; and
(IV) by striking subclause (III); and
(iii) by striking clause (iii).
(B) Continuation of meaningful use determinations for
vbp program.--Section 1848(o)(2) of the Social Security
Act (42 U.S.C. 1395w-4(o)(2)) is amended--
(i) in subparagraph (A), in the matter
preceding clause (i)--
(I) by striking ``For purposes of
paragraph (1), an'' and inserting
``An''; and
(II) by inserting ``, or pursuant to
subparagraph (D) for purposes of
subsection (q), for a performance
period under such subsection for a
year'' after ``under such subsection
for a year''; and
(ii) by adding at the end the following new
subparagraph:
``(D) Continued application for purposes of vbp
program.--With respect to 2017 and each subsequent
payment year, the Secretary shall, for purposes of
subsection (q) and in accordance with paragraph (1)(F)
of such subsection, determine whether an eligible
professional who is a VBP eligible professional (as
defined in subsection (q)(1)(C)) for such year is a
meaningful EHR user under this paragraph for the
performance period under subsection (q) for such
year.''.
(2) Quality reporting.--
(A) Sunsetting separate quality reporting
incentives.--Section 1848(a)(8)(A) of the Social
Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
(i) in clause (i), by striking ``or any
subsequent year'' and inserting ``or 2016'';
and
(ii) in clause (ii)(II), by striking ``and
each subsequent year''.
(B) Continuation of quality measures and processes
for vbp program.--Section 1848 of the Social Security
Act (42 U.S.C. 1395w-4) is amended--
(i) in subsection (k), by adding at the end
the following new paragraph:
``(9) Continued application for purposes of vbp program.--The
Secretary shall, in accordance with subsection (q)(1)(F), carry
out the provisions of this subsection for purposes of
subsection (q).''; and
(ii) in subsection (m)--
(I) by redesignating the paragraph
(7) added by section 10327(a) of Public
Law 111-148 as paragraph (8); and
(II) by adding at the end the
following new paragraph:
``(9) Continued application for purposes of vbp program.--The
Secretary shall, in accordance with subsection (q)(1)(F), carry
out the processes under this subsection for purposes of
subsection (q).''.
(3) Value-based payments.--
(A) Sunsetting separate value-based payments.--Clause
(iii) of section 1848(p)(4)(B) of the Social Security
Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to read as
follows:
``(iii) Application.--The Secretary shall
apply the payment modifier established under
this subsection for items and services
furnished on or after January 1, 2015, but
before January 1, 2017, with respect to
specific physicians and groups of physicians
the Secretary determines appropriate. Such
payment modifier shall not be applied for items
and services furnished on or after January 1,
2017.''.
(B) Continuation of value-based payment modifier
measures for vbp program.--Section 1848(p) of the
Social Security Act (42 U.S.C. 1395w-4(p)) is amended--
(i) in paragraph (2), by adding at the end
the following new subparagraph:
``(C) Continued application for purposes of vbp
program.--The Secretary shall, in accordance with
subsection (q)(1)(F), carry out subparagraph (B) for
purposes of subsection (q).'' ; and
(ii) in paragraph (3), by adding at the end
the following: ``With respect to 2017 and each
subsequent year, the Secretary shall, in
accordance with subsection (q)(1)(F), carry out
this paragraph for purposes of subsection
(q).''.
(c) Value-based Performance Incentive Program.--
(1) In general.--Section 1848 of the Social Security Act (42
U.S.C. 1395w-4) is amended by adding at the end the following
new subsection:
``(q) Value-based Performance Incentive Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary shall
establish an eligible professional value-based
performance incentive program (in this subsection
referred to as the `VBP program') under which the
Secretary shall--
``(i) develop a methodology for assessing the
total performance of each VBP eligible
professional according to performance standards
under paragraph (3) for a performance period
(as established under paragraph (4)) for a
year;
``(ii) using such methodology, provide for a
composite performance score in accordance with
paragraph (5) for each such professional for
each performance period; and
``(iii) use such composite performance score
of the VBP eligible professional for a
performance period for a year to make VBP
program incentive payments under paragraph (7)
to the professional for the year.
``(B) Program implementation.--The VBP program shall
apply to payments for items and services furnished on
or after January 1, 2017.
``(C) VBP eligible professional defined.--
``(i) In general.--For purposes of this
subsection, subject to clauses (ii) and (iv),
the term `VBP eligible professional' means--
``(I) for the first and second years
for which the VBP program applies to
payments (and for the performance
period for such first and second year),
a physician (as defined in section
1861(r)(1)), a physician assistant,
nurse practitioner, and clinical nurse
specialist (as such terms are defined
in section 1861(aa)(5)), and a
certified registered nurse anesthetist
(as defined in section 1861(bb)(2));
and
``(II) for the third year for which
the VBP program applies to payments
(and for the performance period for
such third year) and for each
succeeding year (and for the
performance period for each such year),
the professionals described in
subclause (I) and such other eligible
professionals (as defined in subsection
(k)(3)(B)) as specified by the
Secretary.
``(ii) Exclusions.--For purposes of clause
(i), the term `VBP eligible professional' does
not include, with respect to a year, an
eligible professional (as defined in subsection
(k)(3)(B))--
``(I) who is a qualifying APM
participant (as defined in section
1833(z)(2));
``(II) who, subject to clause (vii),
is a partial qualifying APM participant
(as defined in clause (iii)) for the
most recent period for which data are
available and who, for the performance
period with respect to such year, does
not report on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the VBP
program; or
``(III) who, for the performance
period with respect to such year, does
not exceed the low-volume threshold
measurement selected under clause (iv).
``(iii) Partial qualifying apm participant.--
For purposes of this subparagraph, the term
`partial qualifying APM participant' means,
with respect to a year, an eligible
professional for whom the Secretary determines
the minimum payment percentage (or
percentages), as applicable, described in
paragraph (2) of section 1833(z) for such year
have not been satisfied, but who would be
considered a qualifying APM participant (as
defined in such paragraph) for such year if--
``(I) with respect to 2017 and 2018,
the reference in subparagraph (A) of
such paragraph to 25 percent was
instead a reference to 20 percent;
``(II) with respect to 2019 and
2020--
``(aa) the reference in
subparagraph (B)(i) of such
paragraph to 50 percent was
instead a reference to 40
percent; and
``(bb) the references in
subparagraph (B)(ii) of such
paragraph to 50 percent and 25
percent of such paragraph were
instead references to 40
percent and 20 percent,
respectively; and
``(III) with respect to 2021 and
subsequent years--
``(aa) the reference in
subparagraph (C)(i) of such
paragraph to 75 percent was
instead a reference to 50
percent; and
``(bb) the references in
subparagraph (C)(ii) of such
paragraph to 75 percent and 25
percent of such paragraph were
instead references to 50
percent and 20 percent,
respectively.
``(iv) Selection of low-volume threshold
measurement.--The Secretary shall select one of
the following low-volume threshold measurements
to apply for purposes of clause (ii)(III):
``(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this part
who are treated by the VBP eligible
professional for the performance period
involved.
``(II) The minimum number (as
determined by the Secretary) of items
and services furnished to individuals
enrolled under this part by such
professional for such performance
period.
``(III) The minimum amount (as
determined by the Secretary) of allowed
charges billed by such professional
under this part for such performance
period.
``(v) Treatment of new medicare enrolled
eligible professionals.--In the case of a
professional who first becomes a Medicare
enrolled eligible professional during the
performance period for a year (and had not
previously submitted claims under this title
such as a person, an entity, or a part of a
physician group or under a different billing
number or tax identifier), such professional
shall not be treated under this subsection as a
VBP eligible professional until the subsequent
year and performance period for such subsequent
year.
``(vi) Clarification.--In the case of items
and services furnished during a year by an
individual who is not a VBP eligible
professional (including pursuant to clauses
(ii) and (v)) with respect to a year, in no
case shall a reduction under paragraph (6) or a
VBP program incentive payment under paragraph
(7) apply to such individual for such year.
``(vii) Partial qualifying apm participant
clarification.--In the case of an eligible
professional who is a partial qualifying APM
participant, with respect to a year, and who
for the performance period for such year
reports on applicable measures and activities
described in paragraph (2)(B) that are required
to be reported by such a professional under the
VBP program, such eligible professional is
considered to be a VBP eligible professional
with respect to such year.
``(D) Application to group practices.--
``(i) In general.--Under the VBP program:
``(I) Quality performance category.--
The Secretary shall establish and apply
a process that includes features of the
provisions of subsection (m)(3)(C) for
VBP eligible professionals in a group
practice with respect to assessing
performance of such group with respect
to the performance category described
in clause (i) of paragraph (2)(A).
``(II) Other performance
categories.--The Secretary may
establish and apply a process that
includes features of the provisions of
subsection (m)(3)(C) for VBP eligible
professionals in a group practice with
respect to assessing the performance of
such group with respect to the
performance categories described in
clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group
practice assessment.--The process established
under clause (i) shall to the extent
practicable reflect the full range of items and
services furnished by the VBP eligible
professionals in the group practice involved.
``(iii) Clarification.--VBP eligible
professionals electing to be a virtual group
under paragraph (5)(J) shall not be considered
VBP eligible professionals in a group practice
for purposes of applying this subparagraph.
``(E) Use of registries.--Under the VBP program, the
Secretary shall encourage the use of qualified clinical
data registries pursuant to subsection (m)(3)(E) in
carrying out this subsection.
``(F) Application of certain provisions.--In applying
a provision of subsection (k), (m), (o), or (p) for
purposes of this subsection, the Secretary shall--
``(i) adjust the application of such
provision to ensure the provision is consistent
with the provisions of this subsection; and
``(ii) not apply such provision to the extent
that the provision is duplicative with a
provision of this subsection.
``(2) Measures and activities under performance categories.--
``(A) Performance categories.--Under the VBP program,
the Secretary shall use the following performance
categories (each of which is referred to in this
subsection as a performance category) in determining
the composite performance score under paragraph (5):
``(i) Quality.
``(ii) Resource use.
``(iii) Clinical practice improvement
activities.
``(iv) Meaningful use of certified EHR
technology.
``(B) Measures and activities specified for each
category.--For purposes of paragraph (3)(A) and subject
to subparagraph (C), measures and activities specified
for a performance period (as established under
paragraph (4)) for a year are as follows:
``(i) Quality.--For the performance category
described in subparagraph (A)(i), the quality
measures established for such period under
subsections (k) and (m), including under
subsection (m)(3)(E), and the measures of
quality of care established for such period
under subsection (p)(2).
``(ii) Resource use.--For the performance
category described in subparagraph (A)(ii), the
measurement of resource use for such period
under subsection (p)(3), using the methodology
under subsection (r), as appropriate, and, as
feasible and applicable, accounting for the
cost of covered part D drugs.
``(iii) Clinical practice improvement
activities.--For the performance category
described in subparagraph (A)(iii), clinical
practice improvement activities under
subcategories specified by the Secretary for
such period, which shall include at least the
following:
``(I) The subcategory of expanded
practice access, which shall include
activities such as same day
appointments for urgent needs and after
hours access to clinician advice.
``(II) The subcategory of population
management, which shall include
activities such as monitoring health
conditions of individuals to provide
timely health care interventions or
participation in a qualified clinical
data registry.
``(III) The subcategory of care
coordination, which shall include
activities such as timely communication
of test results, timely exchange of
clinical information to patients and
other providers, and use of remote
monitoring or telehealth.
``(IV) The subcategory of beneficiary
engagement, which shall include
activities such as the establishment of
care plans for individuals with complex
care needs, beneficiary self-management
training, and using shared decision-
making mechanisms.
``(V) The subcategory of patient
safety and practice assessment, such as
through use of clinical or surgical
checklists and practice assessments
related to maintaining certification.
``(VI) The subcategory of
participation in an alternative payment
model (as defined in section
1833(z)(3)(C)).
In establishing activities under this clause,
the Secretary shall give consideration to the
circumstances of small practices (consisting of
fewer than 20 professionals) and practices
located in rural areas and in health
professional shortage areas (as designated
under section 332(a)(1)(A) of the Public Health
Service Act).
``(iv) Meaningful ehr use.--For the
performance category described in subparagraph
(A)(iv), the requirements established for such
period under subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
``(C) Additional provisions.--
``(i) Emphasizing outcome measures under
quality performance category.--In applying
subparagraph (B)(i), the Secretary shall, as
feasible, emphasize the application of outcome
measures.
``(ii) Application of additional system
measures.--The Secretary may use measures used
for a payment system other than for physicians
for purposes of the performance category
described in subparagraph (A)(i).
``(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome measures, and
population-based measures for purposes of the
performance category described in subparagraph
(A)(i).
``(iv) Request for information for clinical
practice improvement activities.--In initially
applying subparagraph (B)(iii), the Secretary
shall use a request for information to solicit
recommendations from stakeholders for
identifying activities described in such
subparagraph and specifying criteria for such
activities.
``(v) Contract authority for clinical
practice improvement activities performance
category.--In applying subparagraph (B)(iii),
the Secretary may contract with entities to
assist the Secretary in--
``(I) identifying activities
described in subparagraph (B)(iii);
``(II) specifying criteria for such
activities; and
``(III) determining whether a VBP
eligible professional meets such
criteria.
``(vi) Application of measures and activities
to non-patient-facing providers.--In carrying
out this paragraph, with respect to measures
and activities specified in subparagraph (B)
for performance categories described in
subparagraph (A), the Secretary--
``(I) shall give consideration to the
circumstances of professional types (or
subcategories of those types determined
by practice characteristics) who
typically provide services that do not
involve face-to-face interaction with a
patient; and
``(II) may, to the extent feasible
and appropriate, take into account such
circumstances and apply under this
subsection with respect to VBP eligible
professionals of such professional
types or subcategories, in lieu of such
a measure or activity, a comparable
measure or activity that fulfills the
goals of the applicable performance
category.
In carrying out the previous sentence, the
Secretary shall consult with professionals of
such professional types or subcategories.
``(3) Performance standards.--
``(A) Establishment.--Under the VBP program, the
Secretary shall establish performance standards with
respect to measures and activities specified under
paragraph (2)(B) for a performance period (as
established under paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph
(2)(B), the Secretary shall take into account the
following:
``(i) Historical performance standards.
``(ii) Improvement rates.
``(iii) The opportunity for continued
improvement.
``(4) Performance period.--The Secretary shall establish a
performance period (or periods) for a year (beginning with the
year described in paragraph (1)(B)). Such performance period
(or periods) shall begin and end prior to the beginning of such
year and be as close as possible to such year. In this
subsection, such performance period (or periods) for a year
shall be referred to as the performance period for the year.
``(5) Composite performance score.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and consistent with
section 2(g)(2) of the SGR Repeal and Medicare
Beneficiary Access Act of 2013, the Secretary shall
develop a methodology for assessing the total
performance of each VBP eligible professional according
to performance standards under paragraph (3) with
respect to applicable measures and activities specified
in paragraph (2)(B) with respect to each performance
category applicable to such professional for a
performance period (as established under paragraph (4))
for a year. Using such methodology, the Secretary shall
provide for a composite assessment (in this subsection
referred to as the `composite performance score') for
each such professional for each performance period.
``(B) Weighting performance categories, measures, and
activities.--Under the methodology under subparagraph
(A), the Secretary--
``(i) may assign different scoring weights
(including a weight of 0) for--
``(I) each performance category based
on the extent to which the category is
applicable to the type of eligible
professional involved; and
``(II) each measure and activity
specified under paragraph (2)(B) with
respect to each such category based on
the extent to which the measure or
activity is applicable to the type of
eligible professional involved; and
``(ii) with respect to the performance
category described in paragraph (2)(A)(i)--
``(I) shall assign a higher scoring
weight to outcomes measures than to
other measures and increase the scoring
weight for outcome measures over time;
and
``(II) may assign a higher scoring
weight to patient experience measures.
``(C) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
``(i) Incentive to report.--Under the
methodology established under subparagraph (A),
the Secretary shall provide that in the case of
a VBP eligible professional who fails to report
on an applicable measure or activity that is
required to be reported by the professional,
the professional shall be treated as achieving
the lowest potential score applicable to such
measure or activity.
``(ii) Encouraging use of certified ehr
technology for reporting quality measures.--
Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage VBP eligible
professionals to report on applicable
measures with respect to the
performance category described in
paragraph (2)(A)(i) through the use of
certified EHR technology; and
``(II) with respect to a performance
period, with respect to a year, for
which a VBP eligible professional
reports such measures through the use
of such EHR technology, treat such
professional as satisfying the clinical
quality measures reporting requirement
described in subsection (o)(2)(A)(iii)
for such year.
``(D) Clinical practice improvement activities
performance score.--
``(i) Rule for accreditation.--A VBP eligible
professional who is in a practice that is
certified as a patient-centered medical home or
comparable specialty practice pursuant to
subsection (b)(8)(B)(i) with respect to a
performance period shall be given the highest
potential score for the performance category
described in paragraph (2)(A)(iii) for such
period.
``(ii) APM participation.--Participation by a
VBP eligible professional in an alternative
payment model (as defined in section
1833(z)(3)(C)) with respect to a performance
period shall earn such eligible professional
one-half of the highest potential score for the
performance category described in paragraph
(2)(A)(iii) for such performance period.
Nothing in the previous sentence shall prevent
such professional from earning more than one-
half of such highest potential score for such
performance period by performing additional
activities with respect to such performance
category.
``(iii) Subcategories.--A VBP eligible
professional shall not be required to perform
activities in each subcategory under paragraph
(2)(B)(iii) to achieve the highest potential
score for the performance category described in
paragraph (2)(A)(iii).
``(E) Distribution.--The Secretary shall ensure that
the application of the methodology developed under
subparagraph (A) results in a continuous distribution
of performance scores, which shall result in
differential payments under paragraph (7).
``(F) Achievement and improvement.--
``(i) Taking into account improvement.--
Beginning with the second year to which the VBP
program applies, in addition to the achievement
score of a VBP eligible professional, the
methodology developed under subparagraph (A)--
``(I) in the case of the performance
score for the performance category
described in clauses (i) and (ii) of
paragraph (2)(A), shall take into
account the improvement of the
professional; and
``(II) in the case of performance
scores for other performance
categories, may take into account the
improvement of the professional.
``(ii) Assigning higher weight for
achievement.--Beginning with the fourth year to
which the VBP program applies, under the
methodology developed under subparagraph (A),
the Secretary may assign a higher scoring
weight under subparagraph (B) with respect to
the achievement score of a VBP eligible
professional with respect to a measure or
activity specified under paragraph (2)(B) (or
with respect to such a measure or activity and
with respect to categories described in
paragraph (2)(A)) than to any improvement score
applied under clause (i) with respect to such
measure or activity (or such measure or
activity and categories).
``(G) Weights for the performance categories.--
``(i) In general.--Under the methodology
developed under subparagraph (A), subject to
clauses (ii) and (iii), the composite
performance score shall be determined as
follows:
``(I) Quality.--
``(aa) In general.--Subject
to item (bb), 30 percent of
such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A).
``(bb) First 2 years and test
year.--For the first and second
years for which the VBP program
applies to payments, 60 percent
of such score shall be based on
performance with respect to the
category described in clause
(i) of paragraph (2)(A). With
respect to the subsequent year,
the percent described in item
(aa) of such score shall be
based on performance with
respect to such category only
for purposes of feedback and 60
percent of such score shall be
based on performance with
respect to such category for
any other purpose under this
subsection.
``(II) Resource use.--
``(aa) In general.--Subject
to item (bb), 30 percent of
such score shall be based on
performance with respect to the
category described in clause
(ii) of paragraph (2)(A).
``(bb) First 2 years and test
year.--For the first and second
years for which the VBP program
applies to payments, zero
percent of such score shall be
based on performance with
respect to the category
described in clause (ii) of
paragraph (2)(A). With respect
to the subsequent year, the
percent described in item (aa)
of such score shall be based on
performance with respect to
such category only for purposes
of feedback and zero percent of
such score shall be based on
performance with respect to
such category for any other
purpose under this subsection.
``(III) Clinical practice improvement
activities.--Fifteen percent of such
score shall be based on performance
with respect to the category described
in clause (iii) of paragraph (2)(A).
``(IV) Meaningful use of certified
ehr technology.--Twenty-five percent of
such score shall be based on
performance with respect to the
category described in clause (iv) of
paragraph (2)(A).
``(ii) Authority to adjust percentages in
case of high ehr meaningful use adoption.--In
any year in which the Secretary estimates that
the proportion of eligible professionals (as
defined in subsection (o)(5)) who are
meaningful EHR users (as determined under
subsection (o)(2)) is 75 percent or greater,
the Secretary may reduce the percent applicable
under clause (i)(IV), but not below 15 percent.
If the Secretary makes such reduction for a
year, the percentages applicable under one or
more of subclauses (I), (II), and (III) of
clause (i) for such year (or, in the case of a
year described in clause (i)(II)(bb),
applicable under one or more of subclauses (I)
and (III)) shall be increased in a manner such
that the total percentage points of the
increase under this clause for such year equals
the total number of percentage points reduced
under the preceding sentence for such year.
``(iii) Authority to adjust percentages for
quality and resource use.--Other than for a
year described in clause (i)(II)(bb), the
percentages described in subclauses (I) and
(II) of clause (i), including after application
of clause (ii), shall be equal.
``(H) Resource use.--Analysis of the performance
category described in paragraph (2)(A)(ii) shall
include results from the methodology described in
subsection (r)(5), as appropriate.
``(I) Inclusion of quality measure data from multiple
payers.--In applying subsections (k), (m), and (p) with
respect to measures described in paragraph (2)(B)(i),
analysis of the performance category described in
paragraph (2)(A)(i) may include data submitted by VBP
eligible professionals with respect to multiple payers.
``(J) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of VBP
eligible professionals electing to be a virtual
group under clause (ii) with respect to a
performance period for a year, for purposes of
applying the methodology under subparagraph
(A)--
``(I) the assessment of performance
provided under such methodology with
respect to the performance categories
described in clauses (i) and (ii) of
paragraph (2)(A) that is to be applied
to each such professional in such group
for such performance period shall be
with respect to the combined
performance of all such professionals
in such group for such period; and
``(II) the composite score provided
under this paragraph for such
performance period with respect to each
such performance category for each such
VBP eligible professional in such
virtual group shall be based on the
assessment of the combined performance
under subclause (I) for the performance
category and performance period.
``(ii) Election of practices to be a virtual
group.--The Secretary shall, in accordance with
clause (iii), establish and have in place a
process to allow an individual VBP eligible
professional or a group practice consisting of
not more than 10 VBP eligible professionals to
elect, with respect to a performance period for
a year, for such individual VBP eligible
professional or all such VBP eligible
professionals in such group practice,
respectively, to be a virtual group under this
subparagraph with at least one other such
individual VBP eligible professional or group
practice making such an election.
``(iii) Requirements.--The process under
clause (ii) shall provide that--
``(I) an election under such clause,
with respect to a performance period,
shall be made before the beginning of
such performance period and may not be
changed during such performance period;
and
``(II) a practice described in such
clause, and each VBP eligible
professional in such practice, may
elect to be in no more than one virtual
group for a performance period.
``(6) Funding for vbp program incentive payments.--
``(A) Total amount for incentive payments.--The total
amount for VBP program incentive payments under
paragraph (7) for all VBP eligible professionals for a
year shall be equal to the total amount of the
performance funding pool for all VBP eligible
professionals under subparagraph (B) for such year, as
estimated by the Secretary.
``(B) Performance funding pool.--
``(i) In general.--In the case of items and
services furnished by a VBP eligible
professional during a year (beginning with
2017), the otherwise applicable fee schedule
amount (as defined in clause (iii)) with
respect to such items and services and eligible
professional for such year shall be reduced by
the applicable percent under clause (ii). The
total amount of such reductions for a year
shall be referred to in this subsection as the
`performance funding pool' for such year.
``(ii) Applicable percent defined.--For
purposes of clause (i), the term `applicable
percent' means--
``(I) for 2017, 4 percent;
``(II) for 2018, 6 percent;
``(III) for 2019, 8 percent;
``(IV) for 2020, 10 percent; and
``(V) for 2021 and subsequent years,
a percent specified by the Secretary
(but in no case less than 10 percent or
more than 12 percent).
``(iii) Otherwise applicable fee schedule
amount.--For purposes of this subparagraph and
paragraph (7), the term `otherwise applicable
fee schedule amount' means, with respect to
items and services furnished by a VBP eligible
professional during a year, the fee schedule
amount for such items and services and year
that would otherwise apply (without application
of this subparagraph or paragraph (7)) with
respect to such eligible professional under
subsection (b), after application of subsection
(a)(3), or under another fee schedule under
this part.
``(7) VBP program incentive payments.--
``(A) VBP program incentive payment adjustment
factor.--Consistent with section 2(g)(2) of the SGR
Repeal and Medicare Beneficiary Access Act of 2013, the
Secretary shall specify a VBP program incentive payment
adjustment factor for each VBP eligible professional
for a year. Such VBP program incentive payment
adjustment factor for a VBP eligible professional for a
year shall be determined--
``(i) by the composite performance score of
the eligible professional for such year;
``(ii) in a manner such that the adjustment
factors specified under this subparagraph for a
year results in differential payments under
this paragraph reflecting the full range of the
distribution of composite performance scores of
VBP eligible professionals determined under
paragraph (5)(E) for such year, with such
professionals having higher composite
performance scores receiving higher payment;
and
``(iii) in a manner such that the adjustment
factors specified under this subparagraph for a
year--
``(I) does not result in a payment
reduction for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year; and
``(II) does not result in a payment
increase for such year by an amount
that exceeds the applicable percent
described in paragraph (6)(B)(ii) for
such year.
``(B) Calculation of vbp program incentive payment
amounts.--The VBP program incentive payment amount with
respect to items and services furnished by a VBP
eligible professional during a year shall be equal to
the difference between--
``(i) the product of--
``(I) the VBP program incentive
payment adjustment factor determined
under subparagraph (A) for such VBP
eligible professional for such year;
and
``(II) the otherwise applicable fee
schedule amount (as defined in
paragraph (6)(B)(iii)) with respect to
such items and services and eligible
professional for such year; and
``(ii) the otherwise applicable fee schedule
amount, as reduced under paragraph (6)(B), with
respect to such items and services, eligible
professional, and year.
The application of the preceding sentence may result in
the VBP program incentive payment amount being 0.0 with
respect to an item or service furnished by a VBP
eligible professional.
``(C) Application of vbp program incentive payment
amount.--In the case of items and services furnished by
a VBP eligible professional during a year (beginning
with 2017), the otherwise applicable fee schedule
amount, as reduced under paragraph (6)(B), with respect
to such items and services and eligible professional
for such year shall be increased, if applicable, by the
VBP program incentive payment amount determined under
subparagraph (B) with respect to such items and
services, professional, and year.
``(D) Budget neutrality.--In specifying the VBP
program incentive payment adjustment factor for each
VBP eligible professional for a year under subparagraph
(A), the Secretary shall ensure that the total amount
of VBP program incentive payment amounts under this
paragraph for all VBP eligible professionals in a year
shall be equal to the performance funding pool for such
year under paragraph (6), as estimated by the
Secretary.
``(8) Announcement of result of adjustments.--Under the VBP
program, the Secretary shall, not later than 60 days prior to
the year involved, make available to each VBP eligible
professional the VBP program incentive payment adjustment
factor under paragraph (7) and the payment reduction under
paragraph (6) applicable to the eligible professional for items
and services furnished by the professional in such year. The
Secretary may include such information in the confidential
feedback under paragraph (13).
``(9) No effect in subsequent years.--The VBP program
incentive payment under paragraph (7) and the payment reduction
under paragraph (6) shall each apply only with respect to the
year involved, and the Secretary shall not take into account
such VBP program incentive payment or payment reduction in
making payments to a VBP eligible professional under this part
in a subsequent year.
``(10) Public reporting.--
``(A) In general.--The Secretary shall, in an easily
understandable format, make available on the Physician
Compare Internet website under subsection (t) the
following:
``(i) Information regarding the performance
of VBP eligible professionals under the VBP
program, which--
``(I) shall include the composite
score for each such VBP eligible
professional and the performance of
each such VBP eligible professional
with respect to each performance
category; and
``(II) may include the performance of
each such VBP eligible professional
with respect to each measure or
activity specified in paragraph (2)(B).
``(ii) The names of eligible professionals in
eligible alternative payment models (as defined
in section 1833(z)(3)(D)) and, to the extent
feasible, the names of such eligible
alternative payment models and performance of
such models.
``(B) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(C) Opportunity to review and submit corrections.--
The Secretary shall provide for an opportunity for a
professional described in subparagraph (A) to review,
and submit corrections for, the information to be made
public with respect to the professional under such
subparagraph prior to such information being made
public.
``(D) Aggregate information.--The Secretary shall
periodically post on the Physician Compare Internet
website aggregate information on the VBP program,
including the range of composite scores for all VBP
eligible professionals and the range of the performance
of all VBP eligible professionals with respect to each
performance category.
``(11) Consultation.--The Secretary shall consult with
stakeholders in carrying out the VBP program, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs (5)(A)
and (7). Such consultation shall include the use of a request
for information or other mechanisms determined appropriate.
``(12) Technical assistance to small practices and practices
in health professional shortage areas.--
``(A) In general.--The Secretary shall enter into
contracts or agreements with appropriate entities (such
as quality improvement organizations, regional
extension centers (as described in section 3012(c) of
the Public Health Service Act), or regional health
collaboratives) to offer guidance and assistance to VBP
eligible professionals in practices of fewer than 20
professionals (with priority given to such practices
located in rural areas, health professional shortage
areas (as designated under in section 332(a)(1)(A) of
the Public Health Service Act), or practices with low
composite scores) with respect to--
``(i) the performance categories described in
clauses (i) through (iv) of paragraph (2)(A);
or
``(ii) how to transition to the
implementation of and participation in an
alternative payment model as described in
section 1833(z)(3)(C).
``(B) Funding for implementation.--For purposes of
implementing subparagraph (A), the Secretary shall
provide for the transfer from the Federal Supplementary
Medical Insurance Trust Fund established under section
1841 to the Centers for Medicare & Medicaid Services
Program Management Account of $50,000,000 for each of
fiscal years 2014 through 2018. Amounts transferred
under this subparagraph for a fiscal year shall be
available until expended.
``(13) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2015,
the Secretary--
``(I) shall make available timely
(such as quarterly) confidential
feedback to each VBP eligible
professional on the performance of such
professional with respect to the
performance categories under clauses
(i) and (ii) of paragraph (2)(A); and
``(II) may make available
confidential feedback to each such
professional on the performance of such
professional with respect to the
performance categories under clauses
(iii) and (iv) of such paragraph.
``(ii) Mechanisms.--The Secretary may use one
or more mechanisms to make feedback available
under clause (i), which may include use of a
web-based portal or other mechanisms determined
appropriate by the Secretary. The Secretary
shall encourage provision of feedback through
qualified clinical data registries as described
in subsection (m)(3)(E)).
``(iii) Use of data.--For purposes of clause
(i), the Secretary may use data, with respect
to a VBP eligible professional, from periods
prior to the current performance period and may
use rolling periods in order to make
illustrative calculations about the performance
of such professional.
``(iv) Disclosure exemption.--Feedback made
available under this subparagraph shall be
exempt from disclosure under section 552 of
title 5, United States Code.
``(v) Receipt of information.--The Secretary
may use the mechanisms established under clause
(ii) to receive information from professionals,
such as information with respect to this
subsection.
``(B) Additional information.--
``(i) In general.--Beginning July 1, 2016,
the Secretary shall make available to each VBP
eligible professional information, with respect
to individuals who are patients of such VBP
eligible professional, about items and services
for which payment is made under this title that
are furnished to such individuals by other
suppliers and providers of services, which may
include information described in clause (ii).
Such information shall be made available under
the previous sentence to such VBP eligible
professionals by mechanisms determined
appropriate by the Secretary, which may include
use of a web-based portal. Such information
shall be made available in accordance with the
same or similar terms as data are made
available to accountable care organizations
under section 1899, including a beneficiary
opt-out.
``(ii) Type of information.--For purposes of
clause (i), the information described in this
clause, is the following:
``(I) With respect to selected items
and services (as determined appropriate
by the Secretary) for which payment is
made under this title and that are
furnished to individuals, who are
patients of a VBP eligible
professional, by another supplier or
provider of services during the most
recent period for which data are
available (such as the most recent
three-month period), the name of such
providers furnishing such items and
services to such patients during such
period, the types of such items and
services so furnished, and the dates
such items and services were so
furnished.
``(II) Historical averages (and other
measures of the distribution if
appropriate) of the total, and
components of, allowed charges (and
other figures as determined appropriate
by the Secretary) for care episodes for
such period.
``(14) Review.--
``(A) Targeted review.--The Secretary shall establish
a process under which a VBP eligible professional may
seek an informal review of the calculation of the VBP
program incentive payment adjustment factor applicable
to such eligible professional under this subsection for
a year. The results of a review conducted pursuant to
the previous sentence shall not be taken into account
for purposes of paragraph (7) with respect to a year
(other than with respect to the calculation of such
eligible professional's VBP program incentive payment
adjustment factor for such year) after the factors
determined in subparagraph (A) of such paragraph have
been determined for such year.
``(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the
amount of the VBP program incentive payment
adjustment factor under paragraph (7) and the
determination of such amount.
``(ii) The determination of the amount of
funding available for such VBP program
incentive payments under paragraph (6)(A) and
the payment reduction under paragraph
(6)(B)(i).
``(iii) The establishment of the performance
standards under paragraph (3) and the
performance period under paragraph (4).
``(iv) The identification of measures and
activities specified under paragraph (2)(B) and
information made public or posted on the
Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under
paragraph (10).
``(v) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation of such
scores, including the weighting of measures and
activities under such methodology.''.
(2) GAO reports.--
(A) Evaluation of eligible professional vbp
program.--Not later than October 1, 2018, and October
1, 2021, the Comptroller General of the United States
shall submit to Congress a report evaluating the
eligible professional value-based performance incentive
program under subsection (q) of section 1848 of the
Social Security Act (42 U.S.C. 1395w-4), as added by
paragraph (1). Such report shall--
(i) examine the distribution of the
performance and incentive payments for VBP
eligible professionals (as defined in
subsection (q)(1)(C) of such section) under
such program, and patterns relating to such
performance and incentive payments, including
based on type of provider, practice size,
geographic location, and patient mix; and
(ii) provide recommendations for improving
such program.
(B) Study to examine alignment of quality measures
used in public and private programs.--Not later than 18
months after the date of the enactment of this Act, the
Comptroller General of the United States shall submit
to Congress a report that--
(i) compares the similarities and differences
in the use of quality measures under the
original medicare fee-for-service program under
parts A and B of title XVIII of the Social
Security Act, the Medicare Advantage program
under part C of such title, and private payer
arrangements; and
(ii) makes recommendations on how to reduce
the administrative burden involved in applying
such quality measures.
(3) Funding for implementation.--For purposes of implementing
the provisions of and the amendments made by this section, the
Secretary of Health and Human Services shall provide for the
transfer of $50,000,000 from the Supplementary Medical
Insurance Trust Fund established under section 1841 of the
Social Security Act (42 U.S.C. 1395t) to the Centers for
Medicare & Medicaid Program Management Account for each of the
fiscal years 2014 through 2017. Amounts transferred under this
paragraph shall be available until expended.
(d) Improving Quality Reporting for Composite Scores.--
(1) Changes for group reporting option.--
(A) In general.--Section 1848(m)(3)(C)(ii)) of the
Social Security Act (42 U.S.C. 1395w-4(m)(3)(C)(ii)) is
amended by inserting ``and, for 2014 and subsequent
years, may provide'' after ``shall provide''.
(B) Clarification of qualified clinical data registry
reporting to group practices.--Section 1848(m)(3)(D) of
the Social Security Act (42 U.S.C. 1395w-4(m)(3)(D)) is
amended by inserting ``and, for 2015 and subsequent
years, subparagraph (A) or (C)'' after ``subparagraph
(A)''.
(2) Changes for multiple reporting periods and alternative
criteria for satisfactory reporting.--Section 1848(m)(5)(F)) of
the Social Security Act (42 U.S.C. 1395w-4(m)(5)(F)) is
amended--
(A) by striking ``and subsequent years'' and
inserting ``through reporting periods occurring in
2013''; and
(B) by inserting ``and, for reporting periods
occurring in 2014 and subsequent years, the Secretary
may establish'' following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under vbp program.--Section 1848(n) of the Social Security Act
(42 U.S.C. 1395w-4(n)) is amended by adding at the end the
following new paragraph:
``(11) Reports ending with 2016.--Reports under the Program
shall not be provided after December 31, 2016. See subsection
(q)(13) for reports beginning with 2017.''.
(4) Coordination with satisfying meaningful ehr use clinical
quality measure reporting requirement.--Section
1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w-
4(o)(2)(A)(iii)) is amended by inserting ``and subsection
(q)(5)(C)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Incentive payments for participation in eligible
alternative payment models.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the following new subsection:
``(z) Incentive Payments for Participation in Eligible Alternative
Payment Models.--
``(1) Payment incentive.--
``(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the period
beginning with 2017 and ending with 2022 and for which
the professional is a qualifying APM participant, in
addition to the amount of payment that would otherwise
be made for such covered professional services under
this part for such year, there also shall be paid to
such professional an amount equal to 5 percent of the
payment amount for the covered professional services
under this part for the preceding year. For purposes of
the previous sentence, the payment amount for the
preceding year may be an estimation for the full
preceding year based on a period of such preceding year
that is less than the full year. The Secretary shall
establish policies to implement this subparagraph in
cases where payment for covered professional services
furnished by a qualifying APM participant in an
alternative payment model is made to an entity
participating in the alternative payment model rather
than directly to the qualifying APM participant.
``(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an annual
basis, as soon as practicable.
``(C) Treatment of payment incentive.--Payments under
this subsection shall not be taken into account for
purposes of determining actual expenditures under an
alternative payment model and for purposes of
determining or rebasing any benchmarks used under the
alternative payment model.
``(D) Coordination.--The amount of the additional
payment for an item or service under this subsection or
subsection (m) shall be determined without regard to
any additional payment for the item or service under
subsection (m) and this subsection, respectively. The
amount of the additional payment for an item or service
under this subsection or subsection (x) shall be
determined without regard to any additional payment for
the item or service under subsection (x) and this
subsection, respectively. The amount of the additional
payment for an item or service under this subsection or
subsection (y) shall be determined without regard to
any additional payment for the item or service under
subsection (y) and this subsection, respectively.
``(2) Qualifying apm participant.--For purposes of this
subsection, the term `qualifying APM participant' means the
following:
``(A) 2017 and 2018.--With respect to 2017 and 2018,
an eligible professional for whom the Secretary
determines that at least 25 percent of payments under
this part for covered professional services furnished
by such professional during the most recent period for
which data are available (which may be less than a
year) were attributable to such services furnished
under this part through an entity that participates in
an eligible alternative payment model with respect to
such services.
``(B) 2019 and 2020.--With respect to 2019 and 2020,
an eligible professional described in either of the
following clauses:
``(i) Medicare revenue threshold option.--An
eligible professional for whom the Secretary
determines that at least 50 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 50 percent
of the sum of--
``(aa) payments described in
clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the Secretary
such information as is necessary for
the Secretary to make a determination
under subclause (I), with respect to
such professional.
``(iii) Requirement.--For purposes of clause
(ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional bears more than
nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures.
``(C) Beginning in 2021.--With respect to 2021 and
each subsequent year, an eligible professional
described in either of the following clauses:
``(i) Medicare revenue threshold option.--An
eligible professional for whom the Secretary
determines that at least 75 percent of payments
under this part for covered professional
services furnished by such professional during
the most recent period for which data are
available (which may be less than a year) were
attributable to such services furnished under
this part through an entity that participates
in an eligible alternative payment model with
respect to such services.
``(ii) Combination all-payer and medicare
revenue threshold option.--An eligible
professional--
``(I) for whom the Secretary
determines, with respect to items and
services furnished by such professional
during the most recent period for which
data are available (which may be less
than a year), that at least 75 percent
of the sum of--
``(aa) payments described in
clause (i); and
``(bb) all other payments,
regardless of payer (other than
payments made by the Secretary
of Defense or the Secretary of
Veterans Affairs under chapter
55 of title 10, United States
Code, or title 38, United
States Code, or any other
provision of law),
meet the requirement described in
clause (iii)(I) with respect to
payments described in item (aa) and
meet the requirement described in
clause (iii)(II) with respect to
payments described in item (bb);
``(II) for whom the Secretary
determines at least 25 percent of
payments under this part for covered
professional services furnished by such
professional during the most recent
period for which data are available
(which may be less than a year) were
attributable to such services furnished
under this part through an entity that
participates in an eligible alternative
payment model with respect to such
services; and
``(III) who provides to the Secretary
such information as is necessary for
the Secretary to make a determination
under subclause (I), with respect to
such professional.
``(iii) Requirement.--For purposes of clause
(ii)(I)--
``(I) the requirement described in
this subclause, with respect to
payments described in item (aa) of such
clause, is that such payments are made
under an eligible alternative payment
model; and
``(II) the requirement described in
this subclause, with respect to
payments described in item (bb) of such
clause, is that such payments are made
under an arrangement in which--
``(aa) quality measures
comparable to measures under
the performance category
described in section
1848(q)(2)(B)(i) apply;
``(bb) certified EHR
technology is used; and
``(cc) the eligible
professional bears more than
nominal financial risk if
actual aggregate expenditures
exceeds expected aggregate
expenditures.
``(2) Additional definitions.--In this subsection:
``(A) Covered professional services.--The term
`covered professional services' has the meaning given
that term in section 1848(k)(3)(A).
``(B) Eligible professional.--The term `eligible
professional' has the meaning given that term in
section 1848(k)(3)(B).
``(C) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(i) A model under section 1115A (other than
a health care innovation award).
``(ii) An accountable care organization under
section 1899.
``(iii) A demonstration under section 1866C.
``(iv) A demonstration required by Federal
law.
``(D) Eligible alternative payment model (apm).--
``(i) In general.--The term `eligible
alternative payment model' means, with respect
to a year, an alternative payment model--
``(I) that requires use of certified
EHR technology (as defined in
subsection (o)(4));
``(II) that provides for payment for
covered professional services based on
quality measures comparable to measures
under the performance category
described in section 1848(q)(2)(B)(i);
and
``(III) that satisfies the
requirement described in clause (ii).
``(ii) Additional requirement.--For purposes
of clause (i)(III), the requirement described
in this clause, with respect to a year and an
alternative payment model, is that the
alternative payment model--
``(I) is one in which one or more
entities bear financial risk for
monetary losses under such model that
are in excess of a nominal amount; or
``(II) is a medical home expanded
under section 1115A(c).
``(3) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise, of the
following:
``(A) The determination that an eligible professional
is a qualifying APM participant under paragraph (2) and
the determination that an alternative payment model is
an eligible alternative payment model under paragraph
(3)(D).
``(B) The determination of the amount of the 5
percent payment incentive under paragraph (1)(A),
including any estimation as part of such
determination.''.
(2) Coordination conforming amendments.--Section 1833 of the
Social Security Act (42 U.S.C. 1395l) is further amended--
(A) in subsection (x)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''; and
(B) in subsection (y)(3), by adding at the end the
following new sentence: ``The amount of the additional
payment for a service under this subsection and
subsection (z) shall be determined without regard to
any additional payment for the service under subsection
(z) and this subsection, respectively.''.
(3) Encouraging development and testing of certain models.--
Section 1115A(b)(2) of the Social Security Act (42 U.S.C.
1315a(b)(2)) is amended--
(A) in subparagraph (B), by adding at the end the
following new clauses:
``(xxi) Focusing primarily on physicians'
services (as defined in section 1848(j)(3))
furnished by physicians who are not primary
care practitioners.
``(xxii) Focusing on practices of fewer than
20 professionals.''; and
(B) in subparagraph (C)(viii), by striking ``other
public sector or private sector payers'' and inserting
``other public sector payers, private sector payers, or
Statewide payment models''.
(f) Study and Report on Fraud Related to Alternative Payment Models
Under the Medicare Program.--
(1) Study.--The Secretary of Health and Human Services, in
consultation with the Inspector General of the Department of
Health and Human Services, shall conduct a study that--
(A) examines the applicability of the Federal fraud
prevention laws to items and services furnished under
title XVIII of the Social Security Act for which
payment is made under an alternative payment model (as
defined in section 1833(z)(3)(C) of such Act (42 U.S.C.
1395l(z)(3)(C)));
(B) identifies aspects of such alternative payment
models that are vulnerable to fraudulent activity; and
(C) examines the implications of waivers to such laws
granted in support of such alternative payment models,
including under any potential expansion of such models.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit to Congress a
report containing the results of the study conducted under
paragraph (1). Such report shall include recommendations for
actions to be taken to reduce the vulnerability of such
alternative payment models to fraudulent activity. Such report
also shall include, as appropriate, recommendations of the
Inspector General for changes in Federal fraud prevention laws
to reduce such vulnerability.
(g) Improving Payment Accuracy.--
(1) Studies and reports of effect of certain information on
quality and resource use .--
(A) Study using existing medicare data.--
(i) Study.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct a study that
examines the effect of individuals'
socioeconomic status on quality and resource
use outcome measures for individuals under the
Medicare program (such as to recognize that
less healthy individuals may require more
intensive interventions). The study shall use
information collected on such individuals in
carrying out such program, such as urban and
rural location, eligibility for Medicaid
(recognizing and accounting for varying
Medicaid eligibility across States), and
eligibility for benefits under the supplemental
security income (SSI) program. The Secretary
shall carry out this paragraph acting through
the Assistant Secretary for Planning and
Evaluation.
(ii) Report.--Not later than 2 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(B) Study using other data.--
(i) Study.--The Secretary shall conduct a
study that examines the impact of risk factors,
such as those described in section 1848(p)(3)
of the Social Security Act (42 U.S.C. 1395w-
4(p)(3)), race, health literacy, limited
English proficiency (LEP), and patient
activation, on quality and resource use outcome
measures under the Medicare program (such as to
recognize that less healthy individuals may
require more intensive interventions). In
conducting such study the Secretary may use
existing Federal data and collect such
additional data as may be necessary to complete
the study.
(ii) Report.--Not later than 5 years after
the date of the enactment of this Act, the
Secretary shall submit to Congress a report on
the study conducted under clause (i).
(C) Examination of data in conducting studies.--In
conducting the studies under subparagraphs (A) and (B),
the Secretary shall examine what non-Medicare data
sets, such as data from the American Community Survey
(ACS), can be useful in conducting the types of studies
under such paragraphs and how such data sets that are
identified as useful can be coordinated with Medicare
administrative data in order to improve the overall
data set available to do such studies and for the
administration of the Medicare program.
(D) Recommendations to account for information in
payment adjustment mechanisms.--If the studies
conducted under subparagraphs (A) and (B) find a
relationship between the factors examined in the
studies and quality and resource use outcome measures,
then the Secretary shall also provide recommendations
for how the Centers for Medicare & Medicaid Services
should--
(i) obtain access to the necessary data (if
such data is not already being collected) on
such factors, including recommendations on how
to address barriers to the Centers in accessing
such data; and
(ii) account for such factors in determining
payment adjustments based on quality and
resource use outcome measures under the
eligible professional value-based performance
incentive program under section 1848(q) of the
Social Security Act (42 U.S.C. 1395w-4(q)) and,
as the Secretary determines appropriate, other
similar provisions of title XVIII of such Act.
(E) Funding.--There are hereby appropriated from the
Federal Supplemental Medical Insurance Trust Fund to
the Secretary to carry out this paragraph $6,000,000,
to remain available until expended.
(2) CMS activities.--
(A) Hierarchal condition category (hcc)
improvement.--Taking into account the relevant studies
conducted and recommendations made in reports under
paragraph (1), the Secretary, on an ongoing basis,
shall estimate how an individual's health status and
other risk factors affect quality and resource use
outcome measures and, as feasible, shall incorporate
information from quality and resource use outcome
measurement (including care episode and patient
condition groups) into the eligible professional value-
based performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(B) Accounting for other factors in payment
adjustment mechanisms.--
(i) In general.--Taking into account the
studies conducted and recommendations made in
reports under paragraph (1), the Secretary
shall account for identified factors (other
than those applied under subparagraph (A)) with
an effect on quality and resource use outcome
measures when determining payment adjustments
under the eligible professional value-based
performance incentive program under section
1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar
provisions of title XVIII of such Act.
(ii) Accessing data.--The Secretary shall
collect or otherwise obtain access to the data
necessary to carry out this paragraph through
existing and new data sources.
(iii) Periodic analyses.--The Secretary shall
carry out periodic analyses, at least every 3
years, based on the factors referred to in
clause (i) so as to monitor changes in possible
relationships.
(C) Funding.--There are hereby appropriated from the
Federal Supplemental Medical Insurance Trust Fund to
the Secretary to carry out this paragraph $10,000,000,
to remain available until expended.
(3) Strategic plan for accessing race and ethnicity data.--
Not later than 18 months after the date of the enactment of
this Act, the Secretary shall develop and report to Congress on
a strategic plan for collecting or otherwise accessing data on
race and ethnicity for purposes of carrying out the eligible
professional value-based performance incentive program under
section 1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar provisions of
title XVIII of such Act.
(h) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities to Improve Resource Use Measurement.--Section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsection (c), is further amended by adding at the end the following
new subsection:
``(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities To Improve Resource Use Measurement.--
``(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in enhancing
the infrastructure for resource use measurement, including for
purposes of the value-based performance incentive program under
subsection (q) and alternative payment models under section
1833(z), the Secretary shall undertake the steps described in
the succeeding provisions of this subsection.
``(2) Development of care episode and patient condition
groups and classification codes.--
``(A) In general.--In order to classify similar
patients into distinct care episode groups and distinct
patient condition groups, the Secretary shall undertake
the steps described in the succeeding provisions of
this paragraph.
``(B) Public availability of existing efforts to
design an episode grouper.--Not later than 60 days
after the date of the enactment of this subsection, the
Secretary shall post on the Internet website of the
Centers for Medicare & Medicaid Services a list of the
episode groups developed pursuant to subsection
(n)(9)(A) and related descriptive information.
``(C) Stakeholder input.--The Secretary shall accept,
through the date that is 60 days after the day the
Secretary posts the list pursuant to subparagraph (B),
suggestions from physician specialty societies,
applicable practitioner organizations, and other
stakeholders for episode groups in addition to those
posted pursuant to such subparagraph, and specific
clinical criteria and patient characteristics to
classify patients into--
``(i) distinct care episode groups; and
``(ii) distinct patient condition groups.
``(D) Development of proposed classification codes.--
``(i) In general.--Taking into account the
information described in subparagraph (B) and
the information received under subparagraph
(C), the Secretary shall--
``(I) establish distinct care episode
groups and distinct patient condition
groups, which account for at least an
estimated two-thirds of expenditures
under parts A and B; and
``(II) assign codes to such groups.
``(ii) Care episode groups.--In establishing
the care episode groups under clause (i), the
Secretary shall take into account--
``(I) the patient's clinical problems
at the time items and services are
furnished during an episode of care,
such as the clinical conditions or
diagnoses, whether or not inpatient
hospitalization is anticipated or
occurs, and the principal procedures or
services planned or furnished; and
``(II) other factors determined
appropriate by the Secretary.
``(iii) Patient condition groups.--In
establishing the patient condition groups under
clause (i), the Secretary shall take into
account--
``(I) the patient's clinical history
at the time of each medical visit, such
as the patient's combination of chronic
conditions, current health status, and
recent significant history (such as
hospitalization and major surgery
during a previous period, such as 3
months); and
``(II) other factors determined
appropriate by the Secretary, such as
eligibility status under this title
(including eligibility under section
226(a), 226(b), or 226A, and dual
eligibility under this title and title
XIX).
``(E) Draft care episode and patient condition groups
and classification codes.--Not later than 120 days
after the end of the comment period described in
subparagraph (C), the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services a draft list of the care episode and patient
condition codes established under subparagraph (D) (and
the criteria and characteristics assigned to such
code).
``(F) Solicitation of input.--The Secretary shall
seek, through the date that is 60 days after the
Secretary posts the list pursuant to subparagraph (E),
comments from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the care episode and patient condition groups
(and codes) posted under subparagraph (E). In seeking
such comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include use of open door forums, town hall
meetings, or other appropriate mechanisms.
``(G) Operational list of care episode and patient
condition groups and codes.--Not later than 120 days
after the end of the comment period described in
subparagraph (F), taking into account the comments
received under such subparagraph, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services an operational list of
care episode and patient condition codes (and the
criteria and characteristics assigned to such code).
``(H) Subsequent revisions.--Not later than November
1 of each year (beginning with 2016), the Secretary
shall, through rulemaking, make revisions to the
operational lists of care episode and patient condition
codes as the Secretary determines may be appropriate.
Such revisions may be based on experience, new
information developed pursuant to subsection (n)(9)(A),
and input from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including representatives of individuals
entitled to benefits under part A or enrolled under
this part.
``(3) Attribution of patients to physicians or
practitioners.--
``(A) In general.--In order to facilitate the
attribution of patients and episodes (in whole or in
part) to one or more physicians or applicable
practitioners furnishing items and services, the
Secretary shall undertake the steps described in the
succeeding provisions of this paragraph.
``(B) Development of patient relationship categories
and codes.--The Secretary shall develop patient
relationship categories and codes that define and
distinguish the relationship and responsibility of a
physician or applicable practitioner with a patient at
the time of furnishing an item or service. Such patient
relationship categories shall include different
relationships of the physician or applicable
practitioner to the patient (and the codes may reflect
combinations of such categories), such as a physician
or applicable practitioner who--
``(i) considers themself to have the primary
responsibility for the general and ongoing care
for the patient over extended periods of time;
``(ii) considers themself to be the lead
physician or practitioner and who furnishes
items and services and coordinates care
furnished by other physicians or practitioners
for the patient during an acute episode;
``(iii) furnishes items and services to the
patient on a continuing basis during an acute
episode of care, but in a supportive rather
than a lead role;
``(iv) furnishes items and services to the
patient on an occasional basis, usually at the
request of another physician or practitioner;
or
``(v) furnishes items and services only as
ordered by another physician or practitioner.
``(C) Draft list of patient relationship categories
and codes.--Not later than 180 days after the date of
the enactment of this subsection, the Secretary shall
post on the Internet website of the Centers for
Medicare & Medicaid Services a draft list of the
patient relationship categories and codes developed
under subparagraph (B).
``(D) Stakeholder input.--The Secretary shall seek,
through the date that is 60 days after the Secretary
posts the list pursuant to subparagraph (C), comments
from physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part,
regarding the patient relationship categories and codes
posted under subparagraph (C). In seeking such
comments, the Secretary shall use one or more
mechanisms (other than notice and comment rulemaking)
that may include open door forums, town hall meetings,
or other appropriate mechanisms.
``(E) Operational list of patient relationship
categories and codes.--Not later than 120 days after
the end of the comment period described in subparagraph
(D), taking into account the comments received under
such subparagraph, the Secretary shall post on the
Internet website of the Centers for Medicare & Medicaid
Services an operational list of patient relationship
categories and codes.
``(F) Subsequent revisions.--Not later than November
1 of each year (beginning with 2016), the Secretary
shall, through rulemaking, make revisions to the
operational list of patient relationship categories and
codes as the Secretary determines appropriate. Such
revisions may be based on experience, new information
developed pursuant to subsection (n)(9)(A), and input
from the physician specialty societies, applicable
practitioner organizations, and other stakeholders,
including representatives of individuals entitled to
benefits under part A or enrolled under this part.
``(4) Reporting of information for resource use
measurement.--Claims submitted for items and services furnished
by a physician or applicable practitioner on or after January
1, 2016, shall, as determined appropriate by the Secretary,
include--
``(A) applicable codes established under paragraphs
(2) and (3); and
``(B) the national provider identifier of the
ordering physician or applicable practitioner (if
different from the billing physician or applicable
practitioner).
``(5) Methodology for resource use analysis.--
``(A) In general.--In order to evaluate the resources
used to treat patients (with respect to care episode
and patient condition groups), the Secretary shall--
``(i) use the patient relationship codes
reported on claims pursuant to paragraph (4) to
attribute patients (in whole or in part) to one
or more physicians and applicable
practitioners;
``(ii) use the care episode and patient
condition codes reported on claims pursuant to
paragraph (4) as a basis to compare similar
patients and care episodes and patient
condition groups; and
``(iii) conduct an analysis of resource use
(with respect to care episodes and patient
condition groups of such patients), as the
Secretary determines appropriate.
``(B) Analysis of patients of physicians and
practitioners.--In conducting the analysis described in
subparagraph (A)(iii) with respect to patients
attributed to physicians and applicable practitioners,
the Secretary shall, as feasible--
``(i) use the claims data experience of such
patients by patient condition codes during a
common period, such as 12 months; and
``(ii) use the claims data experience of such
patients by care episode codes--
``(I) in the case of episodes without
a hospitalization, during periods of
time (such as the number of days)
determined appropriate by the
Secretary; and
``(II) in the case of episodes with a
hospitalization, during periods of time
(such as the number of days) before,
during, and after the hospitalization.
``(C) Measurement of resource use.--In measuring such
resource use, the Secretary--
``(i) shall use per patient total allowed
amounts for all services under part A and this
part (and, if the Secretary determines
appropriate, part D) for the analysis of
patient resource use, by care episode codes and
by patient condition codes; and
``(ii) may, as determined appropriate, use
other measures of allowed amounts (such as
subtotals for categories of items and services)
and measures of utilization of items and
services (such as frequency of specific items
and services and the ratio of specific items
and services among attributed patients or
episodes).
``(D) Stakeholder input.--The Secretary shall seek
comments from the physician specialty societies,
applicable practitioner organizations, and other
stakeholders, including representatives of individuals
entitled to benefits under part A or enrolled under
this part, regarding the resource use methodology
established pursuant to this paragraph. In seeking
comments the Secretary shall use one or more mechanisms
(other than notice and comment rulemaking) that may
include open door forums, town hall meetings, or other
appropriate mechanisms.
``(6) Limitation.--There shall be no administrative or
judicial review under section 1869, section 1878, or otherwise
of--
``(A) care episode and patient condition groups and
codes established under paragraph (2);
``(B) patient relationship categories and codes
established under paragraph (3); and
``(C) measurement of, and analyses of resource use
with respect to, care episode and patient condition
codes and patient relationship codes pursuant to
paragraph (5).
``(7) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to this section.
``(8) Definitions.--In this section:
``(A) Physician.--The term `physician' has the
meaning given such term in section 1861(r)(1).
``(B) Applicable practitioner.--The term `applicable
practitioner' means--
``(i) a physician assistant, nurse
practitioner, and clinical nurse specialist (as
such terms are defined in section 1861(aa)(5));
and
``(ii) beginning January 1, 2017, such other
eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the
Secretary.
``(9) Clarification.--The provisions of sections 1890(b)(7)
and 1890A shall not apply to this subsection.''.
SEC. 3. PRIORITIES AND FUNDING FOR QUALITY MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsections (c) and (h) of section 2, is further amended by
inserting at the end the following new subsection:
``(s) Priorities and Funding for Quality Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--
``(i) Draft plan.--
``(I) In general.--Not later than
October 1, 2014, the Secretary shall
develop, and post on the Internet
website of the Centers for Medicare &
Medicaid Services, a draft plan for the
development of quality measures for
application under the applicable
provisions.
``(II) Requirement.--Such plan shall
address how measures used by private
payers and integrated delivery systems
could be incorporated under such
subsection.
``(ii) Consideration.--In developing the
draft plan under subparagraph (A), the
Secretary shall consider--
``(I) gap analyses conducted by the
entity with a contract under section
1890(a) or other contractors or
entities; and
``(II) whether measures are
applicable across health care settings.
``(iii) Priorities.--In developing the draft
plan under subparagraph (A), the Secretary
shall give priority to the following types of
measures:
``(I) Outcome measures including
patient reported outcome and functional
status measures.
``(II) Patient experience measures.
``(III) Care coordination measures.
``(IV) Measures of appropriate use of
services, including measures of over
use.
``(iv) Definition of applicable provisions.--
In this subsection, the term `applicable
provisions' means the following provisions:
``(I) Subsection (q)(2)(B)(i).
``(II) Section 1833(z)(2)(C).
``(B) Stakeholder input.--The Secretary shall accept
through December 1, 2014, comments on the draft plan
posted under paragraph (1)(A) from the public,
including health care providers, payers, consumers, and
other stakeholders.
``(C) Operational measure development plan.--Not
later than February 1, 2015, taking into account the
comments received under subparagraph (B), the Secretary
shall post on the Internet website of the Centers for
Medicare & Medicaid Services an operational plan for
the development of quality measures for use under
subsection (q)(2)(A)(i).
``(2) Contracts and other arrangements for quality measure
development.--
``(A) In general.--The Secretary shall enter into
contracts or other arrangements with entities for the
purpose of developing, improving, updating, or
expanding quality measures for application under the
applicable provisions. Such entities may include
physician specialty societies and other practitioner
organizations.
``(B) Prioritization.--
``(i) In general.--In entering into contracts
or other arrangements under subparagraph (A),
the Secretary shall give priority to the
development of the types of measures described
in paragraph (1)(A)(iii).
``(ii) Consideration.--In selecting measures
for development under this subsection, the
Secretary shall consider whether such measures
would be electronically specified.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than February 1, 2016,
and annually thereafter, the Secretary shall post on
the Internet website of the Centers for Medicare &
Medicaid Services a report on the progress made in
developing quality measures for application under the
applicable provisions.
``(B) Requirements.--Each report submitted pursuant
to paragraph (1) shall include the following:
``(i) A description of the Secretary's
efforts to implement this subsection.
``(ii) With respect to the measures developed
during the previous year--
``(I) a description of the total
number of quality measures developed
and the types of such measures, such as
an outcome or patient experience
measure;
``(II) the name of each measure
developed;
``(III) the name of the developer and
steward of each measure;
``(IV) with respect to each type of
measure, an estimate of the total
amount expended under this title to
develop all measures of such type; and
``(V) whether the measure would be
electronically specified.
``(iii) With respect to measures in
development at the time of the report--
``(I) the information described in
clause (ii), if available; and
``(II) a timeline for completion of
the development of such measures.
``(iv) An update on the progress in
developing the types of measures described in
paragraph (1)(A)(iii), including a description
of issues affecting such progress.
``(v) A list of quality topics and concepts
that are being considered for development of
measures and the rationale for the selection of
topics and concepts including their
relationship to gap analyses.
``(vi) A description of any updates to the
plan under paragraph (1) (including newly
identified gaps and the status of previously
identified gaps) and the inventory of measures
applicable under the applicable provisions.
``(vii) Other information the Secretary
determines to be appropriate.
``(4) Stakeholder input.--With respect to measures applicable
under the applicable provisions, the Secretary shall seek
stakeholder input with respect to--
``(A) the identification of gaps where no quality
measures exist, particularly with respect to the types
of measures described in paragraph (1)(A)(iii);
``(B) prioritizing quality measure development to
address such gaps; and
``(C) other areas related to quality measure
development determined appropriate by the Secretary.
``(5) Funding.--For purposes of carrying out this subsection,
the Secretary shall provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund under section 1841,
of $15,000,000 to the Centers for Medicare & Medicaid Services
Program Management Account for each of fiscal years 2014
through 2018. Amounts transferred under this paragraph shall
remain available through the end of fiscal year 2021.''.
SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE
NEEDS.
Section 1848(b) of the Social Security Act (42 U.S.C. 1395w-4(b)) is
amended by adding at the end the following new paragraph:
``(8) Encouraging care management for individuals with
chronic care needs.--
``(A) In general.--In order to encourage the
management of care by an applicable provider (as
defined in subparagraph (B)) for individuals with
chronic care needs the Secretary shall--
``(i) establish one or more HCPCS codes for
chronic care management services for such
individuals; and
``(ii) subject to subparagraph (D), make
payment (as the Secretary determines to be
appropriate) under this section for such
management services furnished on or after
January 1, 2015, by an applicable provider.
``(B) Applicable provider defined.--For purposes of
this paragraph, the term `applicable provider' means a
physician (as defined in section 1861(r)(1)), physician
assistant or nurse practitioner (as defined in section
1861(aa)(5)(A)), or clinical nurse specialist (as
defined in section 1861(aa)(5)(B)) who furnishes
services as part of a patient-centered medical home or
a comparable specialty practice that--
``(i) is recognized as such a medical home or
comparable specialty practice by an
organization that is recognized by the
Secretary for purposes of such recognition as
such a medical home or practice; or
``(ii) meets such other comparable
qualifications as the Secretary determines to
be appropriate.
``(C) Budget neutrality.--The budget neutrality
provision under subsection (c)(2)(B)(ii)(II) shall
apply in establishing the payment under subparagraph
(A)(ii).
``(D) Policies relating to payment.--In carrying out
this paragraph, with respect to chronic care management
services, the Secretary shall--
``(i) make payment to only one applicable
provider for such services furnished to an
individual during a period;
``(ii) not make payment under subparagraph
(A) if such payment would be duplicative of
payment that is otherwise made under this title
for such services (such as in the case of
hospice care or home health services); and
``(iii) not require that an annual wellness
visit (as defined in section 1861(hhh)) or an
initial preventive physical examination (as
defined in section 1861(ww)) be furnished as a
condition of payment for such management
services.''.
SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN FEE
SCHEDULE.
(a) Authority To Collect and Use Information on Physicians' Services
in the Determination of Relative Values.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraph:
``(M) Authority to collect and use information on
physicians' services in the determination of relative
values.--
``(i) Collection of information.--
Notwithstanding any other provision of law, the
Secretary may collect or obtain information on
the resources directly or indirectly related to
furnishing services for which payment is made
under the fee schedule established under
subsection (b). Such information may be
collected or obtained from any eligible
professional or any other source.
``(ii) Use of information.--Notwithstanding
any other provision of law, subject to clause
(v), the Secretary may (as the Secretary
determines appropriate) use information
collected or obtained pursuant to clause (i) in
the determination of relative values for
services under this section.
``(iii) Types of information.--The types of
information described in clauses (i) and (ii)
may, at the Secretary's discretion, include any
or all of the following:
``(I) Time involved in furnishing
services.
``(II) Amounts and types of practice
expense inputs involved with furnishing
services.
``(III) Prices (net of any discounts)
for practice expense inputs, which may
include paid invoice prices or other
documentation or records.
``(IV) Overhead and accounting
information for practices of physicians
and other suppliers.
``(V) Any other element that would
improve the valuation of services under
this section.
``(iv) Information collection mechanisms.--
Information may be collected or obtained
pursuant to this subparagraph from any or all
of the following:
``(I) Surveys of physicians, other
suppliers, providers of services,
manufacturers, and vendors.
``(II) Surgical logs, billing
systems, or other practice or facility
records.
``(III) Electronic health records.
``(IV) Any other mechanism determined
appropriate by the Secretary.
``(v) Transparency of use of information.--
``(I) In general.--Subject to
subclauses (II) and (III), if the
Secretary uses information collected or
obtained under this subparagraph in the
determination of relative values under
this subsection, the Secretary shall
disclose the information source and
discuss the use of such information in
such determination of relative values
through notice and comment rulemaking.
``(II) Thresholds for use.--The
Secretary may establish thresholds in
order to use such information,
including the exclusion of information
collected or obtained from eligible
professionals who use very high
resources (as determined by the
Secretary) in furnishing a service.
``(III) Disclosure of information.--
The Secretary shall make aggregate
information available under this
subparagraph but shall not disclose
information in a form or manner that
identifies an eligible professional or
a group practice, or information
collected or obtained pursuant to a
nondisclosure agreement.
``(vi) Incentive to participate.--The
Secretary may provide for such payments under
this part to an eligible professional that
submits such solicited information under this
subparagraph as the Secretary determines
appropriate in order to compensate such
eligible professional for such submission. Such
payments shall be provided in a form and manner
specified by the Secretary.
``(vii) Administration.--Chapter 35 of title
44, United States Code, shall not apply to
information collected or obtained under this
subparagraph.
``(viii) Definition of eligible
professional.--In this subparagraph, the term
`eligible professional' has the meaning given
such term in subsection (k)(3)(B).
``(ix) Funding.--For purposes of carrying out
this subparagraph, in addition to funds
otherwise appropriated, the Secretary shall
provide for the transfer, from the Federal
Supplementary Medical Insurance Trust Fund
under section 1841, of $2,000,000 to the
Centers for Medicare & Medicaid Services
Program Management Account for each fiscal year
beginning with fiscal year 2014. Amounts
transferred under the preceding sentence for a
fiscal year shall be available until
expended.''.
(2) Limitation on review.--Section 1848(i)(1) of the Social
Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``, and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the collection and use of information in the
determination of relative values under subsection
(c)(2)(M).''.
(b) Authority for Alternative Approaches To Establishing Practice
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by
adding at the end the following new subparagraph:
``(N) Authority for alternative approaches to
establishing practice expense relative values.--The
Secretary may establish or adjust practice expense
relative values under this subsection using cost,
charge, or other data from suppliers or providers of
services, including information collected or obtained
under subparagraph (M).''.
(c) Revised and Expanded Identification of Potentially Misvalued
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C.
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
``(ii) Identification of potentially
misvalued codes.--For purposes of identifying
potentially misvalued codes pursuant to clause
(i)(I), the Secretary shall examine codes (and
families of codes as appropriate) based on any
or all of the following criteria:
``(I) Codes that have experienced the
fastest growth.
``(II) Codes that have experienced
substantial changes in practice
expenses.
``(III) Codes that describe new
technologies or services within an
appropriate time period (such as 3
years) after the relative values are
initially established for such codes.
``(IV) Codes which are multiple codes
that are frequently billed in
conjunction with furnishing a single
service.
``(V) Codes with low relative values,
particularly those that are often
billed multiple times for a single
treatment.
``(VI) Codes that have not been
subject to review since implementation
of the fee schedule.
``(VII) Codes that account for the
majority of spending under the
physician fee schedule.
``(VIII) Codes for services that have
experienced a substantial change in the
hospital length of stay or procedure
time.
``(IX) Codes for which there may be a
change in the typical site of service
since the code was last valued.
``(X) Codes for which there is a
significant difference in payment for
the same service between different
sites of service.
``(XI) Codes for which there may be
anomalies in relative values within a
family of codes.
``(XII) Codes for services where
there may be efficiencies when a
service is furnished at the same time
as other services.
``(XIII) Codes with high intra-
service work per unit of time.
``(XIV) Codes with high practice
expense relative value units.
``(XV) Codes with high cost supplies.
``(XVI) Codes as determined
appropriate by the Secretary.''.
(d) Target for Relative Value Adjustments for Misvalued Services.--
(1) In general.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a)
and (b), is amended by adding at the end the following new
subparagraph:
``(O) Target for relative value adjustments for
misvalued services.--With respect to fee schedules
established for each of 2015 through 2018, the
following shall apply:
``(i) Determination of net reduction in
expenditures.--For each year, the Secretary
shall determine the estimated net reduction in
expenditures under the fee schedule under this
section with respect to the year as a result of
adjustments to the relative values established
under this paragraph for misvalued codes.
``(ii) Budget neutral redistribution of funds
if target met and counting overages towards the
target for the succeeding year.--If the
estimated net reduction in expenditures
determined under clause (i) for the year is
equal to or greater than the target for the
year--
``(I) reduced expenditures
attributable to such adjustments shall
be redistributed for the year in a
budget neutral manner in accordance
with subparagraph (B)(ii)(II); and
``(II) the amount by which such
reduced expenditures exceeds the target
for the year shall be treated as a
reduction in expenditures described in
clause (i) for the succeeding year, for
purposes of determining whether the
target has or has not been met under
this subparagraph with respect to that
year.
``(iii) Exemption from budget neutrality if
target not met.--If the estimated net reduction
in expenditures determined under clause (i) for
the year is less than the target for the year,
reduced expenditures in an amount equal to the
target recapture amount shall not be taken into
account in applying subparagraph (B)(ii)(II)
with respect to fee schedules beginning with
2015.
``(iv) Target recapture amount.--For purposes
of clause (iii), the target recapture amount
is, with respect to a year, an amount equal to
the difference between--
``(I) the target for the year; and
``(II) the estimated net reduction in
expenditures determined under clause
(i) for the year.
``(v) Target.--For purposes of this
subparagraph, with respect to a year, the
target is calculated as 0.5 percent of the
estimated amount of expenditures under the fee
schedule under this section for the year.''.
(2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the
Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended
by adding at the end the following new subclause:
``(VIII) Reductions for misvalued
services if target not met.--Effective
for fee schedules beginning with 2015,
reduced expenditures attributable to
the application of the target recapture
amount described in subparagraph
(O)(iii).''.
(e) Phase-in of Significant Relative Value Unit (RVU) Reductions.--
(1) In general.--Section 1848(c) of the Social Security Act
(42 U.S.C. 1395w-4(c)) is amended by adding at the end the
following new paragraph:
``(7) Phase-in of significant relative value unit (rvu)
reductions.--Effective for fee schedules established beginning
with 2015, if the total relative value units for a service for
a year would otherwise be decreased by an estimated amount
equal to or greater than 20 percent as compared to the total
relative value units for the previous year, the applicable
adjustments in work, practice expense, and malpractice relative
value units shall be phased-in over a 2-year period.''.
(2) Conforming amendments.--Section 1848(c)(2) of the Social
Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
(A) in subparagraph (B)(ii)(I), by striking
``subclause (II)'' and inserting ``subclause (II) and
paragraph (7)''; and
(B) in subparagraph (K)(iii)(VI)--
(i) by striking ``provisions of subparagraph
(B)(ii)(II)'' and inserting ``provisions of
subparagraph (B)(ii)(II) and paragraph (7)'';
and
(ii) by striking ``under subparagraph
(B)(ii)(II)'' and inserting ``under
subparagraph (B)(ii)(I)''.
(f) Authority To Smooth Relative Values Within Groups of Services.--
Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C. 1395w-
4(c)(2)(C)) is amended--
(1) in each of clauses (i) and (iii), by striking ``the
service'' and inserting ``the service or group of services''
each place it appears; and
(2) in the first sentence of clause (ii), by inserting ``or
group of services'' before the period.
(g) GAO Study and Report on Relative Value Scale Update Committee.--
(1) Study.--The Comptroller General of the United States (in
this subsection referred to as the ``Comptroller General'')
shall conduct a study of the processes used by the Relative
Value Scale Update Committee (RUC) to provide recommendations
to the Secretary of Health and Human Services regarding
relative values for specific services under the Medicare
physician fee schedule under section 1848 of the Social
Security Act (42 U.S.C. 1395w-4).
(2) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1).
(h) Adjustment to Medicare Payment Localities.--
(1) In general.--Section 1848(e) of the Social Security Act
(42 U.S.C. 1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Use of msas as fee schedule areas in california.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph and notwithstanding the
previous provisions of this subsection, for services
furnished on or after January 1, 2017, the fee schedule
areas used for payment under this section applicable to
California shall be the following:
``(i) Each Metropolitan Statistical Area
(each in this paragraph referred to as an
`MSA'), as defined by the Director of the
Office of Management and Budget as of December
31 of the previous year, shall be a fee
schedule area.
``(ii) All areas not included in an MSA shall
be treated as a single rest-of-State fee
schedule area.
``(B) Transition for msas previously in rest-of-state
payment locality or in locality 3.--
``(i) In general.--For services furnished in
California during a year beginning with 2017
and ending with 2021 in an MSA in a transition
area (as defined in subparagraph (D)), subject
to subparagraph (C), the geographic index
values to be applied under this subsection for
such year shall be equal to the sum of the
following:
``(I) Current law component.--The old
weighting factor (described in clause
(ii)) for such year multiplied by the
geographic index values under this
subsection for the fee schedule area
that included such MSA that would have
applied in such area (as estimated by
the Secretary) if this paragraph did
not apply.
``(II) MSA-based component.--The MSA-
based weighting factor (described in
clause (iii)) for such year multiplied
by the geographic index values computed
for the fee schedule area under
subparagraph (A) for the year
(determined without regard to this
subparagraph).
``(ii) Old weighting factor.--The old
weighting factor described in this clause--
``(I) for 2017, is \5/6\; and
``(II) for each succeeding year, is
the old weighting factor described in
this clause for the previous year minus
\1/6\.
``(iii) MSA-based weighting factor.--The MSA-
based weighting factor described in this clause
for a year is 1 minus the old weighting factor
under clause (ii) for that year.
``(C) Hold harmless.--For services furnished in a
transition area in California during a year beginning
with 2017, the geographic index values to be applied
under this subsection for such year shall not be less
than the corresponding geographic index values that
would have applied in such transition area (as
estimated by the Secretary) if this paragraph did not
apply.
``(D) Transition area defined.--In this paragraph,
the term `transition area' means each of the following
fee schedule areas for 2013:
``(i) The rest-of-State payment locality.
``(ii) Payment locality 3.
``(E) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2017, for
California, any reference in this section to a fee
schedule area shall be deemed a reference to a fee
schedule area established in accordance with this
paragraph.''.
(2) Conforming amendment to definition of fee schedule
area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C.
1395w-4(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(D), the
term''.
SEC. 6. PROMOTING EVIDENCE-BASED CARE.
(a) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
(1) In general.--Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by adding at the end the following new
subsection:
``(p) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
``(1) Program established.--
``(A) In general.--The Secretary shall establish a
program to promote the use of appropriate use criteria
(as defined in subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C)) furnished in
an applicable setting (as defined in subparagraph (D))
by ordering professionals and furnishing professionals
(as defined in subparagraphs (E) and (F),
respectively).
``(B) Appropriate use criteria defined.--In this
subsection, the term `appropriate use criteria' means
criteria to assist ordering professionals and
furnishing professionals in making the most appropriate
treatment decision for a specific clinical condition.
To the extent feasible, such criteria shall be
evidence-based.
``(C) Applicable imaging service defined.--In this
subsection, the term `applicable imaging service' means
an advanced diagnostic imaging service (as defined in
subsection (e)(1)(B)) for which the Secretary
determines--
``(i) one or more applicable appropriate use
criteria specified under paragraph (2) apply;
``(ii) there are one or more qualified
clinical decision support mechanisms listed
under paragraph (3)(C); and
``(iii) one or more of such mechanisms is
available free of charge.
``(D) Applicable setting defined.--In this
subsection, the term `applicable setting' means a
physician's office, a hospital outpatient department
(including an emergency department), an ambulatory
surgical center, and any other outpatient setting
determined appropriate by the Secretary.
``(E) Ordering professional defined.--In this
subsection, the term `ordering professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
orders an applicable imaging service for an individual.
``(F) Furnishing professional defined.--In this
subsection, the term `furnishing professional' means a
physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who
furnishes an applicable imaging service for an
individual.
``(2) Establishment of applicable appropriate use criteria.--
``(A) In general.--Not later than November 15, 2015,
the Secretary shall through rulemaking, and in
consultation with physicians, practitioners, and other
stakeholders, specify applicable appropriate use
criteria for applicable imaging services from among
appropriate use criteria developed or endorsed by
national professional medical specialty societies or
other entities.
``(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph (A), the
Secretary shall take into account whether the
criteria--
``(i) have stakeholder consensus;
``(ii) have been determined to be
scientifically valid and are evidence based;
and
``(iii) are in the public domain.
``(C) Revisions.--The Secretary shall periodically
update and revise (as appropriate) such specification
of applicable appropriate use criteria.
``(D) Treatment of multiple applicable appropriate
use criteria.--In the case where the Secretary
determines that more than one appropriate use criteria
applies with respect to an applicable imaging service,
the Secretary shall specify one or more applicable
appropriate use criteria under this paragraph for the
service.
``(3) Mechanisms for consultation with applicable appropriate
use criteria.--
``(A) Identification of mechanisms to consult with
applicable appropriate use criteria.--
``(i) In general.--The Secretary shall
specify one or more qualified clinical decision
support mechanisms that could be used by
ordering professionals to consult with
applicable appropriate use criteria for
applicable imaging services.
``(ii) Consultation.--The Secretary shall
consult with physicians, practitioners, and
other stakeholders in specifying mechanisms
under this paragraph.
``(iii) Inclusion of certain mechanisms.--
Mechanisms specified under this paragraph may
include any or all of the following that meet
the requirements described in subparagraph
(B)(ii):
``(I) Use of clinical decision
support modules in certified EHR
technology (as defined in section
1848(o)(4)).
``(II) Use of private sector clinical
decision support mechanisms that are
independent from certified EHR
technology, which may include use of
clinical decision support mechanisms
available from medical specialty
organizations.
``(III) Use of a clinical decision
support mechanism established by the
Secretary.
``(B) Qualified clinical decision support
mechanisms.--
``(i) In general.--For purposes of this
subsection, a qualified clinical decision
support mechanism is a mechanism that the
Secretary determines meets the requirements
described in clause (ii).
``(ii) Requirements.--The requirements
described in this clause are the following:
``(I) The mechanism makes available
to the ordering professional applicable
appropriate use criteria specified
under paragraph (2) and the supporting
documentation for the applicable
imaging service ordered.
``(II) In the case where there are
more than one applicable appropriate
use criteria specified under such
paragraph for an applicable imaging
service, the mechanism indicates the
criteria that it uses for the service.
``(III) The mechanism determines the
extent to which an applicable imaging
service ordered is consistent with the
applicable appropriate use criteria so
specified.
``(IV) The mechanism generates and
provides to the ordering professional a
certification or documentation that
documents that the qualified clinical
decision support mechanism was
consulted by the ordering professional.
``(V) The mechanism is updated on a
timely basis to reflect revisions to
the specification of applicable
appropriate use criteria under such
paragraph.
``(VI) The mechanism meets privacy
and security standards under applicable
provisions of law.
``(VII) The mechanism performs such
other functions as specified by the
Secretary, which may include a
requirement to provide aggregate
feedback to the ordering professional.
``(C) List of mechanisms for consultation with
applicable appropriate use criteria.--
``(i) Initial list.--Not later than April 1,
2016, the Secretary shall publish a list of
mechanisms specified under this paragraph.
``(ii) Periodic updating of list.--The
Secretary shall periodically update the list of
qualified clinical decision support mechanisms
specified under this paragraph.
``(4) Consultation with applicable appropriate use
criteria.--
``(A) Consultation by ordering professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
ordered by an ordering professional that would be
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), an ordering professional shall--
``(i) consult with a qualified decision
support mechanism listed under paragraph
(3)(C); and
``(ii) provide to the furnishing professional
the information described in clauses (i)
through (iii) of subparagraph (B).
``(B) Reporting by furnishing professional.--
Beginning with January 1, 2017, subject to subparagraph
(C), with respect to an applicable imaging service
furnished in an applicable setting and paid for under
an applicable payment system (as defined in
subparagraph (D)), payment for such service may only be
made if the claim for the service includes the
following:
``(i) Information about which qualified
clinical decision support mechanism was
consulted by the ordering professional for the
service.
``(ii) Information regarding--
``(I) whether the service ordered
would adhere to the applicable
appropriate use criteria specified
under paragraph (2);
``(II) whether the service ordered
would not adhere to such criteria; or
``(III) whether such criteria was not
applicable to the service ordered.
``(iii) The national provider identifier of
the ordering professional (if different from
the furnishing professional).
``(C) Exceptions.--The provisions of subparagraphs
(A) and (B) and paragraph (6)(A) shall not apply to the
following:
``(i) Emergency services.--An applicable
imaging service ordered for an individual with
an emergency medical condition (as defined in
section 1867(e)(1)).
``(ii) Inpatient services.--An applicable
imaging service ordered for an inpatient and
for which payment is made under part A.
``(iii) Alternative payment models.--An
applicable imaging service ordered by an
ordering professional with respect to an
individual attributed to an alternative payment
model (as defined in section 1833(z)(3)(C)).
``(iv) Significant hardship.--An applicable
imaging service ordered by an ordering
professional who the Secretary may, on a case-
by-case basis, exempt from the application of
such provisions if the Secretary determines,
subject to annual renewal, that consultation
with applicable appropriate use criteria would
result in a significant hardship, such as in
the case of a professional who practices in a
rural area without sufficient Internet access.
``(D) Applicable payment system defined.--In this
subsection, the term `applicable payment system' means
the following:
``(i) The physician fee schedule established
under section 1848(b).
``(ii) The prospective payment system for
hospital outpatient department services under
section 1833(t).
``(iii) The ambulatory surgical center
payment systems under section 1833(i).
``(5) Identification of outlier ordering professionals.--
``(A) In general.--With respect to applicable imaging
services furnished beginning with 2017, the Secretary
shall determine, on a periodic basis (which may be
annually), ordering professionals who are outlier
ordering professionals.
``(B) Outlier ordering professionals.--The
determination of an outlier ordering professional
shall--
``(i) be based on low adherence to applicable
appropriate use criteria specified under
paragraph (2), which may be based on comparison
to other ordering professionals; and
``(ii) include data for ordering
professionals for whom prior authorization
under paragraph (6)(A) applies.
``(C) Use of two years of data.--The Secretary shall
use two years of data to identify outlier ordering
professionals under this paragraph.
``(D) Consultation with stakeholders.--The Secretary
shall consult with physicians, practitioners and other
stakeholders in developing methods to identify outlier
ordering professionals under this paragraph.
``(6) Prior authorization for ordering professionals who are
outliers.--
``(A) In general.--Beginning January 1, 2020, subject
to paragraph (4)(C), with respect to services furnished
during a year, the Secretary shall, for a period
determined appropriate by the Secretary, apply prior
authorization for applicable imaging services that are
ordered by an outlier ordering professional identified
under paragraph (5).
``(B) Funding.--For purposes of carrying out this
paragraph, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $5,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2019
through 2021. Amounts transferred under the preceding
sentence shall remain available until expended.''.
(2) Conforming amendment.--Section 1833(t)(16) of the Social
Security Act (42 U.S.C. 1395l(t)(16)) is amended by adding at
the end the following new subparagraph:
``(E) Application of appropriate use criteria for
certain imaging services.--For provisions relating to
the application of appropriate use criteria for certain
imaging services, see section 1834(p).''.
(b) Establishment of Appropriate Use Program for Other Part B
Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m),
as amended by subsection (a), is amended by adding at the end the
following new subsection:
``(q) Establishment of Appropriate Use Program for Other Part B
Services.--
``(1) Establishment.--
``(A) In general.--The Secretary may establish an
appropriate use program for services under this part
(other than applicable imaging services under
subsection (p)) using a process similar to the process
under such subsection.
``(B) Requirements.--In determining whether to
establish a program under subparagraph (A), the
Secretary shall take into consideration--
``(i) the implementation of appropriate use
criteria for applicable imaging services under
subsection (p); and
``(ii) the report under paragraph (2).
``(C) Input from stakeholders in advance of
rulemaking.--Before issuing a notice of proposed
rulemaking to establish a program under subparagraph
(A), the Secretary shall issue an advance notice of
proposed rulemaking.
``(2) Report on experience of imaging appropriate use
criteria program.--Not later than 18 months after the date of
the enactment of this subsection, the Comptroller General of
the United States shall submit to Congress a report that
includes a description of the extent to which appropriate use
criteria could be used for other services under this part, such
as radiation therapy and clinical diagnostic laboratory
services.''.
SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION ON
PHYSICIANS' SERVICES.
(a) Transferring Freestanding Physician Compare Provision to the
Social Security Act.--
(1) In general.--Section 10331 of Public Law 111-148 is
transferred and redesignated as subsection (t) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4), as amended by
subsections (c) and (h) of section 2 and by section 3.
(2) Conforming redesignations.--Section 1848(t) of the Social
Security Act (42 U.S.C. 1395w-4(t)), as transferred and
redesignated by paragraph (1), is further amended--
(A) by striking the subsection heading and inserting
the following new subsection heading: ``Public
Reporting of Performance and Other Information on
Physician Compare.--'';
(B) by redesignating subsections (a) through (i) as
paragraphs (1) through (9), respectively, and indenting
appropriately;
(C) in paragraph (1), as redesignated by subparagraph
(B)--
(i) by redesignating paragraphs (1) and (2)
as subparagraphs (A) and (B), respectively, and
indenting appropriately;
(ii) in subparagraph (B), as redesignated by
clause (i), by redesignating subparagraphs (A)
through (G) as clauses (i) through (vii),
respectively, and indenting appropriately;
(D) in paragraph (2), as redesignated by subparagraph
(B), by redesignating paragraphs (1) through (7) as
subparagraphs (A) through (G), respectively, and
indenting appropriately; and
(E) in paragraph (9), as redesignated by subparagraph
(B), by redesignating paragraphs (1) through (4) as
subparagraphs (A) through (D), respectively, and
indenting appropriately.
(3) Conforming amendments.--Section 1848(t) of the Social
Security Act (42 U.S.C. 1395w-4(t)), as amended by paragraph
(2), is further amended--
(A) in paragraph (1)--
(i) in subparagraph (A)--
(I) by striking ``the Medicare
program under section 1866(j) of the
Social Security Act (42 U.S.C.
1395cc(j))'' and inserting ``the
program under this title under section
1866(j)''; and
(II) by striking ``of such Act (42
U.S.C. 1395w-4)''; and
(ii) in subparagraph (B), in the matter
preceding clause (i)--
(I) by striking ``subsection (c)''
and inserting ``paragraph (3)'';
(II) by striking ``the Medicare
program under such section 1866(j)''
and inserting ``the program under this
title under section 1866(j)''; and
(III) by striking ``this section''
and inserting ``this subsection'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph (A),
by striking ``subsection (a)(2)'' and inserting
``paragraph (1)(B)'';
(ii) in subparagraph (D), by striking ``the
Medicare program'' and inserting ``the program
under this title''; and
(iii) in each of subparagraphs (F) and (G),
by striking ``this section'' and inserting
``this subsection'';
(C) in paragraph (3), by striking ``this section''
and inserting ``this subsection'';
(D) in paragraph (4)--
(i) by striking ``of the Social Security Act,
as added by section 3014 of this Act''; and
(ii) by striking ``this section'' and
inserting ``this subsection'';
(E) in paragraph (5)--
(i) by striking ``this subsection (a)(2)''
and inserting ``paragraph (1)(B)''; and
(ii) by striking ``(Public Law 110-275)'';
(F) in paragraph (6), by striking ``subsection
(a)(1)'' and inserting ``paragraph (1)(A)'';
(G) in paragraph (7)--
(i) by striking ``subsection (f)'' and
inserting ``paragraph (6)''; and
(ii) by striking ``title XVIII of the Social
Security Act'' and inserting ``this title'';
(H) in paragraph (8)--
(i) by striking ``subparagraphs (A) through
(G) of subsection (a)(2)'' and inserting
``clauses (i) through (vii) of paragraph
(1)(B)'';
(ii) by striking ``title XVIII of the Social
Security Act'' and inserting ``this title'';
and
(iii) by striking ``such title'' and
inserting ``this title''; and
(I) in paragraph (9)--
(i) in the matter preceding subparagraph (A),
by striking ``this section'' and inserting
``this subsection'';
(ii) in subparagraph (A), by striking ``of
the Social Security Act (42 U.S.C. 1395w-4)'';
(iii) in subparagraph (B), by striking ``of
such Act (42 U.S.C. 1395x(r))'';
(iv) in subparagraph (C), by striking
``subsection (a)(1)'' and inserting ``paragraph
(1)(A)''; and
(v) by striking subparagraph (D).
(b) Public Availability of Medicare Data.--Section 1848(t) of the
Social Security Act (42 U.S.C. 1395w-4(t)), as amended by subsection
(a), is further amended--
(1) by redesignating paragraph (9) as paragraph (10);
(2) by inserting after paragraph (8) the following new
paragraph:
``(9) Public availability of eligible professional claims
data.--
``(A) In general.--The Secretary shall make publicly
available on Physician Compare the information
described in subparagraph (B) with respect to eligible
professionals.
``(B) Information described.--The following
information, with respect to an eligible professional,
is described in this subparagraph:
``(i) Information on the number of services
furnished by the eligible professional, which
may include information on the most frequent
services furnished or groupings of services.
``(ii) Information on submitted charges and
payments for services under this part.
``(iii) A unique identifier for the eligible
professional that is available to the public,
such as a national provider identifier.
``(C) Searchability.--The information made available
under this paragraph shall be searchable by at least
the following:
``(i) The specialty or type of the eligible
professional.
``(ii) Characteristics of the services
furnished, such as volume or groupings of
services.
``(iii) The location of the eligible
professional.
``(D) Disclosure.--The information made available
under this paragraph shall indicate, where appropriate,
that publicized information may not be representative
of the eligible professional's entire patient
population, the variety of services furnished by the
eligible professional, or the health conditions of
individuals treated.
``(E) Implementation.--
``(i) Initial implementation.--Physician
Compare shall include the information described
in subparagraph (B)--
``(I) with respect to physicians, by
not later than July 1, 2015; and
``(II) with respect to other eligible
professionals, by not later than July
1, 2016.
``(ii) Annual updating.--The information made
available under this paragraph shall be updated
on Physician Compare not less frequently than
on an annual basis.
``(F) Opportunity to review and submit corrections.--
The Secretary shall provide for an opportunity for an
eligible professional to review, and submit corrections
for, the information to be made public with respect to
the eligible professional under this paragraph prior to
such information being made public.''; and
(3) in paragraph (10)(C), as redesignated by paragraph (1),
by inserting ``(or a successor website)'' before the period at
the end.
SEC. 8. EXPANDING CLAIMS DATA AVAILABILITY TO IMPROVE CARE.
(a) Expansion of Uses of Claims Data by Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended by
adding at the end the following new paragraph:
``(5) Expansion of uses of claims data by qualified
entities.--
``(A) Expansion.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2014,
notwithstanding paragraph (4)(B) (other than clause
(iii) of such paragraph) and the second sentence of
paragraph (4)(D), a qualified entity may, as determined
appropriate by the Secretary, do any or all of the
following:
``(i)(I) Use the combined data described in
paragraph (4)(B)(iii) to conduct analyses,
other than for reports described in paragraph
(4), for entities described in subparagraph (B)
for non-public uses, as determined appropriate
by the Secretary, such as for the purposes
described in subclause (II).
``(II) The purposes described in this
subclause are assisting providers of services
and suppliers in developing and participating
in quality and patient care improvement
activities (including developing new models of
care), population health management, and
disease monitoring, and the purposes described
in subparagraph (C).
``(ii) Provide or sell such analyses to
entities described in subparagraph (B).
``(iii) Provide entities described in clauses
(i), (ii), (v), and (vi) of subparagraph (B)
with access to the combined data described in
paragraph (4)(B)(iii) through a qualified data
enclave (as defined in subparagraph (F)) that
is maintained by the qualified entity in order
for entities described in such clauses to
conduct analyses for non-public uses, such as
for the purposes described in clause (i)(II).
``(B) Entities described.--For the purpose of
subparagraph (A) clauses (i) and (ii), the entities
described in this subparagraph are the following:
``(i) A provider of services.
``(ii) A supplier.
``(iii) Subject to subparagraph (C), an
employer (as defined in section 3(5) of the
Employee Retirement Insurance Security Act of
1974).
``(iv) A health insurance issuer (as defined
in section 2791 of the Public Health Service
Act) that provides data under paragraph
(4)(B)(iii).
``(v) A medical society or hospital
association.
``(vi) Other entities approved by the
Secretary (other than an employer (as so
defined) and a health insurance issuer (as so
defined)).
``(C) Limitation with respect to employers.--Any
analyses provided or sold under this paragraph to an
employer (as so defined) may only be used by such
employer for purposes of providing health insurance to
employees and retirees of the employer.
``(D) Protection of patient identification.--
``(i) In general.--Except as provided in
clause (ii), an analysis provided or sold under
this paragraph shall not contain information
that individually identifies a patient.
``(ii) Information on patients of the
provider of services or supplier.--An analysis
that is provided or sold under this paragraph
to a provider of services or supplier may
contain data that individually identifies a
patient of such provider or supplier but only
with respect to items and services furnished by
such provider or supplier to such patient.
``(iii) Opportunity for providers of services
and suppliers to review.--Prior to a qualified
entity providing or selling an analysis under
this paragraph to an entity described in
subparagraph (B), to the extent that such
analysis would individually identify a provider
of services or supplier who is not being
provided or sold such analysis, such qualified
entity shall provide an opportunity for such
provider or supplier to review and submit
corrections to such analysis.
``(E) No redisclosure.--An entity described in
subparagraph (B) that is provided or sold an analysis
under this paragraph shall not redisclose or make
public such an analysis.
``(F) Requirements for a qualified data enclave.--
``(i) Definition.--For purposes of this
paragraph, the term `qualified data enclave'
means a data enclave that the Secretary
determines meets the following:
``(I) The data enclave is a web-based
portal or comparable mechanism.
``(II) Subject to the requirements
described in clause (ii) and such other
requirements as the Secretary may
specify, the data enclave is capable of
providing access to the combined data
described in subparagraph (A)(iii).
``(ii) Enclave access requirements.--The
requirements described in this clause are the
following:
``(I) A qualified data enclave shall
preclude any entity that obtains access
to the data from removing or extracting
the data from such enclave.
``(II) Subject to the succeeding
sentence, the enclave shall preclude
access to data that individually
identifies a patient, including data on
the patient's name and date of birth
and such other data as the Secretary
shall specify. Such data enclave may
provide providers of services and
suppliers with access to such
individually identifiable patient data
but only with respect to items and
services furnished by such provider or
supplier to such patient.
``(III) Access to data in the enclave
shall not be provided to any entity
unless the qualified entity and the
entity have entered into a data use
agreement, the terms of which contain
the requirements of this paragraph and
such other terms the Secretary may
specify.
``(G) Annual reports.--Any qualified entity that
provides or sells analyses pursuant to subparagraph
(A)(ii) or provides access to a qualified data enclave
pursuant to subparagraph (A)(iii) shall annually submit
to the Secretary a report that includes--
``(i) a summary of the analyses provided or
sold, including the number of such analyses,
the number of purchasers of such analyses, and
the total amount of fees received for such
analyses;
``(ii) a description of the topics and
purposes of such analyses;
``(iii) information on the entities who
obtained access to the qualified data enclave,
the uses of the data, and the total amount of
fees received for providing such access; and
``(iv) other information determined
appropriate by the Secretary.''.
(b) Expansion of Data Available to Qualified Entities.--Section
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
(1) in the subsection heading, by striking ``Medicare''; and
(2) in paragraph (3)--
(A) by inserting after the first sentence the
following new sentence: ``Effective July 1, 2014, if
the Secretary determines appropriate, the data
described in this paragraph may also include
standardized extracts (as determined by the Secretary)
of claims data under titles XIX and XXI for assistance
provided under such titles for one or more specified
geographic areas and time periods requested by a
qualified entity.''; and
(B) in the last sentence, by inserting ``or under
titles XIX or XXI'' before the period at the end.
(c) Access to Medicare Data by Qualified Clinical Data Registries to
Facilitate Quality Improvement.--Section 1848(m)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-4(m)(3)(E)) is amended by adding at the
end the following new clause:
``(vi) Access to medicare data to facilitate
quality improvement.--
``(I) In general.--To the extent
consistent with applicable information,
privacy, security, and disclosure laws,
and subject to other requirements as
the Secretary may specify, beginning
July 1, 2014, the Secretary shall, if
requested by a qualified clinical data
registry under this subparagraph,
subject to subclauses (II) and (III),
provide data as described in section
1874(e)(3) (in a form and manner
determined to be appropriate) to such
registry for purposes of linking such
data with clinical data and performing
analyses and research to support
quality improvement or patient safety.
``(II) Protection.--A qualified
clinical data registry may not publicly
report any data made available under
subclause (I) (or any analyses or
research described in such subclause)
that individually identifies a provider
of services, supplier, or individual
unless the registry obtains the consent
of such provider, supplier, or
individual prior to such reporting.
``(III) Fee.--The data described in
subclause (I) shall be made available
to qualified clinical data registries
at a fee equal to the cost of making
such data available. Any fee collected
pursuant to the preceding sentence
shall be deposited in the Centers for
Medicare & Medicaid Services Program
Management Account.''.
(d) Revision of Placement of Fees.--Section 1874(e)(4)(A) of the
Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the
second sentence--
(1) by inserting ``, for periods prior to July 1, 2014,''
after ``deposited''; and
(2) by inserting the following before the period at the end:
``, and, beginning July 1, 2014, into the Centers for Medicare
& Medicaid Services Program Management Account''.
SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER PROVISIONS.
(a) Medicare Physician and Practitioner Opt-out to Private
Contract.--
(1) Indefinite, continuing automatic extension of opt out
election.--
(A) In general.--Section 1802(b)(3) of the Social
Security Act (42 U.S.C. 1395a(b)(3)) is amended--
(i) in subparagraph (B)(ii), by striking
``during the 2-year period beginning on the
date the affidavit is signed'' and inserting
``during the applicable 2-year period (as
defined in subparagraph (D))'';
(ii) in subparagraph (C), by striking
``during the 2-year period described in
subparagraph (B)(ii)'' and inserting ``during
the applicable 2-year period''; and
(iii) by adding at the end the following new
subparagraph:
``(D) Applicable 2-year periods for effectiveness of
affidavits.--In this subsection, the term `applicable
2-year period' means, with respect to an affidavit of a
physician or practitioner under subparagraph (B), the
2-year period beginning on the date the affidavit is
signed and includes each subsequent 2-year period
unless the physician or practitioner involved provides
notice to the Secretary (in a form and manner specified
by the Secretary), not later than 30 days before the
end of the previous 2-year period, that the physician
or practitioner does not want to extend the application
of the affidavit for such subsequent 2-year period.''.
(B) Effective date.--The amendments made by
subparagraph (A) shall apply to affidavits entered into
on or after the date that is 60 days after the date of
the enactment of this Act.
(2) Public availability of information on opt-out physicians
and practitioners.--Section 1802(b) of the Social Security Act
(42 U.S.C. 1395a(b)) is amended--
(A) in paragraph (5), by adding at the end the
following new subparagraph:
``(D) Opt-out physician or practitioner.--The term
`opt-out physician or practitioner' means a physician
or practitioner who has in effect an affidavit under
paragraph (3)(B).'';
(B) by redesignating paragraph (5) as paragraph (6);
and
(C) by inserting after paragraph (4) the following
new paragraph:
``(5) Posting of information on opt-out physicians and
practitioners.--
``(A) In general.--Beginning not later than February
1, 2015, the Secretary shall make publicly available
through an appropriate publicly accessible website of
the Department of Health and Human Services information
on the number and characteristics of opt-out physicians
and practitioners and shall update such information on
such website not less often than annually.
``(B) Information to be included.--The information to
be made available under subparagraph (A) shall include
at least the following with respect to opt-out
physicians and practitioners:
``(i) Their number.
``(ii) Their physician or professional
specialty or other designation.
``(iii) Their geographic distribution.
``(iv) The timing of their becoming opt-out
physicians and practitioners, relative to when
they first entered practice and with respect to
applicable 2-year periods.
``(v) The proportion of such physicians and
practitioners who billed for emergency or
urgent care services.''.
(b) Medicare Non-participating Physicians Demonstration Project.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish and implement a demonstration project (in this
section referred to as the ``demonstration project'') under
title XVIII of the Social Security Act to provide that payments
for services under such title furnished by non-participating
physicians (as defined in section 1861(r)(1) of the Social
Security Act (42 U.S.C. 1395x(r)(1))) to individuals entitled
to benefits under part A or enrolled under part B of such title
are paid directly to such physicians. The Secretary shall carry
out the demonstration project in a geographic area that is a
statistically significant area no larger than a State.
(2) Advance notice to physicians.--The Secretary shall, in a
timely manner and prior to the beginning of the year in which
payment will be made under the demonstration project, notify
physicians in the geographic area described in paragraph (1) of
the option to participate in the demonstration project.
(3) Timetable for implementation.--
(A) Demonstration start date.--The demonstration
project shall apply with respect to services furnished
beginning on January 1, 2015.
(B) 1-year duration.--The Secretary shall implement
the demonstration project such that payments are made
under such demonstration project for a period of 1
year.
(4) Report.--Not later than 18 months after the date of the
conclusion of the demonstration project, the Secretary shall
submit to Congress a report analyzing the impact of the
demonstration project. Such report shall include an analysis of
the impact, if any, of the demonstration project upon the--
(A) percentage and number of physicians who choose
not to participate under title XVIII of the Social
Security Act and a comparison of such percentage and
number to the previous year;
(B) percentage of claims submitted by and payments
made to physicians in the demonstration that are
unassigned and a comparison of unassigned claims and
payments by non-participating physicians in the
previous year;
(C) percentage and number of the physicians in the
demonstration by specialty designation; and
(D) access to services for which payment is made
under such title for individuals entitled to benefits
under part A or enrolled under part B of such title.
(5) Beneficiary notice.--
(A) Notice by secretary to beneficiaries.--The
Secretary shall notify individuals entitled to benefits
under part A or enrolled under part B of title XVIII of
the Social Security Act in the geographic area in which
the demonstration project is conducted of the
implications of physician participation in the
demonstration project.
(B) Notice by physicians to patients.--A physician
who elects to participate in the demonstration project
shall notify individuals to whom the physician
furnishes services for which payment will be provided
under the demonstration project of such election. Such
notification shall be provided prior to the provision
of service and include a notification, with respect to
each such individual, that--
(i) the right of the individual to payment is
being reassigned to the physician;
(ii) payment for services furnished by the
physician to such individual will be made
directly to the physician; and
(iii) the individual is responsible for the
remaining amount, which may be higher than
would be the case if the physician participated
in the Medicare program.
(c) Gainsharing Study and Report.--Not later than 6 months after the
date of the enactment of this Act, the Secretary of Health and Human
Services, in consultation with the Inspector General of the Department
of Health and Human Services, shall submit to Congress a report with
legislative recommendations to amend existing fraud and abuse laws,
through exceptions, safe harbors, or other narrowly targeted
provisions, to permit gainsharing or similar arrangements between
physicians and hospitals that improve care while reducing waste and
increasing efficiency. The report shall--
(1) consider whether such provisions should apply to
ownership interests, compensation arrangements, or other
relationships; and
(2) describe how the recommendations address accountability,
transparency, and quality, including how best to limit
inducements to stint on care, discharge patients prematurely,
or otherwise reduce or limit medically necessary care; and
(3) consider whether a portion of any savings generated by
such arrangements should accrue to the Medicare program under
title XVIII of the Social Security Act.
(d) Promoting Interoperability of Electronic Health Record Systems.--
(1) Recommendations for achieving widespread ehr
interoperability.--
(A) Objective.--As a consequence of a significant
Federal investment in the implementation of health
information technology through the Medicare EHR
incentive programs, Congress declares it a national
objective to achieve widespread and nationwide exchange
of health information through interoperable certified
EHR technology by December 31, 2019.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term
``widespread interoperability'' means
nationwide interoperability between certified
EHR technology systems employed by meaningful
EHR users under the Medicare EHR incentive
programs and other clinicians and health care
providers.
(ii) Interoperability.--The term
``interoperability'' means the ability of two
or more health information systems or
components to exchange clinical and other
information and to use the information that has
been exchanged using common standards as to
provide access to longitudinal information for
health care providers in order to facilitate
coordinated care and improved patient outcomes.
(C) Establishment of metrics.--Not later than
December 31, 2015, and in consultation with
stakeholders, the Secretary shall establish metrics to
be used to determine if and to the extent that the
objective described in subparagraph (A) has been
achieved.
(D) Recommendations if objective not achieved.--If
the Secretary of Health and Human Services determines
that the objective described in subparagraph (A) has
not been achieved by December 31, 2017, then the
Secretary shall submit to Congress a report, by not
later than December 31, 2018, that identifies barriers
to such objective and recommends actions that the
Federal Government can take to achieve such objective.
Such recommended actions may include recommendations--
(i) to adjust payments for meaningful EHR
users under the Medicare EHR incentive
programs; and
(ii) for criteria for decertifying certified
EHR technology products.
(2) Preventing blocking the sharing of information.--
(A) For meaningful ehr professionals.--Section
1848(o)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395w-4(o)(2)(A)(ii)) is amended by inserting before
the period at the end the following: ``, and the
professional demonstrates (through a process specified
by the Secretary, such as the use of an attestation
similar to that required in the health information
technology donation safe harbor established under
regulations under section 1128B(b)(3)(E)) that the
professional has not and will not take any deliberate
action to limit or restrict the use, compatibility, or
interoperability of the certified EHR technology''.
(B) For meaningful ehr hospitals.--Section
1886(n)(3)(A)(ii) of the Social Security Act (42 U.S.C.
1395ww(n)(3)(A)(ii)) is amended by inserting before the
period at the end the following: ``, and the hospital
demonstrates (through a process specified by the
Secretary, such as the use of an attestation referred
to in section 1848(o)(2)(A)(ii)) that the hospital has
not and will not take any deliberate action to limit or
restrict the use, compatibility, or interoperability of
the certified EHR technology''.
(C) Effective date.--The amendments made by this
subsection shall apply to meaningful EHR users as of
the date that is 6 months after the date of the
enactment of this Act.
(3) Study and report on the feasibility of establishing a
website to compare certified ehr technology products.--
(A) Study.--The Secretary shall conduct a study to
examine the feasibility of establishing a website (in
this subsection referred to as the ``website'') that
includes aggregated results of surveys of meaningful
EHR users on the functionality of certified EHR
technology products to enable such users to directly
compare the functionality and other features of such
products. Such information may be made available
through contracts with physician, hospital, or other
organizations that maintain such comparative
information.
(B) Report.--Not later than 1 year after the date of
the enactment of this Act, the Secretary shall submit
to Congress a report on the website. The report shall
include information on the benefits and resources of
such a website.
(4) Definitions.--In this subsection:
(A) The term ``certified EHR technology'' has the
meaning given such term in section 1848(o)(4) of the
Social Security Act (42 U.S.C. 1395w-4(o)(4)).
(B) The term ``meaningful EHR hospital'' means an
eligible hospital (as defined in section 1886(n)(6)(A)
of the Social Security Act (42 U.S.C. 1395ww(n)(6)(A))
that is a meaningful EHR user.
(C) The term ``meaningful EHR professional'' means an
eligible professional (as defined in section
1848(o)(5)(C) of the Social Security Act (42 U.S.C.
1395w-4(o)(5)(C)) who is a meaningful EHR user.
(D) The term ``meaningful EHR user'' has the meaning
given such term under the Medicare EHR incentive
programs.
(E) The term ``Medicare EHR incentive programs''
means the incentive programs under section 1848(o),
subsections (l) and (m) of section 1853, and section
1886(n) of the Social Security Act (42 U.S.C. 1395w-
4(o), 1395w-23, 1395ww(n)).
(F) The term ``Secretary'' means the Secretary of
Health and Human Services.
(e) GAO Study and Report on the Use of Telehealth Under Federal
Programs.--
(1) Study.--The Comptroller General of the United States
shall conduct a study on the following:
(A) How the definition of telehealth across various
Federal programs and federal efforts can inform the use
of telehealth in the Medicare program under title XVIII
of the Social Security Act (42 U.S.C. 1395 et seq.).
(B) Issues that can facilitate or inhibit the use of
telehealth under the Medicare program under such title,
including oversight and professional licensure,
changing technology, privacy and security,
infrastructure requirements, and varying needs across
urban and rural areas.
(C) Potential implications of greater use of
telehealth with respect to payment and delivery system
transformations under the Medicare program under such
title XVIII and the Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(D) How the Centers for Medicare & Medicaid Services
conducts oversight of payments made under the Medicare
program under such title XVIII to providers for
telehealth services.
(2) Report.--Not later than 24 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(f) Rule of Construction Regarding Health Care Provider Standards of
Care.--
(1) In general.--The development, recognition, or
implementation of any guideline or other standard under any
Federal health care provision shall not be construed to
establish the standard of care or duty of care owed by a health
care provider to a patient in any medical malpractice or
medical product liability action or claim.
(2) Definitions.--For purposes of this subsection:
(A) The term ``Federal health care provision'' means
any provision of the Patient Protection and Affordable
Care Act (Public Law 111-148), title I and subtitle B
of title III of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), and
titles XVIII and XIX of the Social Security Act.
(B) The term ``health care provider'' means any
individual or entity--
(i) licensed, registered, or certified under
Federal or State laws or regulations to provide
health care services; or
(ii) required to be so licensed, registered,
or certified but that is exempted by other
statute or regulation.
(C) The term ``medical malpractice or medical
liability action or claim'' means a medical malpractice
action or claim (as defined in section 431(7) of the
Health Care Quality Improvement Act of 1986 (42 U.S.C.
11151(7))) and includes a liability action or claim
relating to a health care provider's prescription or
provision of a drug, device, or biological product (as
such terms are defined in section 201 of the Federal
Food, Drug, and Cosmetic Act or section 351 of the
Public Health Service Act).
(D) The term ``State'' includes the District of
Columbia, Puerto Rico, and any other commonwealth,
possession, or territory of the United States.
(3) No preemption.--No provision of the Patient Protection
and Affordable Care Act (Public Law 111-148), title I or
subtitle B of title III of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), or title XVIII
or XIX of the Social Security Act shall be construed to preempt
any State or common law governing medical professional or
medical product liability actions or claims.
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The bill, H.R. 2810, the Medicare Patient Access and
Quality Improvement Act of 2013, as reported, repeals the
Sustainable Growth Rate (SGR) mechanism and reforms how
Medicare pays for services furnished by physicians and other
practitioners, referred to as ``professionals.''
The bill repeals the applicability of the SGR to provide
needed long-term stability to payments to professionals. It
establishes an annual payment update of 0.5 percent for the
years 2014, 2015 and 2016. After this three-year period during
which no other changes are made to the current payment system,
the bill establishes a single professional payment incentive
program that represents consolidation and improvement of the
three incentive programs that existing under current law. This
single incentive program, referred to as the Value-Based
Performance Incentive Program (VBP), continues the focus on
quality, resource use, and electronic health record (EHR) use
with which professionals are familiar, but in a cohesive
program that avoids redundancies. The bill provides incentives
for professionals to participate in alternative payment models
(APMs).
The bill also: improves the coordination of care furnished
to beneficiaries; improves the accuracy of payment rates;
provides information to providers and beneficiaries to
facilitate high-quality, efficient care; and ensures that
payments by federal programs for the provision of care could
not be used to establish a standard of care in medical
liability cases.
B. Background and Need for Legislation
In the Omnibus Budget Reconciliation Act (OBRA) of 1989,
Congress established the Resource-Based Relative Value Scale
(RBRVS) as the system for paying professionals for the services
they provide to Medicare beneficiaries. The RBRVS system bases
payments on the amount of resources, or inputs, involved in
providing each individual service. The schedule of payments, or
fees, set for each service replaced the previous method of
paying based on the lesser of what was considered to be the
``customary, prevailing, or reasonable'' charge for a service.
OBRA of 1989 also established a system that created an
aggregate annual target for spending under the RBRVS, known as
Medicare Volume Performance Standards (MVPS). The MVPS system
included no significant penalty for professionals if the target
was exceeded. The RBRVS and the MVPS were implemented in 1992.
However, Congress established the SGR mechanism in the Balanced
Budget Act of 1997 (BBA) to replace MVPS as a mechanism for
constraining physician fee schedule spending because
expenditures consistently exceeded MVPS targets.
The SGR mechanism determines updates to the physician fee
schedule by establishing an annual growth allowance that is
tied to the rate of growth in the overall economy. The SGR is
cumulative, meaning that an ongoing tally of actual and target
expenditures has been maintained since the formula's inception.
If actual expenditures are lower than the cumulative target in
a year, payments for professionals' services are increased in
the following year. If actual expenditures are higher than the
cumulative target, payments for services are decreased. While
the SGR addresses payment for individual services, there is no
limit on the volume or intensity of services provided.
Actual physician fee schedule spending came in under the
target from 1997 through 2000, resulting in significant payment
increases during those years; however, since 2001, spending has
consistently exceeded the target. Accordingly, the SGR
mechanism has called for a reduction in physician fee schedule
service payments in each year since 2002. Congress has
intervened to avert the cut each year since 2003 through
numerous pieces of legislation. Starting in 2006, the
legislative efforts to override the SGR's cuts were fashioned
to reduce the cost at the time of action, but result in deeper
subsequent cuts. As a result of such legislation and the
cumulative nature of the SGR, the current projected payment
reduction to professionals' services is significant. With the
most recent Congressional intervention, through the Bipartisan
Budget Act of 2013 (P.L. 113-67), the effects of the SGR have
been delayed until March 31, 2014. Without further action,
there will be an across-the-board reduction in payments of
nearly 24 percent beginning on April 1, 2014.
The Committee believes that the SGR is flawed and needs to
be repealed. The SGR is a blunt payment mechanism based on
macro-economic indicators and has shown little ability to
influence care decisions made by individual professionals.
Further, it results in a payment increase or decrease that
applies equally to all services and professionals regardless of
their individual practice patterns. The looming threat of an
SGR payment reduction is disruptive to professionals and
threatens beneficiary access to care. Congress has spent a
total of more than $150 billion enacting numerous laws to avert
pending SGR cuts without addressing the underlying problems of
the SGR. This spending has historically been offset by policy
changes that reduce spending elsewhere in the Medicare program.
The perpetual need to address pending SGR cuts occupies an
inordinate amount of Congress' time and attention, which
detracts from other priorities. The Committee believes now is
the time to address the underlying problem by eliminating the
SGR and enacting critical payment system reforms that promote
more accountable, value-driven care.
C. Legislative History
BACKGROUND
The Chairman's Amendment in the Nature of a Substitute
(AINS) to H.R. 2810, the ``Medicare Patient Access and Quality
Improvement Act of 2013,'' was made publicly available through
the Committee's website on December 11, 2013.
COMMITTEE ACTION
The Committee marked up H.R. 2810 on December 12, 2013 and
ordered the bill favorably reported to the House of
Representatives as amended by a rollcall vote of 39 yeas and 0
nays (with a quorum being present).
COMMITTEE HEARINGS
On July 24, 2012, the Subcommittee on Health had a hearing
on physician organization efforts to enhance the value of care
delivered to patients. The Subcommittee heard testimony from:
Dr. Lawrence Riddles, President, American
College of Physician Executives;
Dr. David Bronson, President, American
College of Physicians;
Dr. Michael Weinstein, American
Gastroenterological Association;
Dr. Peter Mandrell, American Academy of
Orthopaedic Surgeons;
Aric Sharp, CEO, Quincy Medical Group,
Quincy, IL; and
Dr. John Jenrette, CEO, Sharp Community
Medical Group, San Diego, CA.
On February 7, 2012, the Subcommittee on Health had a
hearing on private payers efforts to reward professionals who
deliver high-quality and efficient care. The Subcommittee heard
testimony from:
Lewis G. Sandy, MD, Senior Vice President,
Clinical Advancement, UnitedHealth Group;
David Share, MD, MPH, Vice President, Value
Partnerships, Blue Cross Blue Shield Michigan;
Jack Lewin, MD, Chief Executive Officer,
American College of Cardiology;
John L. Bender, MD, President and CEO,
Miramont Family Medicine, Ft. Collins, Colorado; and
Len M. Nichols, PhD, Professor of Health
Policy, Director of Center for Health Policy Research
and Ethics, George Mason University.
On February 12, 2011, the Subcommittee on Health had a
hearing on innovative models that provide an alternative to
fee-for-service payments. The Subcommittee heard testimony
from:
Stuart Guterman, MA, Vice President, Payment
and System Reform/Executive Director, Commission on a
High Performance Health System, The Commonwealth Fund;
Lisa Dulsky Watkins, MD, Associate Director,
Vermont Blueprint for Health, Department of Vermont
Health Access;
Dana Gelb Safran, ScD, Senior Vice President
for Performance Measurement and Improvement, Blue Cross
Blue Shield of Massachusetts; and
Keith Wilson, MD, Chair, Governing Board and
Executive Committee, California Association of
Physician Groups.
II. EXPLANATION OF THE BILL
Section 1. Short title
The short title of the bill is the ``SGR Repeal and
Medicare Beneficiary Access Act of 2013.''
Section 2. Repealing the Sustainable Growth Rate (SGR) and improving
Medicare payment for physicians' services
PRESENT LAW
In the Omnibus Budget Reconciliation Act (OBRA) of 1989,
Congress established the Resource-Based Relative Value Scale
(RBRVS) as the system for paying professionals for the services
they provide to Medicare beneficiaries. The RBRVS system bases
payments on the amount of resources (inputs) involved in
providing each service. The schedule of payments, or fees, set
for each service replaced the previous method of paying based
on the lesser of what was considered to be the ``customary,
prevailing, or reasonable'' charge for a service.
Under the RBRVS, the Secretary assigns relative value units
(RVUs) to each of the approximately 7,500 service codes that
reflect the amount of work, practice expenses and professional
liability costs. RVU assignments are meant to reflect the
relative difference in the resources between the various
services. The assigned RVUs are then adjusted for geographic
variation in resource costs. The adjusted relative values are
then converted into a dollar payment amount by a conversion
factor.
OBRA of 1989 also established a system that created an
annual target for spending under the RBRVS, known as Medicare
Volume Performance Standards (MVPS). The MVPS system
established an aggregate annual spending target, though there
was no significant consequence if it was exceeded. The RBRVS
and the MVPS were implemented in 1992. Congress established the
SGR mechanism in the Balanced Budget Act of 1997 (BBA) as a
more forceful mechanism for constraining physician fee schedule
spending after expenditures consistently exceeded MVPS targets.
The SGR mechanism established an annual growth allowance
that tied the rate of growth in payments for professionals'
services to growth in the overall economy. The SGR is
cumulative, meaning that an ongoing tally of actual and target
expenditures has been maintained since the formula's inception.
If actual expenditures are lower than the cumulative target in
a year, payments for professionals' services are increased in
the following year. If actual expenditures are higher than the
cumulative target, payments are decreased. The BBA, however,
did not cap total spending on professionals' services. Thus,
even if payments for services were reduced, spending could
increase if more services or more costly services were
provided.
Given the state of the economy at the time, actual
physician fee schedule spending came in under the target from
1997 through 2000, which resulted in significant payment
increases during that period. However, spending has
consistently exceeded the target in subsequent years.
Accordingly, the SGR mechanism has called for a reduction in
physician fee schedule service payments in each year since
2002. Congress has intervened to avert the cut each year since
2003 through numerous pieces of legislation. As a result of
such legislation and the cumulative nature of the SGR, the
projected payment reduction to professionals' services is
significant. With the most recent Congressional intervention,
through the Bipartisan Budget Act of 2013 (P.L. 113-67), the
effects of the SGR have been delayed until March 31, 2014.
However, without further action, the SGR mechanism will result
in an across the board reduction in payments for professionals'
services of nearly 24 percent beginning on April 1, 2014.
Over time, Congress has added incentive programs that
adjust physician fee schedule payments with the intent to
improve the quality of care delivered to Medicare beneficiaries
and constrain the growth of spending for professional services.
The three main incentive programs are described below.
The Physician Quality Reporting System (PQRS) adjusts
payments based on whether professionals report on quality of
care measures. Professionals receive bonus payments for
successful reporting through 2014, with those who fail to
successfully report receiving a downward payment adjustment
starting in 2015.
The Value-Based Modifier (VBM) adjusts payment based on
quality and resource use. Adjustments are made in a budget-
neutral manner, meaning that increased payments to high
performers are funded by payment reductions to low performers.
The EHR Meaningful Use program (EHR MU) adjusts payments
based on whether a professional meets certain requirements in
the use of a certified EHR system. Professionals receive a
bonus payment through 2016, with those who fail to demonstrate
meaningful use receiving a reduction starting in 2015.
In addition, there are various Medicare alternative payment
models (APMs) available under current law, though
professionals' ability to participate in them depends on a
number of factors. Medicare pilots and demonstration projects,
which are generally mandated by Congress or established by the
Secretary using administrative authority, are often conducted
in a specific geographic area and have a limit on the number of
participants. Congress established the Medicare Shared Savings
Program (MSSP) that enables professionals and other providers
to participate as Accountable Care Organizations (ACOs) that
meet certain criteria on a nationwide basis.
COMMITTEE BILL
Stabilizing fee updates
This section permanently repeals the flawed SGR mechanism
that updates payments, averting a 23.7 percent SGR-induced cut
scheduled for January 1, 2014. Professionals receive an annual
update of 0.5 percent in 2014-2016. The rates in 2016 are
maintained through 2023. In 2023 and subsequent years,
professionals participating in APMs that meet certain criteria
receive annual updates of 2 percent, while all other
professionals receive annual updates of 1 percent.
The Medicare Payment Advisory Commission (MedPAC) is
required to submit reports to Congress in 2016 and 2020 that
assesses the relationship between spending on services
furnished by professionals under Medicare Part B and total
expenditures under Medicare Parts A, B, and D. The Committee
recognizes the critical role of professionals in directing care
and service use and believes it important to evaluate their
impact on total program spending, including under the VBP
program.
Consolidating current law programs into single incentive
program
Payments to professionals are adjusted based on performance
under a single, budget-neutral VBP starting in 2017. The VBP
streamlines and improves upon the three distinct current law
incentive programs mentioned above. The payment implications
associated with the current law incentive program penalties are
sunset at the end of 2016. The penalties that would have been
assessed under those programs remain in the payment system.
Professionals to whom VBP applies
The VBP applies to: physicians, physician assistants, nurse
practitioners, clinical nurse specialists, and certified
registered nurse anesthetists beginning in 2017. It could apply
to all others professionals paid under the physician fee
schedule beginning in 2019. While the Secretary has discretion
to decide whether to expand to these other professionals, the
Committee intends that all professionals with metrics that
enable a fair assessment of performance be included in the VBP.
Professionals who treat few Medicare beneficiaries are excluded
from the VBP. The Committee intends that this low beneficiary
volume threshold be set so as to exclude professionals whose
performance cannot be reliably assessed.
VBP assessment categories
The VBP assesses the performance of eligible professionals
in four categories: quality; resource use; EHR Meaningful Use;
and clinical practice improvement activities.
Quality measures used in PQRS are to be used for the
quality category. However, the Secretary is required to solicit
recommended measures annually and fund both professional
organizations and others to develop additional measures for
consideration. Measures used in qualified clinical data
registries can be used to assess performance. The Committee
believes that these steps promote the development and use of
measures that are meaningful to beneficiaries.
Metrics used in the current VBM program are to be used for
the resource use category. However, the methodology that the
Secretary is currently developing to identify resources
associated with specific episodes of care will be enhanced
through public input and an alternative process that directly
engages professionals. The alternative mechanism entails
professionals reporting their specific role in treating the
beneficiary (e.g., primary care or specialist) and the type of
treatment (e.g., chronic condition, acute episode) on the
billing claim form. This supplemental mechanism addresses
concerns that algorithms and attribution rules fail to
accurately link the cost of services to a professional.
Further, the section requires additional research and
recommendations on how to improve risk adjustment methodology
to ensure that professionals are not penalized for serving sick
or more costly patients. The Committee is concerned that
providers who serve individuals with complex care needs or
individuals from challenging socio-economic environments may
have greater difficulty meeting some of the goals of value-
based purchasing programs. The Secretary is required to
complete two studies--one using existing Medicare data and
another using other relevant risk factors--to examine the
effects of patient-level variables on providers' performance
under the VBP and similar Medicare programs. To the extent that
these variables are found to have an effect, the results of
these studies will be incorporated into the VBP, the Hierarchal
Condition Category (HCC), and other Medicare value-based
purchasing programs to ensure these programs accurately account
for the characteristics associated with providers' specific
patient populations. The Committee intends for the Secretary to
use this information to continually improve the accuracy
Medicare provider payments and to guard against potential
selection issues that might compromise access to care for
vulnerable populations.
The Committee believes the collection of race and ethnicity
data is incomplete and that accurate data is necessary to
better inform value-based purchasing programs. This section
requires the Secretary to develop and report to Congress on a
plan to collect and utilize this information within 18 months
of enactment.
Resource use is to be first assessed in the VBP in 2020, a
three-year delay from the 2017 start date that applies to the
other categories. The Committee believes this delay provides
more time for the development and improvement of methodologies,
including more precise risk adjustment, that allow for more
accurate resource use assessments and the associated payment
incentives.
EHR Meaningful Use requirements, demonstrated by use of a
certified system, continues to apply as the determinant of
whether professionals receive credit in this category. To
prevent duplicative reporting, professionals who report
comparable quality measures through certified EHR systems are
deemed to meet the meaningful use clinical quality measure
component.
Professionals will be assessed on their effort to engage in
clinical practice improvement activities. The menu of
recognized activities is to be established in collaboration
with professionals. Activities must be applicable to all
specialties and attainable for small practices and
professionals in rural and underserved areas. The Committee
believes that the inclusion of this category recognizes
professionals who are currently performing such activities,
prompts activities that can improve beneficiary care, and
facilitates professionals' future participation in APMs.
Amount tied to performance and performance score
determination
The funding available for VBP incentive payments is drawn
from penalties assessed on low performers. In 2017, it is equal
to 4 percent of the total estimated spending; in 2018, 6
percent; in 2019, 8 percent; and 10 percent in 2020. Starting
2021 or later, the funding pool could increase percent to 12
percent. The Committee believes that this phased-in approach,
which reduces the amount of funding tied to incentive programs
compared to current law in the initial VBP years, affords
professionals more time to acclimate to the VBP program, as
well as more time to develop meaningful quality and resource
use metrics applicable to a broad range of professionals. It
also ensures that VBP penalties remain and are redistributed
within Medicare's fee schedule.
The entire funding pool for a year is required to be paid
out in that year. Professionals' VBP payment reduction is to be
no greater than the size of the funding percentage amount for
the year (e.g., 4 percent in 2017); the maximum payment
increase is to be no greater than funding percentage amount
(e.g., 4 percent in 2017). While no professional is required to
get the minimum or maximum, the Committee believes that these
parameters provide certainty as to the potential payment
adjustment range.
Professionals are to be assessed and receive payment
adjustments based on a composite score determined by
performance on the four categories. To incentivize upward
movement, professionals also receive credit for improvement
from one year to the next in the determination of their quality
and resource use performance category scores.
As the Committee believes that professionals should be
assessed on categories, measures, and activities relevant to
their practice and important to the beneficiaries that they
treat, this section directs the Secretary to assess performance
on only those metrics that apply to a professional's practice.
Further, the Secretary is directed to ensure that professionals
who typically do not have face-to-face encounters with patients
are assessed on meaningful metrics appropriate to their
situation. The Committee intends that the Secretary will work
with these professionals to establish appropriate metrics
consistent with the intent of the categories, measures, and
activities under the VBP.
The Government Accountability Office (GAO) is required to
evaluate the VBP and issue reports in 2018 and 2021, including
an assessment of the provider types, practice sizes, practice
geography, and provider patient mix that are receiving VBP
payment increases and reductions. The Committee believes it is
important to evaluate the impact of the VBP on an on-going
basis, with these GAO reports contributing to that effort.
Expanded participation options and tools to enable success
The Committee believes it important to provide
professionals with VBP participation options that enable
engagement in the manner that best fits their practice
situation. The Committee also believes it necessary to reduce
the administrative burden associated with participation, as
well as to provide information and assistance to promote
success.
VBP participations options include: use of EHRs and
clinical quality data registries maintained by physician
specialty organizations; and the ability to be assessed as a
group, as a ``virtual'' group, or with an affiliated hospital
or other facility.
Professionals will receive confidential feedback on
performance in the quality and resource use categories on an at
least quarterly basis, likely through a web-based portal. This
system of timely and actionable feedback replaces other, less
effective mechanisms in current law. The portal allows
professionals to report VBP information, as feasible and
appropriate.
Technical assistance will be available through contracts
with appropriate entities (such as Quality Improvement
Organizations) to help practices with fewer than 20
professionals improve VBP performance or transition to APMs.
Priority is to be given to practices with low VBP scores and
those in rural and underserved areas. Funding is provided at
$50 million annually from 2014 to 2018.
Encouraging participation in APMs
The Committee encourages participation in the testing of
payment models that could serve as an alternative to the fee-
for-service payment system and intends that APMs be available
to interested professionals.
Professionals who receive a significant share of their
revenues through an APM(s) that involves risk of financial
losses and a quality measurement component receive a 5 percent
bonus each year from 2017-2022. A patient-centered medical home
APM is exempt from the downside financial risk requirement if
proven to work in the Medicare population. Two tracks are
available for professionals to qualify for the bonus. The first
option is based on receiving a significant percent of Medicare
revenue through an APM; the second is based on receiving a
significant percent of APM revenue combined from Medicare and
other payers. The second option makes it possible for
professionals to qualify for the APM bonus even if Medicare APM
options are limited in their area. Because APMs should be
designed to contain specific accountability and measurement
requirements, the Committee legislation stipulates that
professionals who participate in APMs are excluded from the VBP
assessment and most EHR meaningful use requirements.
To make the bonus opportunity available to the greatest
number of professionals, the Secretary is specifically
encouraged to test APMs relevant to specialty professionals and
professionals in small practices, as well as those models that
align with private and state-based payer initiatives.
While supportive of APM testing, the Committee highlights a
few issues worthy of exploration. The Committee believes it
prudent to examine the potential for fraud vulnerabilities
associated with new models. Thus, this section directs the
Secretary, in consultation with the Office of the Inspector
General, to provide a report to Congress identifying program
integrity vulnerabilities in new payment systems and, if found,
provide recommendations with respect to needed legislative
changes. Further, the Committee does not intend for APMs to
compromise beneficiary access to needed care or innovative
medical technologies or treatments. Scenarios that raise
potential for concern include the time lapse that is common
before the use of an approved innovation can be assessed
through a well-vetted quality measure. Likewise, it is critical
to design and monitor APMs for the possibility of stinting or
other incentives that could diminish access to needed care. The
Committee intends for the Secretary to work with stakeholders
to ensure that APMs do not discourage needed care or
innovation.
The Committee believes that APMs should be developed in
consultation with professionals and other stakeholders and that
public input can strengthen model development.
Section 3. Priorities and funding for quality measure development
PRESENT LAW
Measures for professionals are currently concentrated in
certain specialties and services while other specialties and
services have an insufficient number of measure. In addition,
many current measures are process measures rather than more
advanced measures, such as those for: outcomes; functional
status; patient experience; care coordination; and appropriate
use of services.
COMMITTEE BILL
This section addresses gaps in quality measurement programs
to ensure meaningful measures on which to assess professionals
and provides funding for measure development priorities.
The Secretary, with stakeholder input, is required to
develop and publish a plan for the development of quality
measures for use in the VBP and in APMs, by February 1, 2015.
The plan is to take into account how measures from the private
sector and integrated delivery systems can be utilized in the
Medicare program. The plan is to prioritize outcome measures,
patient experience measures, care coordination measures, and
measures of appropriate use of services, and consider gaps in
quality measurement and applicability of measures across health
care settings.
By February 1, 2016, and annually thereafter, the Secretary
is required to make public a report on the progress made in
developing quality measures. The report is to include
descriptions of the number of measures developed, including the
name and type of each measure. The report will also include
descriptions of measures under development, including an
estimated timeline for completion of such measures, as well as
quality areas being considered for future measure development.
The Secretary is required to seek stakeholder input regarding
gaps and prioritization of measure development in relation to
the annual report.
This section makes available $15 million in annual funding
in 2014 to 2018 for professional quality measure development.
The Secretary is required to contract with entities, including
physician organizations, to develop priority measures and
encourage electronic specification of such measures. The
funding remains available through fiscal year 2021. The
Committee believes that organizations receiving such contracts
should have measure development experience or otherwise
demonstrate needed capability.
The Committee intends that the funding available for
quality measure development facilitate the establishment and
use of measures that are meaningful to beneficiaries and
relevant to all professional types. The Committee believes that
the funding helps offset the development costs of new measures
that some physician organizations and other stakeholders view
as a barrier to their development and use. The Committee
intends that the Secretary work with stakeholders on an on-
going basis to facilitate meaningful measures and coordination
between developing entities.
Section 4. Encouraging care management for individuals with chronic
care needs
PRESENT LAW
The most common physician fee schedule service is a visit
to a professional's office for evaluation and management of a
beneficiary's condition. Generally, the professional must have
this type of face-to-face interaction with the beneficiary for
Medicare to pay for a service. Beneficiaries with chronic care
needs often require care management services, which typically
involve a number of interventions that occur outside the face-
to-face encounter. While payments for office visits are
calculated to include some non-face-to-face care management,
the amount is widely believed to be inadequate to properly
coordinate the care of beneficiaries with complex care needs.
In the 2014 Medicare physician fee schedule final rule, CMS
established a new payment for professionals for non-face-to-
face chronic care management services that will begin January
1, 2015. The chronic care management payment will be in
addition to the standard payment for a beneficiary visit to the
professional's office. CMS intends to develop the requirements
that a professional must meet to bill for these services
through rulemaking for the 2015 physician fee schedule.
COMMITTEE BILL
This section establishes at least one payment code for use
by professionals furnishing care management services to
individuals with chronic conditions. Payment for such services
is to be made to professionals practicing in a patient-centered
medical home or comparable specialty practice certified by an
organization(s) recognized by the Secretary beginning January
1, 2015. Only one professional or group practice can receive
payment for these services provided to an individual during a
specified period to prevent Medicare from making duplicative
payments. Payment for this code(s) is budget-neutral within the
physician fee schedule, and is not to be tied to an annual
wellness or other preventive physical examination.
Section 5. Ensuring accurate valuation of services under the Physician
Fee Schedule
PRESENT LAW
Medicare pays for more than 7,000 services under the
physician fee schedule. Payment is equal to the sum of the
relative value units (RVU)--adjusted for geographic differences
in costs--for physician work, practice expense, and
professional liability insurance for each service. A RVU
reflects the relative resources (e.g., time, overhead, etc.) of
one physician fee schedule service compared to another.
The Secretary is responsible for maintaining the physician
fee schedule, which includes refining the methodology for
establishing RVUs and modifying the RVUs assigned to each
service. In establishing RVUs, the Secretary receives
recommendations from the public, including the American Medical
Association/Relative-Value Scale Update Committee (RUC).
Modifications to RVUs for a service are done in a budget-
neutral manner. Thus, payment increases from changes to the
RVUs for some services must be offset by reductions in payment
for all other services. The Secretary is required to review the
RVUs no less than every five years.
Specifically, the Secretary is required to identify
physician fee schedule services as being potentially misvalued
on an on-going basis. To identify potentially misvalued
services, the Secretary is to examine codes (and families of
codes, as appropriate) that meet certain criteria, such as
rapid growth in use.
COMMITTEE BILL
This section promotes greater accuracy in the values that
are assigned to each individual service paid under the
physician fee schedule.
Process to facilitate accurate valuation of services
The section permits the collection of information from
professionals, other providers, and suppliers to assist in
accurate valuation of services. Such information could include:
practice expense inputs, time involved in furnishing services,
cost and charge data, and other elements. The information could
be collected via such mechanisms as surveys, practice logs,
facility records, and electronic health records. This section
makes funding available to compensate professionals who submit
the requested information starting in 2014.
It expands the list of criteria the Secretary can use to
identify services that may be misvalued to include codes: that
account for a majority of spending; with substantial changes in
procedure time; for which there may be a change in the site of
service or a significant difference in payment between sites of
service; services that may have greater efficiencies when
performed together; or with high practice expenses or high cost
supplies.
The Secretary is required to make any change to the
valuation of a service through notice and comment rulemaking.
This section also sets an annual target for identifying
misvalued services of 0.5 percent of the estimated amount of
fee schedule expenditures in 2015, 2016, 2017, and 2018. If the
target is met, that amount is redistributed in a budget-neutral
manner within the physician fee schedule. If the target is not
met, fee schedule payments for the year are reduced by the
difference between the target and the amount of misvalued
services identified in a given year. If the target is exceeded,
the amount in excess of the target is credited toward the
following year's target.
The Committee does not intend to provide the Secretary new
authority to establish or adjust service values by using
service value or payment rates established under a system for
paying other Medicare providers.
Other provisions
This section requires that downward adjustments to the
total value of a service of 20 percent or more (as compared to
the previous year) be phased-in over a two-year period. It
provides the Secretary the authority to adjust service values
to ensure that the difference between similar services is
logical. The Committee expects only minor adjustments to be
made to adjust for such differences.
The GAO is required to study the AMA/Specialty Society
Relative Value Scale Update Committee (RUC) processes for
making recommendations on the valuation of physician fee
schedule services. The report is due no later than one year
after enactment.
Adjustment to Medicare payment localities in California
This section improves the accuracy of physician fee
schedule payments to professionals in California. Beginning in
2017, California payment areas transition from county-based
localities, which have not been updated in 16 years, to
Metropolitan Statistical Areas (MSAs), which are updated
annually by the Office of Management and Budget (OMB) and
factor into Medicare payments to hospitals. Areas not in an MSA
are grouped together in a single ``rest of state'' payment
area. MSAs better reflect the population movement that has
occurred in California over that last decade and a half; under
the present law county-based locality system San Diego and
Sacramento are still classified as rural. Payments for areas
that increase are phased-in over a six-year period. Areas that
would experience a payment decrease under the new locality
determinations are held harmless in that their payments cannot
fall below the amount as it was adjusted under the county-based
locality system.
Section 6. Promoting evidence-based care
PRESENT LAW
Medicare pays for outpatient imaging services through the
physician fee schedule. Each imaging service is separated into
two separate components: a ``technical component,'' which
encompasses the overhead required to furnish the service; and a
``professional component,'' which represents the work involved
in interpreting the results.
The Deficit Reduction Act of 2005 capped the technical
component of the payment for services paid under the physician
fee schedule at the level paid under the hospital outpatient
prospective payment system effective January 1, 2007. Services
subject to the cap are: X-rays, ultrasound (including
echocardiography), nuclear medicine (including positron
emission tomography), magnetic resonance imaging, computed
tomography, and fluoroscopy.
The Secretary subsequently established and maintains
policies that reduce payment for imaging services performed on
noncontiguous body areas and the professional component for the
second and subsequent services to the same patient, in the same
session, on the same day.
The Secretary assumes a rate at which imaging machines are
operated in calculating the payment amount for imaging
services. Prior to 2011, the Secretary assumed that imaging
machines were in use 50 percent of the time (25 hours per week)
that practices are open for business. Congress required that
the assumed use rate for imaging machines increase from 50
percent to 75 percent beginning January 1, 2011. Congress
subsequently enacted legislation that will increase the assumed
use rate to 90 percent beginning January 1, 2014.
COMMITTEE BILL
The Committee supports advanced diagnostic imaging services
for beneficiaries who are in need of those services, but seeks
to ensure that they receive the most appropriate service for
their condition.
Selection of Appropriate Use Criteria (AUC)
This section requires the Secretary to establish a program
that requires consultation with AUC for advanced imaging as a
condition of Medicare payment. The Secretary is to specify one
or more AUC(s) from among those developed or endorsed by
national professional medical specialty societies or other
entities by November 15, 2015. The Secretary is to take into
account whether such criteria: have stakeholder consensus; are
evidence-based; and are in the public domain. The Committee
clarifies that the Secretary does not have the authority to
develop AUC that can be used as a condition of payment for
advanced imaging or any other Part B service.
Selection of qualified Clinical Decision Support (CDS)
mechanisms
This section requires the Secretary to identify and publish
a list of qualified CDS mechanisms, at least one of which must
be free of charge, that could be used by ordering professionals
to consult with applicable AUCs by April 1, 2016. Such
mechanisms, which could be included in, or independent from, a
certified EHR technology must: make available the applicable
AUC(s) and supporting documentation; indicate the AUC(s) being
used when more than one is available; determine the extent to
which an imaging order follows the AUC(s); provide
documentation to the ordering professional that such
consultation occurred; be updated to reflect revisions to the
AUC(s); and meet applicable privacy and security standards. The
mechanism could be required to provide feedback to the ordering
professional regarding that professional's aggregate adherence
to applicable AUC(s).
Consultation with qualified CDS mechanisms
Beginning January 1, 2017, payment is only made to the
furnishing professional for an advanced imaging service if the
claim for such service includes information: showing that the
ordering professional consulted with a qualified CDS mechanism;
as to whether the ordered service adheres to the applicable
AUC(s); and listing the national provider identifier (NPI) of
the ordering professional.
The requirement to consult with AUC(s) as a condition of
payment does not apply to advanced imaging services: ordered
for an individual with an emergency medical condition as
defined under EMTALA; paid under Part A; ordered by
professionals for individuals attributed to a APM that meets
certain criteria; or ordered by professionals who meet hardship
criteria, such as lack of Internet access.
Prior authorization
The Secretary is required to identify ordering
professionals with low adherence to applicable AUC(s)
(``outliers'') based on two years of data. Beginning January 1,
2020, outliers shall be subject to prior authorization for
specified advanced imaging services. This section provides $5
million in each of 2019, 2020, and 2021 for the Secretary to
carry out the prior authorization program.
Potential application to other services
The GAO is required to provide a report to Congress no
later than 18 months after enactment of the bill regarding
other Part B services for which the use of clinical decision
support mechanism is appropriate, such as radiation therapy and
clinical diagnostic laboratory services.
The Secretary could establish an AUC program for other Part
B services. The Secretary is required to consider the
experience with the use of AUC(s) for advanced imaging services
and the GAO report referenced above. The Secretary is required
to obtain input from stakeholders through an Advanced Notice of
Proposed Rulemaking prior to even proposing use of AUCs as
condition for payment for another service for a specific year.
The Committee intends that the Secretary use the process
established in statute for advanced imaging services if
exercising the discretion to apply AUCs as a condition for
payment for other Medicare Part B services. The Committee
strongly believes it important that AUCs be developed or
endorsed by physician specialty organizations or other
organizations representing other providers as applicable. It
clarifies that the Advanced Notice of Proposed Rulemaking is
required to ensure thorough vetting prior to expansion to
another service.
Section 7. Empowering beneficiary choices through access to information
on physician services
PRESENT LAW
Congress required the Secretary to establish a Physician
Compare website by January 1, 2011 that includes information on
the physicians and other professionals who participate in the
Physician Quality Reporting System (PQRS). The initial focus is
on quality measures collected under PQRS. The Secretary is
required to expand the information available to include
information on efficiency, safety, patient health outcomes, and
patient experience. The Secretary is required to ensure that
data made publicly available are statistically valid and
reliable. The Secretary is required to report to Congress on
the Compare website not later than January 1, 2015.
COMMITTEE BILL
The Committee believes it is important to make information
on professionals' services publicly available to empower
beneficiaries in making decisions about their health care.
Not later than July 1, 2015, for physicians and July 1,
2016, for other professionals, this section requires the
Secretary to make utilization and payment data publicly
available through the Medicare ``Physician Compare'' website.
Such information is to include the number of services
furnished, the charges submitted, and payments made for such
services. The information is required to be searchable by the
eligible professional name, provider type, specialty, location,
and services furnished.
This section requires that the website indicate that the
information may not be representative of the professional's
entire patient population, variety of services furnished, or
the health conditions of the individuals treated. Professionals
must be given an opportunity to review and correct this
information prior to its posting on the website.
The Committee expects that this information be presented in
an easily understandable manner. The Committee believes that
beneficiaries benefit most from information on the services (or
group of similar services) that the professional furnishes most
frequently.
Section 8. Expanding claims data availability to improve care
PRESENT LAW
Congress established a program that requires the Secretary
to make claims data available to qualified entities (QEs) that
can be used to measure health care provider performance. The
Secretary provides QEs with standardized extracts of Medicare
Parts A, B, and D claims data for one or more specified
geographic areas and time periods. The fees for making data
available are to be equal to the cost of providing the data.
The Secretary must take action necessary to protect the
identity of beneficiaries.
To be certified as a QE, entities must agree to: use claims
data to evaluate the performance of providers on measures of
quality, efficiency, effectiveness, and resource use;
requirements governing the use of the data; and make
performance reports on providers public.
When requesting Medicare data, a QE must submit to the
Secretary a description of the methodologies that will be used
to evaluate provider performance. They must also combine the
Medicare data with claims data from another source.
A QE's public reports must include descriptive information
on elements such as the quality measures and the professional
attribution method used. Prior to their public release, any
professional or other provider must be given an opportunity to
appeal and correct errors.
Data released to a QE is not subject to discovery or
admission as evidence in judicial or administrative proceedings
without consent of the applicable provider.
COMMITTEE BILL
Qualified entities
Consistent with relevant privacy and security laws,
entities that currently receive Medicare data for public
reporting purposes (qualified entities, ``QEs'') are permitted
to provide or sell non-public analyses and claims data to
physicians, other professionals, providers, medical societies,
and hospital associations to assist them in their quality
improvement activities. In order to ensure data security, the
claims data are only to be accessible through a qualified data
enclave (e.g., a web-based portal) from which the data could
not be extracted. Any data or analyses must be de-identified,
except for services furnished by the provider accessing the
data enclave or receiving an analysis. QEs are permitted to
provide or sell non-public analyses to health insurers and
self-insured employers (only for purposes of providing health
insurance to their employees or retirees). Providers identified
in such analyses must be given an opportunity to review and
submit corrections before the QE provides or sells the analysis
to other entities.
QEs that provide or sell analyses or provide access to a
data enclave are required to provide an annual report to the
Secretary that includes an accounting of: the analyses provided
or sold, including the number of analysis and purchasers, fees
received, the topics and purposes; and access to the data
enclave, including fees received, the entities that accessed
the enclave, and how such data were used. Claims data available
to QEs is expanded to include Medicaid and Children's Health
Insurance Program data.
Qualified clinical data registries
Consistent with relevant privacy and security laws, the
Secretary is required to make data available, for a fee that
covers the cost of preparing the data, to qualified clinical
data registries to support quality improvement and patient
safety activities. Such registries must obtain consent prior to
publicly reporting any data or analysis based on such data that
is not de-identified.
Section 9. Reducing administrative burden and other provisions
PRESENT LAW
Physicians and some other professionals can ``opt-out'' of
Medicare by informing the Secretary and providing certain
information, including an affidavit. Professionals who opt out
are generally prohibited from billing Medicare for services
provided to any beneficiary for a two-year period. The
professional has to inform the Secretary and provide the
required information for each two-year opt-out period.
There is currently no requirement that the Secretary make
public information on the number and characteristics of
professionals who opt-out of Medicare.
Enrolled professionals identify annually whether they are
Medicare ``participating'' or ``non-participating.''
Participating professionals agree to accept the physician fee
schedule amount, referred to as the ``allowed'' amount, as the
full payment for the service provided. Medicare makes its
payment, typically 80 percent of the allowed amount, directly
to the professional; the professional collects the remainder of
the allowed amount from the beneficiary. Non-participating
professionals can collect up to 115 percent of the Medicare
allowed amount for a service. Medicare makes its payment, which
is 75 percent of the allowed amount, to the beneficiary; the
professional collects the full amount up to the 115 ``limiting
charge'' from the beneficiary.
Under the EHR MU program, professionals must meet
progressively rigorous requirements as established by the
Secretary to demonstrate they are using an EHR in a meaningful
way. The Secretary published the requirements for the second of
three planned stages in 2012. These ``Stage 2'' rules require
that a professional's EHR has exchanged information with at
least one other EHR product. Stage 2 requirements do not
emphasize interoperability between the wide variety of EHR
products or widespread sharing of relevant information across
provider settings and geographic areas.
COMMITTEE BILL
Rule of Construction regarding standard of care
This section provides that the development, recognition, or
implementation of any guideline or other standard under any
Federal health care provision, including Medicare, cannot be
construed to establish the standard of care or duty of care
owed by a health care professional to a patient in any medical
malpractice or medical product liability action or claim.
Other provisions
This section: allows professionals who opt-out of Medicare
to automatically renew at the end of each two-year cycle;
requires regular reporting of opt-out professional
characteristics; creates a demonstration project where Medicare
pays a non-participating professional directly instead of
paying a beneficiary for Medicare-approved services; requires
that EHR programs be interoperable by 2019 and prohibits
providers from deliberately blocking information sharing with
other EHR vendor products; requires the Secretary to issue a
report recommending how a permanent physician-hospital
gainsharing program can best be established; and requires GAO
to report on barriers to expanded use of telemedicine.
III. Votes of the Committee
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, the following statements are made
concerning the votes of the Committee on its consideration of
the AINS to H.R. 2810.
The bill, the ``SGR Repeal and Medicare Beneficiary Access
Act of 2013,'' was ordered favorably reported to the House of
Representatives as amended by a rollcall vote of 39 yeas and 0
nays (with a quorum being present). The vote was as follows:
VOTES OF THE COMMITTEE
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 2810 ``Medicare Patient Access and
Quality Improvement Act of 2013.''
The bill, H.R. 2810, was ordered favorably reported by a
rollcall vote of 39 yeas to 0 nays (with a quorum being
present). The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Camp....................... X ........ ......... Mr. Levin........ X ........ .........
Mr. Johnson.................... X ........ ......... Mr. Rangel....... X ........ .........
Mr. Brady...................... X ........ ......... Mr. McDermott.... X ........ .........
Mr. Ryan....................... X ........ ......... Mr. Lewis........ X ........ .........
Mr. Nunes...................... X ........ ......... Mr. Neal......... X ........ .........
Mr. Tiberi..................... X ........ ......... Mr. Becerra...... X ........ .........
Mr. Reichert................... X ........ ......... Mr. Doggett...... X ........ .........
Mr. Boustany................... X ........ ......... Mr. Thompson..... X ........ .........
Mr. Roskam..................... X ........ ......... Mr. Larson....... X ........ .........
Mr. Gerlach.................... X ........ ......... Mr. Blumenauer... X ........ .........
Mr. Price...................... X ........ ......... Mr. Kind......... X ........ .........
Mr. Buchanan................... X ........ ......... Mr. Pascrell..... X ........ .........
Mr. Smith...................... X ........ ......... Mr. Crowley...... X ........ .........
Mr. Schock..................... X ........ ......... Ms. Schwartz..... X ........ .........
Ms. Jenkins.................... X ........ ......... Mr. Davis........ X ........ .........
Mr. Paulsen.................... X ........ ......... Ms. Sanchez...... X ........ .........
Mr. Marchant................... X ........ .........
Ms. Black...................... X ........ .........
Mr. Reed....................... X ........ .........
Mr. Young...................... X ........ .........
Mr. Kelly...................... X ........ .........
Mr. Griffin.................... X ........ .........
Mr. Renacci.................... X ........ .........
----------------------------------------------------------------------------------------------------------------
Votes on Amendments
No amendments to the bill were offered.
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
In compliance with clause 3(d) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the effects on the budget of the revenue provisions
of the bill as reported: The Committee agrees with the
estimates prepared by the Congressional Budget Office (CBO),
which is included below.
Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee finds that the
bill would result in increased expenditures of $121 billion
over the 2014-2023 budget window.
B. Cost Estimate Prepared by the Congressional Budget Office
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, requiring a cost estimate
prepared by the CBO, the following statement by CBO is
provided.
U.S. Congress,
Congressional Budget Office,
Washington, DC, January 24, 2014.
Hon. Dave Camp,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 2810, the SGR
Repeal and Medicare Beneficiary Access Act of 2013.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lori Housman.
Sincerely,
Douglas W. Elmendorf.
Enclosure.
H.R. 2810--SGR Repeal and Medicare Beneficiary Access Act of 2013
Summary: H.R. 2810 would replace the Sustainable Growth
Rate (SGR) formula, which determines the annual updates to
payment rates for physician services in Medicare, with new
systems for establishing those payment rates. CBO estimates
that enacting H.R. 2810 would increase direct spending by about
$121 billion over the 2014-2023 period. (The legislation would
not affect federal revenues.) Pay-as-you-go procedures apply to
this legislation because it would affect direct spending.
H.R. 2810 would impose an intergovernmental mandate as
defined in the Unfunded Mandates Reform Act (UMRA) by
preempting state laws governing the evidentiary rules and
practices of medical malpractice claims. CBO estimates that the
costs of the intergovernmental mandate would be small and would
not exceed the threshold established in UMRA ($76 million in
2014, adjusted annually for inflation). The bill contains no
private-sector mandates as defined in UMRA.
Estimated cost to the federal government: The estimated
budgetary impact of H.R. 2810 is shown in the following table.
The costs of this legislation fall within budget functions 570
(Medicare) and 550 (health).
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in billions of dollars--
-----------------------------------------------------------------------------------------------------
2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2014-2018 2014-2023
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Estimated Budget Authority........................ 5.3 10.6 10.9 11.1 10.7 12.0 13.5 14.9 16.5 15.5 48.7 121.1
Estimated Outlays................................. 5.3 10.6 10.9 11.1 10.7 12.0 13.5 14.9 16.5 15.5 48.7 121.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Components may not sum to totals because of rounding.
Background and major provisions: Medicare compensates
physicians for services they provide on the basis of a fee
schedule that specifies payment rates for each type of covered
service. Payment rates are based on a measure of the resources
required to provide a given service (measured in relative value
units or RVUs), adjusted to account for geographical
differences in input prices, and translated into a dollar
amount by applying a ``conversion factor.'' The SGR formula
determines the annual update to the conversion factor. Under
current law, Medicare's payment rates for physicians' services
are slated to drop by about 24 percent in April 2014, and CBO
projects those payment rates will increase by small amounts in
most subsequent years but will remain below current levels
throughout the next 10 years.
The Bipartisan Budget Act of 2013 (enacted as Public Law
113-67 in December of last year) made multiple changes to the
Medicare program, including providing for a temporary increase
of one-half percent in payment rates for services on the
physician fee schedule furnished during January through March
of 2014. As a result, conforming changes would have to be made
to the version of H.R. 2810 that was approved by the Committee
on Ways and Means earlier in December for its provisions to
have the intended effects on Medicare payment rates. This
estimate reflects the assumption that the legislation will
include such conforming changes.
H.R. 2810 would replace the SGR with new payment systems
over the next several years. The major provisions of the new
payment systems specified in H.R. 2810 are as follows:
The bill would increase Medicare's payment rates
for services on the physician fee schedule by 0.5 percent for
services furnished during calendar year 2015 and by another 0.5
percent for services furnished during 2016. (The Bipartisan
Budget Act increased those payment rates by 0.5 percent for the
first three months of calendar year 2014. This estimate assumes
that conforming changes to H.R. 2810 would maintain payment
rates at those levels for services on the physician fee
schedule for the rest of calendar year 2014.)
Payment rates for services on the physician fee
schedule would remain at the 2016 level through 2023, but the
amounts paid to individual providers would be subject to
adjustment through one of two mechanisms, depending on whether
the physician chooses to participate in a Value-Based
Performance Incentive (VBP) program or an Alternative Payment
Model (APM) program. (Both programs are described at greater
length below.)
Payments to providers who participate in the VBP
program would be subject to positive or negative performance
adjustments financed through a funding pool, with the positive
and negative adjustments designed to be offsetting so that they
have no net effect on overall payments. The performance
adjustments could be as large as 4-percent of the amounts paid
on the physician fee schedule for services provided by
physicians participating in the VBP program in 2017, and that
percentage would increase to between 10 percent and 12 percent
in 2021 and subsequent years. The performance adjustment for an
individual provider would depend on that provider's
performance.
Payments to providers who participate in an APM
program (in particular, who receive a substantial portion of
their revenue from alternative payment models) would receive,
in 2017 through 2022, a lump-sum payment equal to 5 percent of
their Medicare payments in the prior year for services paid on
the physician fee schedule. Providers with revenue close to the
APM revenue threshold would receive either no adjustment to
their Medicare payments or the VBP performance adjustment if
they reported measures and activities in that program.
Providers would not be eligible for a lump-sum payment in 2023.
For 2024 and subsequent years, there would be
two payment rates for services paid on the physician fee
schedule. For providers paid through the VBP program, payment
rates would be increased each year by 1 percent. For providers
paid through an APM, payment rates would be increased each year
by 2 percent.
In addition, the bill would eliminate current-law penalties
for providers who do not achieve meaningful use of electronic
health records or satisfactorily report data on quality.
However, physicians would have to meet standards for use of EHR
and quality as part of the VBP program. Also, the bill would
modify payment rates in certain California counties, adjust
relative value units for certain physicians' services, and
require the development of payment codes that would encourage
care coordination and the use of medical homes.
Value-Based Performance Incentive Program
The legislation would establish a VBP that would measure
the total performance of physicians and other medical providers
based on information reported by those providers regarding
quality measures, clinical practice improvement activities,
resource use, and meaningful use of electronic health records.
The Secretary of Health and Human Services would develop a
methodology to assess total performance and determine a
composite score. Beginning in 2017, providers with higher
composite scores would receive positive performance adjustments
and providers with lower composite scores would receive no or
negative performance adjustments. The performance adjustments
would not increase Medicare spending because reductions in
payments made to providers with lower composite scores would be
used to provide higher performance adjustments to providers
with higher composite scores.
The Secretary would establish a funding pool to be used to
distribute VBP payment adjustments by modifying the amount paid
for each service based on the provider's composite score. The
funding pool would rise from 4 percent of total payments under
the physician fee schedule in 2017 to between 10 percent and
12-percent in 2021 and subsequent years.
Alternative Payment Model (APM) Program
From 2017 through 2022, certain providers who participate
in eligible APMs would receive a lump-sum incentive payment
equal to 5 percent of their aggregate payments from Medicare
for the preceding year.
The legislation specifies the following types of Medicare-
eligible APMs:
Models that: (1) require the provider to
bear financial risk, meet standards related to the use
of electronic medical records, and meet quality
measures comparable to the VBP program, and (2) are
being tested through a demonstration program (or have
been expanded after being tested) under Medicare or the
Center for Medicare and Medicaid Innovation (CMMI); or
A medical home program expanded after a
successful demonstration conducted by CMMI that meets
standards related to the use of electronic medical
records and quality measures.
For 2017 and 2018, a provider would be eligible for the
lump-sum payment of 5 percent if at least 25 percent of the
provider's Medicare payments were for services furnished in an
eligible APM. Providers who do not come within 5 percentage
points of the Medicare share-of-revenue threshold would be
subject to the rules of the VBP program. However, a provider
who comes within 5 percentage points of meeting the threshold
could choose between being paid the fee-schedule amount
(without further adjustment) or being paid under the rules of
the VBP program.
Beginning in 2019, the threshold for the share of revenue
from eligible APMs necessary to be eligible for the lump-sum
payment of 5 percent would rise, but the provider could count
revenue from comparable non-Medicare APMs. Also beginning in
that year, providers with revenue from an APM that is close to
those thresholds would have a choice similar to that facing
providers close to the thresholds in 2017 and 2018.
Basis of estimate: CBO estimates that enacting H.R. 2810
would increase direct spending by $48.7 billion over the 2014-
2018 period and $121.1 billion over the 2014-2023 period,
assuming enactment in the spring of 2014. Nearly all of the
estimated increase in spending would stem from the specified
updates to payment rates for services paid on the physician fee
schedule. CBO estimates that maintaining current payment rates
for the rest of 2014, providing 0.5 percent updates for 2015
and 2016, and then maintaining the 2016 level through 2023
would increase Medicare spending by $118.4 billion over the
2014-2023 period.
In addition, CBO estimates that establishing the VBP and
APM programs with the opportunity for providers to choose to
participate in only one of the programs would increase Medicare
spending by $5.5 billion through 2023. That estimate largely
reflects CBO's expectation that each provider will choose the
program that is most attractive financially to that provider.
Other provisions in the bill would modify payment rates in
certain California counties, adjust RVUs for certain
physicians' services, require the development of payment codes
that would encourage care coordination and the use of medical
homes, and eliminate current-law penalties associated with not
meeting quality or EHR standards. Those provisions would result
in estimated net savings of $2.8 billion through 2023.
CBO's estimate of the budgetary effects of the legislation
incorporates the effects of: changes in Medicare spending for
services furnished in the fee-for-service sector on payments to
Medicare Advantage (MA) plans; changes in receipts from
premiums paid by beneficiaries; an increased likelihood that
the Independent Payment Advisory Board (IPAB) mechanism would
be triggered; and changes in spending by the Department of
Defense's TRICARE program owing to changes in Medicare payment
rates:
Spending for the MA program would rise because
the ``benchmarks'' that Medicare uses to determine how much the
program pays for MA enrollees are adjusted for changes in
Medicare spending per beneficiary in the fee-for-service
sector. There would be no impact on MA spending under H.R. 2810
until 2016 because the payment rates currently in effect
through March of 2014 will be used to set benchmarks for 2015.
The effect on MA would account for about $42 billion of the
total estimated increase in direct spending from the
legislation over the 2015-2023 period.
Beneficiaries enrolled in Part B of Medicare
(which covers physicians' and other outpatient services) pay
premiums that offset about 25 percent of the costs of those
benefits. Such premium collections are recorded as offsetting
receipts (a credit against direct spending). Therefore, about
one-quarter of the gross increase in Medicare spending would be
offset by changes in those premium receipts. Premiums for 2014
have been set, so changes to offsetting receipts for this
legislation would begin in 2015. Over the 2015-2023 period, CBO
estimates that aggregate Part B premium receipts would rise by
about $35 billion.
For 2015 and subsequent years, the IPAB is
obligated to make changes to the Medicare program that will
reduce spending if the rate of growth in spending per
beneficiary is projected to exceed a target rate of growth
linked to the consumer price index and per capita changes in
nominal gross domestic product. CBO's projections of the rates
of growth in spending per beneficiary in its May 2013 baseline
are below the target rates of growth for fiscal years 2015
through 2023. However, enacting H.R. 2810 would increase
Medicare spending, which would increase the likelihood that the
IPAB mechanism would be triggered. CBO estimates the expected
value of the savings from triggering the IPAB mechanism would
be a $0.5 billion reduction in Medicare spending over the 2015-
2023 period.
The TRICARE program pays Medicare coinsurance
and deductibles for military retirees. Those coinsurance and
deductible payments would be higher under the legislation
because the prices of physicians' services in Medicare would be
higher. CBO estimates that the effect on TRICARE from the
legislation would increase direct spending by about $1 billion
over ten years.
Pay-As-You-Go considerations: The Statutory Pay-As-You-Go
(S-PAYGO) Act of 2010 establishes budget-reporting and
enforcement procedures for legislation affecting direct
spending or revenues for the current year and ten years
beginning with the budget year as defined by the Balanced
Budget and Emergency Deficit Control Act. Beginning in January
2014, the budget year is fiscal year 2015, so the following S-
PAYGO estimates go through 2024. The net changes in outlays
that are subject to those pay-as-you-go procedures are shown in
the following table.
CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 2810, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON WAYS AND MEANS ON DECEMBER 12, 2013
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in billions of dollars--
-------------------------------------------------------------------------------------------------------------
2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2014-2019 2014-2024
--------------------------------------------------------------------------------------------------------------------------------------------------------
NET INCREASE IN THE DEFICIT
Statutory Pay-As-You-Go Impact............ 5.3 10.6 10.9 11.1 10.7 12.0 13.5 14.9 16.5 15.5 16.2 60.7 137.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Estimated impact on state, local, and tribal governments:
H.R. 2810 would shield health care providers from liability
claims based on any federal guidelines or standards developed,
recognized, or implemented under any health care provision of
the Affordable Care Act. That provision would impose an
intergovernmental mandate as defined in UMRA because it would
preempt state laws that allow for the use of such guidelines or
standards in medical malpractice claims. While the preemption
would limit the application of state laws, CBO estimates that
it would not impose significant costs and would fall well below
the threshold established in UMRA for intergovernmental
mandates ($76 million in 2014, adjusted annually for
inflation).
Estimated impact on the private sector: This bill contains
no new private-sector mandates as defined in UMRA.
Previous CBO estimate: On September 13, 2013, CBO estimated
that enacting H.R. 2810 as ordered reported by the House
Committee on Energy and Commerce on July 31, 2013, would cost
about $175 billion over the 2014-2023 period. We have
subsequently reduced that estimate to $146 billion, reflecting
two final actions. First, the Centers for Medicare and Medicaid
Services published a final rule that announced the update to
the conversion factor for the physician fee schedule for 2014
and other current-law adjustments. The revised payment rates,
as well as other information provided in the final rule,
changed CBO's projections of Medicare payment rates for
services provided on the physician fee schedule for 2014 and
future years. Second, enactment of the Bipartisan Budget Act of
2013 temporarily sets updates to payment rates for services on
the physician fee schedule to 0.5 percent from January 1, 2014,
to March 31, 2014.
This estimate for the Ways and Means version of H.R. 2810
reflects both of those final actions. CBO's estimate for the
version of H.R. 2810 approved by the Committee on Ways and
Means is lower than CBO's estimate for the version of H.R. 2810
approved by the Committee on Energy and Commerce primarily
because of lower annual updates to payment rates for services
on the physician fee schedule and lower costs associated with
payments made through APMs.
Estimate prepared by: Federal Costs: Lori Housman; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Alexia Diorio.
Estimate approved by: Holly Harvey, Deputy Assistant
Director for Budget Analysis.
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE OF
REPRESENTATIVES
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee held hearings and
made findings that are reflected in this report.
B. Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the performance goals and
objectives of the Committee are reflected in the descriptive
portions of this report.
C. Duplication of Federal Programs
No provision of the bill establishes or reauthorizes a
program of the Federal Government known to be duplicative of
another Federal program, a program that was included in any
report from the Government Accountability Office to Congress
pursuant to section 21 of Public Law 111-139, or a program
related to a program identified in the most recent Catalog of
Federal Domestic Assistance.
D. Information Related to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Act of 1995 (Public Law 104-4). The
Committee adopts as its own the estimate of Federal mandates
prepared by the Director of the Congressional Budget Office.
E. Applicability to House Rule XXI 5(b)
Clause 5(b) of rule XXI of the Rules of the House of
Representatives provides, in part, that ``A bill or joint
resolution, amendment, or conference report carrying a Federal
income tax rate increase may not be considered as passed or
agreed to unless so determined by a vote of not less than
three-fifths of the Members voting, a quorum being present.''
The Committee states that the bill does not involve any Federal
income tax rate increases within the meaning of the rule.
F. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee states that the
provisions of the bill do not contain any congressional
earmarks, limited tax benefits, or limited tariff benefits
within the meaning of the rule.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
SOCIAL SECURITY ACT
* * * * * * *
TITLE XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE
SIMPLIFICATION
* * * * * * *
Part A--General Provisions
* * * * * * *
center for medicare and medicaid innovation
Sec. 1115A. (a) * * *
* * * * * * *
(b) Testing of Models (Phase I).--
(1) * * *
(2) Selection of models to be tested.--
(A) * * *
(B) Opportunities.--The models described in
this subparagraph are the following models:
(i) * * *
* * * * * * *
(xxi) Focusing primarily on
physicians' services (as defined in
section 1848(j)(3)) furnished by
physicians who are not primary care
practitioners.
(xxii) Focusing on practices of fewer
than 20 professionals.
(C) Additional factors for consideration.--In
selecting models for testing under subparagraph
(A), the CMI may consider the following
additional factors:
(i) * * *
* * * * * * *
(viii) Whether the model demonstrates
effective linkage with [other public
sector or private sector payers] other
public sector payers, private sector
payers, or Statewide payment models.
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
free choice by patient guaranteed
Sec. 1802. (a) * * *
(b) Use of Private Contracts by Medicare Beneficiaries.--
(1) * * *
* * * * * * *
(3) Physician or practitioner requirements.--
(A) * * *
(B) Affidavit.--An affidavit is described in
this subparagraph if--
(i) * * *
(ii) the affidavit provides that the
physician or practitioner will not
submit any claim under this title for
any item or service provided to any
medicare beneficiary (and will not
receive any reimbursement or amount
described in paragraph (1)(B) for any
such item or service) [during the 2-
year period beginning on the date the
affidavit is signed] during the
applicable 2-year period (as defined in
subparagraph (D)); and
* * * * * * *
(C) Enforcement.--If a physician or
practitioner signing an affidavit under
subparagraph (B) knowingly and willfully
submits a claim under this title for any item
or service provided [during the 2-year period
described in subparagraph (B)(ii)] during the
applicable 2-year period (or receives any
reimbursement or amount described in paragraph
(1)(B) for any such item or service) with
respect to such affidavit--
(i) * * *
* * * * * * *
(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.
* * * * * * *
(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.
[(5)] (6) Definitions.--In this subsection:
(A) * * *
* * * * * * *
(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).
* * * * * * *
Part B--Supplementary Medical Insurance Benefits for the Aged and
Disabled
* * * * * * *
PAYMENT OF BENEFITS
Sec. 1833. (a) * * *
* * * * * * *
(t) Prospective Payment System for Hospital Outpatient
Department Services.--
(1) * * *
* * * * * * *
(16) Miscellaneous provisions.--
(A) * * *
* * * * * * *
(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).
* * * * * * *
(x) Incentive Payments for Primary Care Services.--
(1) * * *
* * * * * * *
(3) Coordination with other payments.--The amount of
the additional payment for a service under this
subsection and subsection (m) shall be determined
without regard to any additional payment for the
service under subsection (m) and this subsection,
respectively. 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.
* * * * * * *
(y) Incentive Payments for Major Surgical Procedures
Furnished in Health Professional Shortage Areas.--
(1) * * *
* * * * * * *
(3) Coordination with other payments.--The amount of
the additional payment for a service under this
subsection and subsection (m) shall be determined
without regard to any additional payment for the
service under subsection (m) and this subsection,
respectively. 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.
* * * * * * *
(z) Incentive Payments for Participation in Eligible
Alternative Payment Models.--
(1) Payment incentive.--
(A) In general.--In the case of covered
professional services furnished by an eligible
professional during a year that is in the
period beginning with 2017 and ending with 2022
and for which the professional is a qualifying
APM participant, in addition to the amount of
payment that would otherwise be made for such
covered professional services under this part
for such year, there also shall be paid to such
professional an amount equal to 5 percent of
the payment amount for the covered professional
services under this part for the preceding
year. For purposes of the previous sentence,
the payment amount for the preceding year may
be an estimation for the full preceding year
based on a period of such preceding year that
is less than the full year. The Secretary shall
establish policies to implement this
subparagraph in cases where payment for covered
professional services furnished by a qualifying
APM participant in an alternative payment model
is made to an entity participating in the
alternative payment model rather than directly
to the qualifying APM participant.
(B) Form of payment.--Payments under this
subsection shall be made in a lump sum, on an
annual basis, as soon as practicable.
(C) Treatment of payment incentive.--Payments
under this subsection shall not be taken into
account for purposes of determining actual
expenditures under an alternative payment model
and for purposes of determining or rebasing any
benchmarks used under the alternative payment
model.
(D) Coordination.--The amount of the
additional payment for an item or service under
this subsection or subsection (m) shall be
determined without regard to any additional
payment for the item or service under
subsection (m) and this subsection,
respectively. The amount of the additional
payment for an item or service under this
subsection or subsection (x) shall be
determined without regard to any additional
payment for the item or service under
subsection (x) and this subsection,
respectively. The amount of the additional
payment for an item or service under this
subsection or subsection (y) shall be
determined without regard to any additional
payment for the item or service under
subsection (y) and this subsection,
respectively.
(2) Qualifying APM participant.--For purposes of this
subsection, the term ``qualifying APM participant''
means the following:
(A) 2017 and 2018.--With respect to 2017 and
2018, an eligible professional for whom the
Secretary determines that at least 25 percent
of payments under this part for covered
professional services furnished by such
professional during the most recent period for
which data are available (which may be less
than a year) were attributable to such services
furnished under this part through an entity
that participates in an eligible alternative
payment model with respect to such services.
(B) 2019 and 2020.--With respect to 2019 and
2020, an eligible professional described in
either of the following clauses:
(i) Medicare revenue threshold
option.--An eligible professional for
whom the Secretary determines that at
least 50 percent of payments under this
part for covered professional services
furnished by such professional during
the most recent period for which data
are available (which may be less than a
year) were attributable to such
services furnished under this part
through an entity that participates in
an eligible alternative payment model
with respect to such services.
(ii) Combination all-payer and
Medicare revenue threshold option.--An
eligible professional--
(I) for whom the Secretary
determines, with respect to
items and services furnished by
such professional during the
most recent period for which
data are available (which may
be less than a year), that at
least 50 percent of the sum
of--
(aa) payments
described in clause
(i); and
(bb) all other
payments, regardless of
payer (other than
payments made by the
Secretary of Defense or
the Secretary of
Veterans Affairs under
chapter 55 of title 10,
United States Code, or
title 38, United States
Code, or any other
provision of law),
meet the requirement described
in clause (iii)(I) with respect
to payments described in item
(aa) and meet the requirement
described in clause (iii)(II)
with respect to payments
described in item (bb);
(II) for whom the Secretary
determines at least 25 percent
of payments under this part for
covered professional services
furnished by such professional
during the most recent period
for which data are available
(which may be less than a year)
were attributable to such
services furnished under this
part through an entity that
participates in an eligible
alternative payment model with
respect to such services; and
(III) who provides to the
Secretary such information as
is necessary for the Secretary
to make a determination under
subclause (I), with respect to
such professional.
(iii) Requirement.--For purposes of
clause (ii)(I)--
(I) the requirement described
in this subclause, with respect
to payments described in item
(aa) of such clause, is that
such payments are made under an
eligible alternative payment
model; and
(II) the requirement
described in this subclause,
with respect to payments
described in item (bb) of such
clause, is that such payments
are made under an arrangement
in which--
(aa) quality measures
comparable to measures
under the performance
category described in
section
1848(q)(2)(B)(i) apply;
(bb) certified EHR
technology is used; and
(cc) the eligible
professional bears more
than nominal financial
risk if actual
aggregate expenditures
exceeds expected
aggregate expenditures.
(C) Beginning in 2021.--With respect to 2021
and each subsequent year, an eligible
professional described in either of the
following clauses:
(i) Medicare revenue threshold
option.--An eligible professional for
whom the Secretary determines that at
least 75 percent of payments under this
part for covered professional services
furnished by such professional during
the most recent period for which data
are available (which may be less than a
year) were attributable to such
services furnished under this part
through an entity that participates in
an eligible alternative payment model
with respect to such services.
(ii) Combination all-payer and
Medicare revenue threshold option.--An
eligible professional--
(I) for whom the Secretary
determines, with respect to
items and services furnished by
such professional during the
most recent period for which
data are available (which may
be less than a year), that at
least 75 percent of the sum
of--
(aa) payments
described in clause
(i); and
(bb) all other
payments, regardless of
payer (other than
payments made by the
Secretary of Defense or
the Secretary of
Veterans Affairs under
chapter 55 of title 10,
United States Code, or
title 38, United States
Code, or any other
provision of law),
meet the requirement described
in clause (iii)(I) with respect
to payments described in item
(aa) and meet the requirement
described in clause (iii)(II)
with respect to payments
described in item (bb);
(II) for whom the Secretary
determines at least 25 percent
of payments under this part for
covered professional services
furnished by such professional
during the most recent period
for which data are available
(which may be less than a year)
were attributable to such
services furnished under this
part through an entity that
participates in an eligible
alternative payment model with
respect to such services; and
(III) who provides to the
Secretary such information as
is necessary for the Secretary
to make a determination under
subclause (I), with respect to
such professional.
(iii) Requirement.--For purposes of
clause (ii)(I)--
(I) the requirement described
in this subclause, with respect
to payments described in item
(aa) of such clause, is that
such payments are made under an
eligible alternative payment
model; and
(II) the requirement
described in this subclause,
with respect to payments
described in item (bb) of such
clause, is that such payments
are made under an arrangement
in which--
(aa) quality measures
comparable to measures
under the performance
category described in
section
1848(q)(2)(B)(i) apply;
(bb) certified EHR
technology is used; and
(cc) the eligible
professional bears more
than nominal financial
risk if actual
aggregate expenditures
exceeds expected
aggregate expenditures.
(2) Additional definitions.--In this subsection:
(A) Covered professional services.--The term
``covered professional services'' has the
meaning given that term in section
1848(k)(3)(A).
(B) Eligible professional.--The term
``eligible professional'' has the meaning given
that term in section 1848(k)(3)(B).
(C) Alternative payment model (APM).--The
term ``alternative payment model'' means any of
the following:
(i) A model under section 1115A
(other than a health care innovation
award).
(ii) An accountable care organization
under section 1899.
(iii) A demonstration under section
1866C.
(iv) A demonstration required by
Federal law.
(D) Eligible alternative payment model
(APM).--
(i) In general.--The term ``eligible
alternative payment model'' means, with
respect to a year, an alternative
payment model--
(I) that requires use of
certified EHR technology (as
defined in subsection (o)(4));
(II) that provides for
payment for covered
professional services based on
quality measures comparable to
measures under the performance
category described in section
1848(q)(2)(B)(i); and
(III) that satisfies the
requirement described in clause
(ii).
(ii) Additional requirement.--For
purposes of clause (i)(III), the
requirement described in this clause,
with respect to a year and an
alternative payment model, is that the
alternative payment model--
(I) is one in which one or
more entities bear financial
risk for monetary losses under
such model that are in excess
of a nominal amount; or
(II) is a medical home
expanded under section
1115A(c).
(3) Limitation.--There shall be no administrative or
judicial review under section 1869, 1878, or otherwise,
of the following:
(A) The determination that an eligible
professional is a qualifying APM participant
under paragraph (2) and the determination that
an alternative payment model is an eligible
alternative payment model under paragraph
(3)(D).
(B) The determination of the amount of the 5
percent payment incentive under paragraph
(1)(A), including any estimation as part of
such determination.
SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
Sec. 1834. (a) * * *
* * * * * * *
(p) Recognizing Appropriate Use Criteria for Certain Imaging
Services.--
(1) Program established.--
(A) In general.--The Secretary shall
establish a program to promote the use of
appropriate use criteria (as defined in
subparagraph (B)) for applicable imaging
services (as defined in subparagraph (C))
furnished in an applicable setting (as defined
in subparagraph (D)) by ordering professionals
and furnishing professionals (as defined in
subparagraphs (E) and (F), respectively).
(B) Appropriate use criteria defined.--In
this subsection, the term ``appropriate use
criteria'' means criteria to assist ordering
professionals and furnishing professionals in
making the most appropriate treatment decision
for a specific clinical condition. To the
extent feasible, such criteria shall be
evidence-based.
(C) Applicable imaging service defined.--In
this subsection, the term ``applicable imaging
service'' means an advanced diagnostic imaging
service (as defined in subsection (e)(1)(B))
for which the Secretary determines--
(i) one or more applicable
appropriate use criteria specified
under paragraph (2) apply;
(ii) there are one or more qualified
clinical decision support mechanisms
listed under paragraph (3)(C); and
(iii) one or more of such mechanisms
is available free of charge.
(D) Applicable setting defined.--In this
subsection, the term ``applicable setting''
means a physician's office, a hospital
outpatient department (including an emergency
department), an ambulatory surgical center, and
any other outpatient setting determined
appropriate by the Secretary.
(E) Ordering professional defined.--In this
subsection, the term ``ordering professional''
means a physician (as defined in section
1861(r)) or a practitioner described in section
1842(b)(18)(C) who orders an applicable imaging
service for an individual.
(F) Furnishing professional defined.--In this
subsection, the term ``furnishing
professional'' means a physician (as defined in
section 1861(r)) or a practitioner described in
section 1842(b)(18)(C) who furnishes an
applicable imaging service for an individual.
(2) Establishment of applicable appropriate use
criteria.--
(A) In general.--Not later than November 15,
2015, the Secretary shall through rulemaking,
and in consultation with physicians,
practitioners, and other stakeholders, specify
applicable appropriate use criteria for
applicable imaging services from among
appropriate use criteria developed or endorsed
by national professional medical specialty
societies or other entities.
(B) Considerations.--In specifying applicable
appropriate use criteria under subparagraph
(A), the Secretary shall take into account
whether the criteria--
(i) have stakeholder consensus;
(ii) have been determined to be
scientifically valid and are evidence
based; and
(iii) are in the public domain.
(C) Revisions.--The Secretary shall
periodically update and revise (as appropriate)
such specification of applicable appropriate
use criteria.
(D) Treatment of multiple applicable
appropriate use criteria.--In the case where
the Secretary determines that more than one
appropriate use criteria applies with respect
to an applicable imaging service, the Secretary
shall specify one or more applicable
appropriate use criteria under this paragraph
for the service.
(3) Mechanisms for consultation with applicable
appropriate use criteria.--
(A) Identification of mechanisms to consult
with applicable appropriate use criteria.--
(i) In general.--The Secretary shall
specify one or more qualified clinical
decision support mechanisms that could
be used by ordering professionals to
consult with applicable appropriate use
criteria for applicable imaging
services.
(ii) Consultation.--The Secretary
shall consult with physicians,
practitioners, and other stakeholders
in specifying mechanisms under this
paragraph.
(iii) Inclusion of certain
mechanisms.--Mechanisms specified under
this paragraph may include any or all
of the following that meet the
requirements described in subparagraph
(B)(ii):
(I) Use of clinical decision
support modules in certified
EHR technology (as defined in
section 1848(o)(4)).
(II) Use of private sector
clinical decision support
mechanisms that are independent
from certified EHR technology,
which may include use of
clinical decision support
mechanisms available from
medical specialty
organizations.
(III) Use of a clinical
decision support mechanism
established by the Secretary.
(B) Qualified clinical decision support
mechanisms.--
(i) In general.--For purposes of this
subsection, a qualified clinical
decision support mechanism is a
mechanism that the Secretary determines
meets the requirements described in
clause (ii).
(ii) Requirements.--The requirements
described in this clause are the
following:
(I) The mechanism makes
available to the ordering
professional applicable
appropriate use criteria
specified under paragraph (2)
and the supporting
documentation for the
applicable imaging service
ordered.
(II) In the case where there
are more than one applicable
appropriate use criteria
specified under such paragraph
for an applicable imaging
service, the mechanism
indicates the criteria that it
uses for the service.
(III) The mechanism
determines the extent to which
an applicable imaging service
ordered is consistent with the
applicable appropriate use
criteria so specified.
(IV) The mechanism generates
and provides to the ordering
professional a certification or
documentation that documents
that the qualified clinical
decision support mechanism was
consulted by the ordering
professional.
(V) The mechanism is updated
on a timely basis to reflect
revisions to the specification
of applicable appropriate use
criteria under such paragraph.
(VI) The mechanism meets
privacy and security standards
under applicable provisions of
law.
(VII) The mechanism performs
such other functions as
specified by the Secretary,
which may include a requirement
to provide aggregate feedback
to the ordering professional.
(C) List of mechanisms for consultation with
applicable appropriate use criteria.--
(i) Initial list.--Not later than
April 1, 2016, the Secretary shall
publish a list of mechanisms specified
under this paragraph.
(ii) Periodic updating of list.--The
Secretary shall periodically update the
list of qualified clinical decision
support mechanisms specified under this
paragraph.
(4) Consultation with applicable appropriate use
criteria.--
(A) Consultation by ordering professional.--
Beginning with January 1, 2017, subject to
subparagraph (C), with respect to an applicable
imaging service ordered by an ordering
professional that would be furnished in an
applicable setting and paid for under an
applicable payment system (as defined in
subparagraph (D)), an ordering professional
shall--
(i) consult with a qualified decision
support mechanism listed under
paragraph (3)(C); and
(ii) provide to the furnishing
professional the information described
in clauses (i) through (iii) of
subparagraph (B).
(B) Reporting by furnishing professional.--
Beginning with January 1, 2017, subject to
subparagraph (C), with respect to an applicable
imaging service furnished in an applicable
setting and paid for under an applicable
payment system (as defined in subparagraph
(D)), payment for such service may only be made
if the claim for the service includes the
following:
(i) Information about which qualified
clinical decision support mechanism was
consulted by the ordering professional
for the service.
(ii) Information regarding--
(I) whether the service
ordered would adhere to the
applicable appropriate use
criteria specified under
paragraph (2);
(II) whether the service
ordered would not adhere to
such criteria; or
(III) whether such criteria
was not applicable to the
service ordered.
(iii) The national provider
identifier of the ordering professional
(if different from the furnishing
professional).
(C) Exceptions.--The provisions of
subparagraphs (A) and (B) and paragraph (6)(A)
shall not apply to the following:
(i) Emergency services.--An
applicable imaging service ordered for
an individual with an emergency medical
condition (as defined in section
1867(e)(1)).
(ii) Inpatient services.--An
applicable imaging service ordered for
an inpatient and for which payment is
made under part A.
(iii) Alternative payment models.--An
applicable imaging service ordered by
an ordering professional with respect
to an individual attributed to an
alternative payment model (as defined
in section 1833(z)(3)(C)).
(iv) Significant hardship.--An
applicable imaging service ordered by
an ordering professional who the
Secretary may, on a case-by-case basis,
exempt from the application of such
provisions if the Secretary determines,
subject to annual renewal, that
consultation with applicable
appropriate use criteria would result
in a significant hardship, such as in
the case of a professional who
practices in a rural area without
sufficient Internet access.
(D) Applicable payment system defined.--In
this subsection, the term ``applicable payment
system'' means the following:
(i) The physician fee schedule
established under section 1848(b).
(ii) The prospective payment system
for hospital outpatient department
services under section 1833(t).
(iii) The ambulatory surgical center
payment systems under section 1833(i).
(5) Identification of outlier ordering
professionals.--
(A) In general.--With respect to applicable
imaging services furnished beginning with 2017,
the Secretary shall determine, on a periodic
basis (which may be annually), ordering
professionals who are outlier ordering
professionals.
(B) Outlier ordering professionals.--The
determination of an outlier ordering
professional shall--
(i) be based on low adherence to
applicable appropriate use criteria
specified under paragraph (2), which
may be based on comparison to other
ordering professionals; and
(ii) include data for ordering
professionals for whom prior
authorization under paragraph (6)(A)
applies.
(C) Use of two years of data.--The Secretary
shall use two years of data to identify outlier
ordering professionals under this paragraph.
(D) Consultation with stakeholders.--The
Secretary shall consult with physicians,
practitioners and other stakeholders in
developing methods to identify outlier ordering
professionals under this paragraph.
(6) Prior authorization for ordering professionals
who are outliers.--
(A) In general.--Beginning January 1, 2020,
subject to paragraph (4)(C), with respect to
services furnished during a year, the Secretary
shall, for a period determined appropriate by
the Secretary, apply prior authorization for
applicable imaging services that are ordered by
an outlier ordering professional identified
under paragraph (5).
(B) Funding.--For purposes of carrying out
this paragraph, the Secretary shall provide for
the transfer, from the Federal Supplementary
Medical Insurance Trust Fund under section
1841, of $5,000,000 to the Centers for Medicare
& Medicaid Services Program Management Account
for each of fiscal years 2019 through 2021.
Amounts transferred under the preceding
sentence shall remain available until expended.
(q) Establishment of Appropriate Use Program for Other Part B
Services.--
(1) Establishment.--
(A) In general.--The Secretary may establish
an appropriate use program for services under
this part (other than applicable imaging
services under subsection (p)) using a process
similar to the process under such subsection.
(B) Requirements.--In determining whether to
establish a program under subparagraph (A), the
Secretary shall take into consideration--
(i) the implementation of appropriate
use criteria for applicable imaging
services under subsection (p); and
(ii) the report under paragraph (2).
(C) Input from stakeholders in advance of
rulemaking.--Before issuing a notice of
proposed rulemaking to establish a program
under subparagraph (A), the Secretary shall
issue an advance notice of proposed rulemaking.
(2) Report on experience of imaging appropriate use
criteria program.--Not later than 18 months after the
date of the enactment of this subsection, the
Comptroller General of the United States shall submit
to Congress a report that includes a description of the
extent to which appropriate use criteria could be used
for other services under this part, such as radiation
therapy and clinical diagnostic laboratory services.
* * * * * * *
PAYMENT FOR PHYSICIANS' SERVICES
Sec. 1848. (a) Payment Based on Fee Schedule.--
(1) * * *
* * * * * * *
(7) Incentives for meaningful use of certified ehr
technology.--
(A) Adjustment.--
(i) In general.--Subject to
subparagraphs (B) and (D), with respect
to covered professional services
furnished by an eligible professional
during 2015 [or any subsequent payment
year] or 2016, if the eligible
professional is not a meaningful EHR
user (as determined under subsection
(o)(2)) for an EHR reporting period for
the year, the fee schedule amount for
such services furnished by such
professional during the year (including
the fee schedule amount for purposes of
determining a payment based on such
amount) shall be equal to the
applicable percent of the fee schedule
amount that would otherwise apply to
such services under this subsection
(determined after application of
paragraph (3) but without regard to
this paragraph).
(ii) Applicable percent.-- [Subject
to clause (iii), for] For purposes of
clause (i), the term ``applicable
percent'' means--
(I) for 2015, 99 percent (or,
in the case of an eligible
professional who was subject to
the application of the payment
adjustment under section
1848(a)(5) for 2014, 98
percent); and
(II) for 2016, 98 percent[;
and].
[(III) for 2017 and each
subsequent year, 97 percent.]
[(iii) Authority to decrease
applicable percentage for 2018 and
subsequent years.--For 2018 and each
subsequent year, if the Secretary finds
that the proportion of eligible
professionals who are meaningful EHR
users (as determined under subsection
(o)(2)) is less than 75 percent, the
applicable percent shall be decreased
by 1 percentage point from the
applicable percent in the preceding
year, but in no case shall the
applicable percent be less than 95
percent.]
* * * * * * *
(8) Incentives for quality reporting.--
(A) Adjustment.--
(i) In general.--With respect to
covered professional services furnished
by an eligible professional during 2015
[or any subsequent year] or 2016, if
the eligible professional does not
satisfactorily submit data on quality
measures for covered professional
services for the quality reporting
period for the year (as determined
under subsection (m)(3)(A)), the fee
schedule amount for such services
furnished by such professional during
the year (including the fee schedule
amount for purposes of determining a
payment based on such amount) shall be
equal to the applicable percent of the
fee schedule amount that would
otherwise apply to such services under
this subsection (determined after
application of paragraphs (3), (5), and
(7), but without regard to this
paragraph).
(ii) Applicable percent.--For
purposes of clause (i), the term
``applicable percent'' means--
(I) * * *
(II) for 2016 [and each
subsequent year], 98 percent.
* * * * * * *
(b) Establishment of Fee Schedules.--
(1) * * *
* * * * * * *
(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.
(c) Determination of Relative Values for Physicians'
Services.--
(1) * * *
(2) Determination of relative values.--
(A) * * *
(B) Periodic review and adjustments in
relative values.--
(i) * * *
(ii) Adjustments.--
(I) In general.--The
Secretary shall, to the extent
the Secretary determines to be
necessary and subject to
[subclause (II)] subclause (II)
and paragraph (7), adjust the
number of such units to take
into account changes in medical
practice, coding changes, new
data on relative value
components, or the addition of
new procedures. The Secretary
shall publish an explanation of
the basis for such adjustments.
* * * * * * *
(v) Exemption of certain reduced
expenditures from budget-neutrality
calculation.--The following reduced
expenditures, as estimated by the
Secretary, shall not be taken into
account in applying clause (ii)(II):
(I) * * *
* * * * * * *
(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).
* * * * * * *
(C) Computation of relative value units for
components.--For purposes of this section for
each physicians' service--
(i) Work relative value units.--The
Secretary shall determine a number of
work relative value units for [the
service] the service or group of
services based on the relative
resources incorporating physician time
and intensity required in furnishing
[the service] the service or group of
services.
(ii) Practice expense relative value
units.--The Secretary shall determine a
number of practice expense relative
value units for the service for years
before 1999 equal to the product of--
(I) the base allowed charges
(as defined in subparagraph
(D)) for the service, and
(II) the practice expense
percentage for the service (as
determined under paragraph
(3)(C)(ii)),
and for years beginning with 1999 based
on the relative practice expense
resources involved in furnishing the
service or group of services. For 1999,
such number of units shall be
determined based 75 percent on such
product and based 25 percent on the
relative practice expense resources
involved in furnishing the service. For
2000, such number of units shall be
determined based 50 percent on such
product and based 50 percent on such
relative practice expense resources.
For 2001, such number of units shall be
determined based 25 percent on such
product and based 75 percent on such
relative practice expense resources.
For a subsequent year, such number of
units shall be determined based
entirely on such relative practice
expense resources.
(iii) Malpractice relative value
units.--The Secretary shall determine a
number of malpractice relative value
units for [the service] the service or
group of services for years before 2000
equal to the product of--
(I) the base allowed charges
(as defined in subparagraph
(D)) for [the service] the
service or group of services,
and
(II) the malpractice
percentage for [the service]
the service or group of
services (as determined under
paragraph (3)(C)(iii)),
and for years beginning with 2000 based
on the malpractice expense resources
involved in furnishing [the service]
the service or group of services.
* * * * * * *
(K) Potentially misvalued codes.--
(i) * * *
[(ii) Identification of potentially
misvalued codes.--For purposes of
identifying potentially misvalued
services pursuant to clause (i)(I), the
Secretary shall examine (as the
Secretary determines to be appropriate)
codes (and families of codes as
appropriate) for which there has been
the fastest growth; codes (and families
of codes as appropriate) that have
experienced substantial changes in
practice expenses; codes for new
technologies or services within an
appropriate period (such as 3 years)
after the relative values are initially
established for such codes; multiple
codes that are frequently billed in
conjunction with furnishing a single
service; codes with low relative
values, particularly those that are
often billed multiple times for a
single treatment; codes which have not
been subject to review since the
implementation of the RBRVS (the so-
called ``Harvard-valued codes''); and
such other codes determined to be
appropriate by the Secretary.]
(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.
(iii) Review and adjustments.--
(I) * * *
* * * * * * *
(VI) The [provisions of
subparagraph (B)(ii)(II)]
provisions of subparagraph
(B)(ii)(II) and paragraph (7)
shall apply to adjustments to
relative value units made
pursuant to this subparagraph
in the same manner as such
provisions apply to adjustments
[under subparagraph
(B)(ii)(II)] under subparagraph
(B)(ii)(I).
* * * * * * *
(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.
(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).
(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.
* * * * * * *
(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.
(d) Conversion Factors.--
(1) Establishment.--
(A) In general.--The conversion factor for
each year shall be the conversion factor
established under this subsection for the
previous year (or, in the case of 1992,
specified in subparagraph (B)) adjusted by the
update (established under paragraph (3)) for
the year involved (for years before 2001) and,
for years beginning with 2001, multiplied by
the update (established under paragraph (4) or
a subsequent paragraph) for the year involved.
* * * * * * *
(4) Update for years beginning with 2001 and ending
with 2013.--
(A) In general.--Unless otherwise provided by
law, subject to the budget-neutrality factor
determined by the Secretary under subsection
(c)(2)(B)(ii) and subject to adjustment under
subparagraph (F), the update to the single
conversion factor established in paragraph
(1)(C) for a year beginning with 2001 and
ending with 2013 is equal to the product of--
(i) * * *
* * * * * * *
(15) Update for 2014 through 2016.--The update to the
single conversion factor established in paragraph
(1)(C) for each of 2014 through 2016 shall be 0.5
percent.
(16) Update for 2017 through 2023.--The update to the
single conversion factor established in paragraph
(1)(C) for each of 2017 through 2023 shall be zero
percent.
(17) Update for 2024 and subsequent years.--The
update to the single conversion factor established in
paragraph (1)(C) for 2024 and each subsequent year
shall be--
(A) for items and services furnished by a
qualifying APM participant (as defined in
section 1833(z)(2)) for such year, 2 percent;
and
(B) for other items and services, 1 percent.
(e) Geographic Adjustment Factors.--
(1) * * *
* * * * * * *
(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.
(f) Sustainable Growth Rate.--
(1) Publication.--The Secretary shall cause to have
published in the Federal Register not later than--
(A) * * *
(B) November 1 of each succeeding year
through 2013 the sustainable growth rate for
such succeeding year and each of the preceding
2 years.
(2) Specification of growth rate.--The sustainable
growth rate for all physicians' services for a fiscal
year (beginning with fiscal year 1998 and ending with
fiscal year 2000) and a year beginning with 2000 and
ending with 2013 shall be equal to the product of--
(A) * * *
* * * * * * *
(i) Miscellaneous Provisions.--
(1) Restriction on administrative and judicial
review.--There shall be no administrative or judicial
review under section 1869 or otherwise of--
(A) * * *
* * * * * * *
(D) the establishment of geographic
adjustment factors under subsection (e), [and]
(E) the establishment of the system for the
coding of physicians' services under this
section[.], and
(F) the collection and use of information in
the determination of relative values under
subsection (c)(2)(M).
* * * * * * *
(j) Definitions.--In this section:
(1) * * *
(2) Fee schedule area.-- [The term] Except as
provided in subsection (e)(6)(D), the term ``fee
schedule area'' means a locality used under section
1842(b) for purposes of computing payment amounts for
physicians' services.
* * * * * * *
(k) Quality Reporting System.--
(1) * * *
* * * * * * *
(9) Continued application for purposes of vbp
program.--The Secretary shall, in accordance with
subsection (q)(1)(F), carry out the provisions of this
subsection for purposes of subsection (q).
* * * * * * *
(m) Incentive Payments for Quality Reporting.--
(1) * * *
* * * * * * *
(3) Satisfactory reporting and successful electronic
prescriber and described.--
(A) * * *
* * * * * * *
(C) Satisfactory reporting measures for group
practices.--
(i) * * *
(ii) Statistical sampling model.--The
process under clause (i) shall provide
and, for 2014 and subsequent years, may
provide for the use of a statistical
sampling model to submit data on
measures, such as the model used under
the Physician Group Practice
demonstration project under section
1866A.
* * * * * * *
(D) Satisfactory reporting measures through
participation in a qualified clinical data
registry.--For 2014 and subsequent years, the
Secretary shall treat an eligible professional
as satisfactorily submitting data on quality
measures under subparagraph (A) and, for 2015
and subsequent years, subparagraph (A) or (C)
if, in lieu of reporting measures under
subsection (k)(2)(C), the eligible professional
is satisfactorily participating, as determined
by the Secretary, in a qualified clinical data
registry (as described in subparagraph (E)) for
the year.
(E) Qualified clinical data registry.--
(i) * * *
* * * * * * *
(vi) Access to medicare data to
facilitate quality improvement.--
(I) In general.--To the
extent consistent with
applicable information,
privacy, security, and
disclosure laws, and subject to
other requirements as the
Secretary may specify,
beginning July 1, 2014, the
Secretary shall, if requested
by a qualified clinical data
registry under this
subparagraph, subject to
subclauses (II) and (III),
provide data as described in
section 1874(e)(3) (in a form
and manner determined to be
appropriate) to such registry
for purposes of linking such
data with clinical data and
performing analyses and
research to support quality
improvement or patient safety.
(II) Protection.--A qualified
clinical data registry may not
publicly report any data made
available under subclause (I)
(or any analyses or research
described in such subclause)
that individually identifies a
provider of services, supplier,
or individual unless the
registry obtains the consent of
such provider, supplier, or
individual prior to such
reporting.
(III) Fee.--The data
described in subclause (I)
shall be made available to
qualified clinical data
registries at a fee equal to
the cost of making such data
available. Any fee collected
pursuant to the preceding
sentence shall be deposited in
the Centers for Medicare &
Medicaid Services Program
Management Account.
* * * * * * *
(5) Application.--
(A) * * *
* * * * * * *
(F) Extension.--For 2008 [and subsequent
years] through reporting periods occurring in
2013, the Secretary shall establish and, for
reporting periods occurring in 2014 and
subsequent years, the Secretary may establish
alternative criteria for satisfactorily
reporting under this subsection and alternative
reporting periods under paragraph (6)(C) for
reporting groups of measures under subsection
(k)(2)(B) and for reporting using the method
specified in subsection (k)(4).
* * * * * * *
[(7)] (8) Additional incentive payment.--
(A) * * *
* * * * * * *
(9) Continued application for purposes of vbp
program.--The Secretary shall, in accordance with
subsection (q)(1)(F), carry out the processes under
this subsection for purposes of subsection (q).
(n) Physician Feedback Program.--
(1) * * *
* * * * * * *
(11) Reports ending with 2016.--Reports under the
Program shall not be provided after December 31, 2016.
See subsection (q)(13) for reports beginning with 2017.
(o) Incentives for Adoption and Meaningful Use of Certified
EHR Technology.--
(1) * * *
(2) Meaningful ehr user.--
(A) In general.--[For purposes of paragraph
(1), an] An eligible professional shall be
treated as a meaningful EHR user for an EHR
reporting period for a payment year (or, for
purposes of subsection (a)(7), for an EHR
reporting period under such subsection for a
year, or pursuant to subparagraph (D) for
purposes of subsection (q), for a performance
period under such subsection for a year) if
each of the following requirements is met:
(i) * * *
(ii) Information exchange.--The
eligible professional demonstrates to
the satisfaction of the Secretary, in
accordance with subparagraph (C)(i),
that during such period such certified
EHR technology is connected in a manner
that provides, in accordance with law
and standards applicable to the
exchange of information, for the
electronic exchange of health
information to improve the quality of
health care, such as promoting care
coordination, and the professional
demonstrates (through a process
specified by the Secretary, such as the
use of an attestation similar to that
required in the health information
technology donation safe harbor
established under regulations under
section 1128B(b)(3)(E)) that the
professional has not and will not take
any deliberate action to limit or
restrict the use, compatibility, or
interoperability of the certified EHR
technology.
(iii) Reporting on measures using
ehr.--Subject to subparagraph (B)(ii)
and subsection (q)(5)(C)(ii)(II) and
using such certified EHR technology,
the eligible professional submits
information for such period, in a form
and manner specified by the Secretary,
on such clinical quality measures and
such other measures as selected by the
Secretary under subparagraph (B)(i).
* * * * * * *
(D) Continued application for purposes of vbp
program.--With respect to 2017 and each
subsequent payment year, the Secretary shall,
for purposes of subsection (q) and in
accordance with paragraph (1)(F) of such
subsection, determine whether an eligible
professional who is a VBP eligible professional
(as defined in subsection (q)(1)(C)) for such
year is a meaningful EHR user under this
paragraph for the performance period under
subsection (q) for such year.
* * * * * * *
(p) Establishment of Value-based Payment Modifier.--
(1) * * *
(2) Quality.--
(A) * * *
* * * * * * *
(C) Continued application for purposes of vbp
program.--The Secretary shall, in accordance
with subsection (q)(1)(F), carry out
subparagraph (B) for purposes of subsection
(q).
(3) Costs.--For purposes of paragraph (1), costs
shall be evaluated, to the extent practicable, based on
a composite of appropriate measures of costs
established by the Secretary (such as the composite
measure under the methodology established under
subsection (n)(9)(C)(iii)) that eliminate the effect of
geographic adjustments in payment rates (as described
in subsection (e)), and take into account risk factors
(such as socioeconomic and demographic characteristics,
ethnicity, and health status of individuals (such as to
recognize that less healthy individuals may require
more intensive interventions) and other factors
determined appropriate by the Secretary. With respect
to 2017 and each subsequent year, the Secretary shall,
in accordance with subsection (q)(1)(F), carry out this
paragraph for purposes of subsection (q).
(4) Implementation.--
(A) * * *
(B) Deadlines for implementation.--
(i) * * *
* * * * * * *
[(iii) Application.--The Secretary
shall apply the payment modifier
established under this subsection for
items and services furnished--
[(I) beginning on January 1,
2015, with respect to specific
physicians and groups of
physicians the Secretary
determines appropriate; and
[(II) beginning not later
than January 1, 2017, with
respect to all physicians and
groups of physicians.]
(iii) Application.--The Secretary
shall apply the payment modifier
established under this subsection for
items and services furnished on or
after January 1, 2015, but before
January 1, 2017, with respect to
specific physicians and groups of
physicians the Secretary determines
appropriate. Such payment modifier
shall not be applied for items and
services furnished on or after January
1, 2017.
* * * * * * *
(q) Value-based Performance Incentive Program.--
(1) Establishment.--
(A) In general.--Subject to the succeeding
provisions of this subsection, the Secretary
shall establish an eligible professional value-
based performance incentive program (in this
subsection referred to as the ``VBP program'')
under which the Secretary shall--
(i) develop a methodology for
assessing the total performance of each
VBP eligible professional according to
performance standards under paragraph
(3) for a performance period (as
established under paragraph (4)) for a
year;
(ii) using such methodology, provide
for a composite performance score in
accordance with paragraph (5) for each
such professional for each performance
period; and
(iii) use such composite performance
score of the VBP eligible professional
for a performance period for a year to
make VBP program incentive payments
under paragraph (7) to the professional
for the year.
(B) Program implementation.--The VBP program
shall apply to payments for items and services
furnished on or after January 1, 2017.
(C) VBP eligible professional defined.--
(i) In general.--For purposes of this
subsection, subject to clauses (ii) and
(iv), the term ``VBP eligible
professional'' means--
(I) for the first and second
years for which the VBP program
applies to payments (and for
the performance period for such
first and second year), a
physician (as defined in
section 1861(r)(1)), a
physician assistant, nurse
practitioner, and clinical
nurse specialist (as such terms
are defined in section
1861(aa)(5)), and a certified
registered nurse anesthetist
(as defined in section
1861(bb)(2)); and
(II) for the third year for
which the VBP program applies
to payments (and for the
performance period for such
third year) and for each
succeeding year (and for the
performance period for each
such year), the professionals
described in subclause (I) and
such other eligible
professionals (as defined in
subsection (k)(3)(B)) as
specified by the Secretary.
(ii) Exclusions.--For purposes of
clause (i), the term ``VBP eligible
professional'' does not include, with
respect to a year, an eligible
professional (as defined in subsection
(k)(3)(B))--
(I) who is a qualifying APM
participant (as defined in
section 1833(z)(2));
(II) who, subject to clause
(vii), is a partial qualifying
APM participant (as defined in
clause (iii)) for the most
recent period for which data
are available and who, for the
performance period with respect
to such year, does not report
on applicable measures and
activities described in
paragraph (2)(B) that are
required to be reported by such
a professional under the VBP
program; or
(III) who, for the
performance period with respect
to such year, does not exceed
the low-volume threshold
measurement selected under
clause (iv).
(iii) Partial qualifying APM
participant.--For purposes of this
subparagraph, the term ``partial
qualifying APM participant'' means,
with respect to a year, an eligible
professional for whom the Secretary
determines the minimum payment
percentage (or percentages), as
applicable, described in paragraph (2)
of section 1833(z) for such year have
not been satisfied, but who would be
considered a qualifying APM participant
(as defined in such paragraph) for such
year if--
(I) with respect to 2017 and
2018, the reference in
subparagraph (A) of such
paragraph to 25 percent was
instead a reference to 20
percent;
(II) with respect to 2019 and
2020--
(aa) the reference in
subparagraph (B)(i) of
such paragraph to 50
percent was instead a
reference to 40
percent; and
(bb) the references
in subparagraph (B)(ii)
of such paragraph to 50
percent and 25 percent
of such paragraph were
instead references to
40 percent and 20
percent, respectively;
and
(III) with respect to 2021
and subsequent years--
(aa) the reference in
subparagraph (C)(i) of
such paragraph to 75
percent was instead a
reference to 50
percent; and
(bb) the references
in subparagraph (C)(ii)
of such paragraph to 75
percent and 25 percent
of such paragraph were
instead references to
50 percent and 20
percent, respectively.
(iv) Selection of low-volume
threshold measurement.--The Secretary
shall select one of the following low-
volume threshold measurements to apply
for purposes of clause (ii)(III):
(I) The minimum number (as
determined by the Secretary) of
individuals enrolled under this
part who are treated by the VBP
eligible professional for the
performance period involved.
(II) The minimum number (as
determined by the Secretary) of
items and services furnished to
individuals enrolled under this
part by such professional for
such performance period.
(III) The minimum amount (as
determined by the Secretary) of
allowed charges billed by such
professional under this part
for such performance period.
(v) Treatment of new medicare
enrolled eligible professionals.--In
the case of a professional who first
becomes a Medicare enrolled eligible
professional during the performance
period for a year (and had not
previously submitted claims under this
title such as a person, an entity, or a
part of a physician group or under a
different billing number or tax
identifier), such professional shall
not be treated under this subsection as
a VBP eligible professional until the
subsequent year and performance period
for such subsequent year.
(vi) Clarification.--In the case of
items and services furnished during a
year by an individual who is not a VBP
eligible professional (including
pursuant to clauses (ii) and (v)) with
respect to a year, in no case shall a
reduction under paragraph (6) or a VBP
program incentive payment under
paragraph (7) apply to such individual
for such year.
(vii) Partial qualifying apm
participant clarification.--In the case
of an eligible professional who is a
partial qualifying APM participant,
with respect to a year, and who for the
performance period for such year
reports on applicable measures and
activities described in paragraph
(2)(B) that are required to be reported
by such a professional under the VBP
program, such eligible professional is
considered to be a VBP eligible
professional with respect to such year.
(D) Application to group practices.--
(i) In general.--Under the VBP
program:
(I) Quality performance
category.--The Secretary shall
establish and apply a process
that includes features of the
provisions of subsection
(m)(3)(C) for VBP eligible
professionals in a group
practice with respect to
assessing performance of such
group with respect to the
performance category described
in clause (i) of paragraph
(2)(A).
(II) Other performance
categories.--The Secretary may
establish and apply a process
that includes features of the
provisions of subsection
(m)(3)(C) for VBP eligible
professionals in a group
practice with respect to
assessing the performance of
such group with respect to the
performance categories
described in clauses (ii)
through (iv) of such paragraph.
(ii) Ensuring comprehensiveness of
group practice assessment.--The process
established under clause (i) shall to
the extent practicable reflect the full
range of items and services furnished
by the VBP eligible professionals in
the group practice involved.
(iii) Clarification.--VBP eligible
professionals electing to be a virtual
group under paragraph (5)(J) shall not
be considered VBP eligible
professionals in a group practice for
purposes of applying this subparagraph.
(E) Use of registries.--Under the VBP
program, the Secretary shall encourage the use
of qualified clinical data registries pursuant
to subsection (m)(3)(E) in carrying out this
subsection.
(F) Application of certain provisions.--In
applying a provision of subsection (k), (m),
(o), or (p) for purposes of this subsection,
the Secretary shall--
(i) adjust the application of such
provision to ensure the provision is
consistent with the provisions of this
subsection; and
(ii) not apply such provision to the
extent that the provision is
duplicative with a provision of this
subsection.
(2) Measures and activities under performance
categories.--
(A) Performance categories.--Under the VBP
program, the Secretary shall use the following
performance categories (each of which is
referred to in this subsection as a performance
category) in determining the composite
performance score under paragraph (5):
(i) Quality.
(ii) Resource use.
(iii) Clinical practice improvement
activities.
(iv) Meaningful use of certified EHR
technology.
(B) Measures and activities specified for
each category.--For purposes of paragraph
(3)(A) and subject to subparagraph (C),
measures and activities specified for a
performance period (as established under
paragraph (4)) for a year are as follows:
(i) Quality.--For the performance
category described in subparagraph
(A)(i), the quality measures
established for such period under
subsections (k) and (m), including
under subsection (m)(3)(E), and the
measures of quality of care established
for such period under subsection
(p)(2).
(ii) Resource use.--For the
performance category described in
subparagraph (A)(ii), the measurement
of resource use for such period under
subsection (p)(3), using the
methodology under subsection (r), as
appropriate, and, as feasible and
applicable, accounting for the cost of
covered part D drugs.
(iii) Clinical practice improvement
activities.--For the performance
category described in subparagraph
(A)(iii), clinical practice improvement
activities under subcategories
specified by the Secretary for such
period, which shall include at least
the following:
(I) The subcategory of
expanded practice access, which
shall include activities such
as same day appointments for
urgent needs and after hours
access to clinician advice.
(II) The subcategory of
population management, which
shall include activities such
as monitoring health conditions
of individuals to provide
timely health care
interventions or participation
in a qualified clinical data
registry.
(III) The subcategory of care
coordination, which shall
include activities such as
timely communication of test
results, timely exchange of
clinical information to
patients and other providers,
and use of remote monitoring or
telehealth.
(IV) The subcategory of
beneficiary engagement, which
shall include activities such
as the establishment of care
plans for individuals with
complex care needs, beneficiary
self-management training, and
using shared decision-making
mechanisms.
(V) The subcategory of
patient safety and practice
assessment, such as through use
of clinical or surgical
checklists and practice
assessments related to
maintaining certification.
(VI) The subcategory of
participation in an alternative
payment model (as defined in
section 1833(z)(3)(C)).
In establishing activities under this
clause, the Secretary shall give
consideration to the circumstances of
small practices (consisting of fewer
than 20 professionals) and practices
located in rural areas and in health
professional shortage areas (as
designated under section 332(a)(1)(A)
of the Public Health Service Act).
(iv) Meaningful ehr use.--For the
performance category described in
subparagraph (A)(iv), the requirements
established for such period under
subsection (o)(2) for determining
whether an eligible professional is a
meaningful EHR user.
(C) Additional provisions.--
(i) Emphasizing outcome measures
under quality performance category.--In
applying subparagraph (B)(i), the
Secretary shall, as feasible, emphasize
the application of outcome measures.
(ii) Application of additional system
measures.--The Secretary may use
measures used for a payment system
other than for physicians for purposes
of the performance category described
in subparagraph (A)(i).
(iii) Global and population-based
measures.--The Secretary may use global
measures, such as global outcome
measures, and population-based measures
for purposes of the performance
category described in subparagraph
(A)(i).
(iv) Request for information for
clinical practice improvement
activities.--In initially applying
subparagraph (B)(iii), the Secretary
shall use a request for information to
solicit recommendations from
stakeholders for identifying activities
described in such subparagraph and
specifying criteria for such
activities.
(v) Contract authority for clinical
practice improvement activities
performance category.--In applying
subparagraph (B)(iii), the Secretary
may contract with entities to assist
the Secretary in--
(I) identifying activities
described in subparagraph
(B)(iii);
(II) specifying criteria for
such activities; and
(III) determining whether a
VBP eligible professional meets
such criteria.
(vi) Application of measures and
activities to non-patient-facing
providers.--In carrying out this
paragraph, with respect to measures and
activities specified in subparagraph
(B) for performance categories
described in subparagraph (A), the
Secretary--
(I) shall give consideration
to the circumstances of
professional types (or
subcategories of those types
determined by practice
characteristics) who typically
provide services that do not
involve face-to-face
interaction with a patient; and
(II) may, to the extent
feasible and appropriate, take
into account such circumstances
and apply under this subsection
with respect to VBP eligible
professionals of such
professional types or
subcategories, in lieu of such
a measure or activity, a
comparable measure or activity
that fulfills the goals of the
applicable performance
category.
In carrying out the previous sentence,
the Secretary shall consult with
professionals of such professional
types or subcategories.
(3) Performance standards.--
(A) Establishment.--Under the VBP program,
the Secretary shall establish performance
standards with respect to measures and
activities specified under paragraph (2)(B) for
a performance period (as established under
paragraph (4)) for a year.
(B) Considerations in establishing
standards.--In establishing such performance
standards with respect to measures and
activities specified under paragraph (2)(B),
the Secretary shall take into account the
following:
(i) Historical performance standards.
(ii) Improvement rates.
(iii) The opportunity for continued
improvement.
(4) Performance period.--The Secretary shall
establish a performance period (or periods) for a year
(beginning with the year described in paragraph
(1)(B)). Such performance period (or periods) shall
begin and end prior to the beginning of such year and
be as close as possible to such year. In this
subsection, such performance period (or periods) for a
year shall be referred to as the performance period for
the year.
(5) Composite performance score.--
(A) In general.--Subject to the succeeding
provisions of this paragraph and consistent
with section 2(g)(2) of the SGR Repeal and
Medicare Beneficiary Access Act of 2013, the
Secretary shall develop a methodology for
assessing the total performance of each VBP
eligible professional according to performance
standards under paragraph (3) with respect to
applicable measures and activities specified in
paragraph (2)(B) with respect to each
performance category applicable to such
professional for a performance period (as
established under paragraph (4)) for a year.
Using such methodology, the Secretary shall
provide for a composite assessment (in this
subsection referred to as the ``composite
performance score'') for each such professional
for each performance period.
(B) Weighting performance categories,
measures, and activities.--Under the
methodology under subparagraph (A), the
Secretary--
(i) may assign different scoring
weights (including a weight of 0) for--
(I) each performance category
based on the extent to which
the category is applicable to
the type of eligible
professional involved; and
(II) each measure and
activity specified under
paragraph (2)(B) with respect
to each such category based on
the extent to which the measure
or activity is applicable to
the type of eligible
professional involved; and
(ii) with respect to the performance
category described in paragraph
(2)(A)(i)--
(I) shall assign a higher
scoring weight to outcomes
measures than to other measures
and increase the scoring weight
for outcome measures over time;
and
(II) may assign a higher
scoring weight to patient
experience measures.
(C) Incentive to report; encouraging use of
certified ehr technology for reporting quality
measures.--
(i) Incentive to report.--Under the
methodology established under
subparagraph (A), the Secretary shall
provide that in the case of a VBP
eligible professional who fails to
report on an applicable measure or
activity that is required to be
reported by the professional, the
professional shall be treated as
achieving the lowest potential score
applicable to such measure or activity.
(ii) Encouraging use of certified ehr
technology for reporting quality
measures.--Under the methodology
established under subparagraph (A), the
Secretary shall--
(I) encourage VBP eligible
professionals to report on
applicable measures with
respect to the performance
category described in paragraph
(2)(A)(i) through the use of
certified EHR technology; and
(II) with respect to a
performance period, with
respect to a year, for which a
VBP eligible professional
reports such measures through
the use of such EHR technology,
treat such professional as
satisfying the clinical quality
measures reporting requirement
described in subsection
(o)(2)(A)(iii) for such year.
(D) Clinical practice improvement activities
performance score.--
(i) Rule for accreditation.--A VBP
eligible professional who is in a
practice that is certified as a
patient-centered medical home or
comparable specialty practice pursuant
to subsection (b)(8)(B)(i) with respect
to a performance period shall be given
the highest potential score for the
performance category described in
paragraph (2)(A)(iii) for such period.
(ii) APM participation.--
Participation by a VBP eligible
professional in an alternative payment
model (as defined in section
1833(z)(3)(C)) with respect to a
performance period shall earn such
eligible professional one-half of the
highest potential score for the
performance category described in
paragraph (2)(A)(iii) for such
performance period. Nothing in the
previous sentence shall prevent such
professional from earning more than
one-half of such highest potential
score for such performance period by
performing additional activities with
respect to such performance category.
(iii) Subcategories.--A VBP eligible
professional shall not be required to
perform activities in each subcategory
under paragraph (2)(B)(iii) to achieve
the highest potential score for the
performance category described in
paragraph (2)(A)(iii).
(E) Distribution.--The Secretary shall ensure
that the application of the methodology
developed under subparagraph (A) results in a
continuous distribution of performance scores,
which shall result in differential payments
under paragraph (7).
(F) Achievement and improvement.--
(i) Taking into account
improvement.--Beginning with the second
year to which the VBP program applies,
in addition to the achievement score of
a VBP eligible professional, the
methodology developed under
subparagraph (A)--
(I) in the case of the
performance score for the
performance category described
in clauses (i) and (ii) of
paragraph (2)(A), shall take
into account the improvement of
the professional; and
(II) in the case of
performance scores for other
performance categories, may
take into account the
improvement of the
professional.
(ii) Assigning higher weight for
achievement.--Beginning with the fourth
year to which the VBP program applies,
under the methodology developed under
subparagraph (A), the Secretary may
assign a higher scoring weight under
subparagraph (B) with respect to the
achievement score of a VBP eligible
professional with respect to a measure
or activity specified under paragraph
(2)(B) (or with respect to such a
measure or activity and with respect to
categories described in paragraph
(2)(A)) than to any improvement score
applied under clause (i) with respect
to such measure or activity (or such
measure or activity and categories).
(G) Weights for the performance categories.--
(i) In general.--Under the
methodology developed under
subparagraph (A), subject to clauses
(ii) and (iii), the composite
performance score shall be determined
as follows:
(I) Quality.--
(aa) In general.--
Subject to item (bb),
30 percent of such
score shall be based on
performance with
respect to the category
described in clause (i)
of paragraph (2)(A).
(bb) First 2 years
and test year.--For the
first and second years
for which the VBP
program applies to
payments, 60 percent of
such score shall be
based on performance
with respect to the
category described in
clause (i) of paragraph
(2)(A). With respect to
the subsequent year,
the percent described
in item (aa) of such
score shall be based on
performance with
respect to such
category only for
purposes of feedback
and 60 percent of such
score shall be based on
performance with
respect to such
category for any other
purpose under this
subsection.
(II) Resource use.--
(aa) In general.--
Subject to item (bb),
30 percent of such
score shall be based on
performance with
respect to the category
described in clause
(ii) of paragraph
(2)(A).
(bb) First 2 years
and test year.--For the
first and second years
for which the VBP
program applies to
payments, zero percent
of such score shall be
based on performance
with respect to the
category described in
clause (ii) of
paragraph (2)(A). With
respect to the
subsequent year, the
percent described in
item (aa) of such score
shall be based on
performance with
respect to such
category only for
purposes of feedback
and zero percent of
such score shall be
based on performance
with respect to such
category for any other
purpose under this
subsection.
(III) Clinical practice
improvement activities.--
Fifteen percent of such score
shall be based on performance
with respect to the category
described in clause (iii) of
paragraph (2)(A).
(IV) Meaningful use of
certified EHR technology.--
Twenty-five percent of such
score shall be based on
performance with respect to the
category described in clause
(iv) of paragraph (2)(A).
(ii) Authority to adjust percentages
in case of high ehr meaningful use
adoption.--In any year in which the
Secretary estimates that the proportion
of eligible professionals (as defined
in subsection (o)(5)) who are
meaningful EHR users (as determined
under subsection (o)(2)) is 75 percent
or greater, the Secretary may reduce
the percent applicable under clause
(i)(IV), but not below 15 percent. If
the Secretary makes such reduction for
a year, the percentages applicable
under one or more of subclauses (I),
(II), and (III) of clause (i) for such
year (or, in the case of a year
described in clause (i)(II)(bb),
applicable under one or more of
subclauses (I) and (III)) shall be
increased in a manner such that the
total percentage points of the increase
under this clause for such year equals
the total number of percentage points
reduced under the preceding sentence
for such year.
(iii) Authority to adjust percentages
for quality and resource use.--Other
than for a year described in clause
(i)(II)(bb), the percentages described
in subclauses (I) and (II) of clause
(i), including after application of
clause (ii), shall be equal.
(H) Resource use.--Analysis of the
performance category described in paragraph
(2)(A)(ii) shall include results from the
methodology described in subsection (r)(5), as
appropriate.
(I) Inclusion of quality measure data from
multiple payers.--In applying subsections (k),
(m), and (p) with respect to measures described
in paragraph (2)(B)(i), analysis of the
performance category described in paragraph
(2)(A)(i) may include data submitted by VBP
eligible professionals with respect to multiple
payers.
(J) Use of voluntary virtual groups for
certain assessment purposes.--
(i) In general.--In the case of VBP
eligible professionals electing to be a
virtual group under clause (ii) with
respect to a performance period for a
year, for purposes of applying the
methodology under subparagraph (A)--
(I) the assessment of
performance provided under such
methodology with respect to the
performance categories
described in clauses (i) and
(ii) of paragraph (2)(A) that
is to be applied to each such
professional in such group for
such performance period shall
be with respect to the combined
performance of all such
professionals in such group for
such period; and
(II) the composite score
provided under this paragraph
for such performance period
with respect to each such
performance category for each
such VBP eligible professional
in such virtual group shall be
based on the assessment of the
combined performance under
subclause (I) for the
performance category and
performance period.
(ii) Election of practices to be a
virtual group.--The Secretary shall, in
accordance with clause (iii), establish
and have in place a process to allow an
individual VBP eligible professional or
a group practice consisting of not more
than 10 VBP eligible professionals to
elect, with respect to a performance
period for a year, for such individual
VBP eligible professional or all such
VBP eligible professionals in such
group practice, respectively, to be a
virtual group under this subparagraph
with at least one other such individual
VBP eligible professional or group
practice making such an election.
(iii) Requirements.--The process
under clause (ii) shall provide that--
(I) an election under such
clause, with respect to a
performance period, shall be
made before the beginning of
such performance period and may
not be changed during such
performance period; and
(II) a practice described in
such clause, and each VBP
eligible professional in such
practice, may elect to be in no
more than one virtual group for
a performance period.
(6) Funding for vbp program incentive payments.--
(A) Total amount for incentive payments.--The
total amount for VBP program incentive payments
under paragraph (7) for all VBP eligible
professionals for a year shall be equal to the
total amount of the performance funding pool
for all VBP eligible professionals under
subparagraph (B) for such year, as estimated by
the Secretary.
(B) Performance funding pool.--
(i) In general.--In the case of items
and services furnished by a VBP
eligible professional during a year
(beginning with 2017), the otherwise
applicable fee schedule amount (as
defined in clause (iii)) with respect
to such items and services and eligible
professional for such year shall be
reduced by the applicable percent under
clause (ii). The total amount of such
reductions for a year shall be referred
to in this subsection as the
``performance funding pool'' for such
year.
(ii) Applicable percent defined.--For
purposes of clause (i), the term
``applicable percent'' means--
(I) for 2017, 4 percent;
(II) for 2018, 6 percent;
(III) for 2019, 8 percent;
(IV) for 2020, 10 percent;
and
(V) for 2021 and subsequent
years, a percent specified by
the Secretary (but in no case
less than 10 percent or more
than 12 percent).
(iii) Otherwise applicable fee
schedule amount.--For purposes of this
subparagraph and paragraph (7), the
term ``otherwise applicable fee
schedule amount'' means, with respect
to items and services furnished by a
VBP eligible professional during a
year, the fee schedule amount for such
items and services and year that would
otherwise apply (without application of
this subparagraph or paragraph (7))
with respect to such eligible
professional under subsection (b),
after application of subsection (a)(3),
or under another fee schedule under
this part.
(7) VBP program incentive payments.--
(A) VBP program incentive payment adjustment
factor.--Consistent with section 2(g)(2) of the
SGR Repeal and Medicare Beneficiary Access Act
of 2013, the Secretary shall specify a VBP
program incentive payment adjustment factor for
each VBP eligible professional for a year. Such
VBP program incentive payment adjustment factor
for a VBP eligible professional for a year
shall be determined--
(i) by the composite performance
score of the eligible professional for
such year;
(ii) in a manner such that the
adjustment factors specified under this
subparagraph for a year results in
differential payments under this
paragraph reflecting the full range of
the distribution of composite
performance scores of VBP eligible
professionals determined under
paragraph (5)(E) for such year, with
such professionals having higher
composite performance scores receiving
higher payment; and
(iii) in a manner such that the
adjustment factors specified under this
subparagraph for a year--
(I) does not result in a
payment reduction for such year
by an amount that exceeds the
applicable percent described in
paragraph (6)(B)(ii) for such
year; and
(II) does not result in a
payment increase for such year
by an amount that exceeds the
applicable percent described in
paragraph (6)(B)(ii) for such
year.
(B) Calculation of vbp program incentive
payment amounts.--The VBP program incentive
payment amount with respect to items and
services furnished by a VBP eligible
professional during a year shall be equal to
the difference between--
(i) the product of--
(I) the VBP program incentive
payment adjustment factor
determined under subparagraph
(A) for such VBP eligible
professional for such year; and
(II) the otherwise applicable
fee schedule amount (as defined
in paragraph (6)(B)(iii)) with
respect to such items and
services and eligible
professional for such year; and
(ii) the otherwise applicable fee
schedule amount, as reduced under
paragraph (6)(B), with respect to such
items and services, eligible
professional, and year.
The application of the preceding sentence may
result in the VBP program incentive payment
amount being 0.0 with respect to an item or
service furnished by a VBP eligible
professional.
(C) Application of vbp program incentive
payment amount.--In the case of items and
services furnished by a VBP eligible
professional during a year (beginning with
2017), the otherwise applicable fee schedule
amount, as reduced under paragraph (6)(B), with
respect to such items and services and eligible
professional for such year shall be increased,
if applicable, by the VBP program incentive
payment amount determined under subparagraph
(B) with respect to such items and services,
professional, and year.
(D) Budget neutrality.--In specifying the VBP
program incentive payment adjustment factor for
each VBP eligible professional for a year under
subparagraph (A), the Secretary shall ensure
that the total amount of VBP program incentive
payment amounts under this paragraph for all
VBP eligible professionals in a year shall be
equal to the performance funding pool for such
year under paragraph (6), as estimated by the
Secretary.
(8) Announcement of result of adjustments.--Under the
VBP program, the Secretary shall, not later than 60
days prior to the year involved, make available to each
VBP eligible professional the VBP program incentive
payment adjustment factor under paragraph (7) and the
payment reduction under paragraph (6) applicable to the
eligible professional for items and services furnished
by the professional in such year. The Secretary may
include such information in the confidential feedback
under paragraph (13).
(9) No effect in subsequent years.--The VBP program
incentive payment under paragraph (7) and the payment
reduction under paragraph (6) shall each apply only
with respect to the year involved, and the Secretary
shall not take into account such VBP program incentive
payment or payment reduction in making payments to a
VBP eligible professional under this part in a
subsequent year.
(10) Public reporting.--
(A) In general.--The Secretary shall, in an
easily understandable format, make available on
the Physician Compare Internet website under
subsection (t) the following:
(i) Information regarding the
performance of VBP eligible
professionals under the VBP program,
which--
(I) shall include the
composite score for each such
VBP eligible professional and
the performance of each such
VBP eligible professional with
respect to each performance
category; and
(II) may include the
performance of each such VBP
eligible professional with
respect to each measure or
activity specified in paragraph
(2)(B).
(ii) The names of eligible
professionals in eligible alternative
payment models (as defined in section
1833(z)(3)(D)) and, to the extent
feasible, the names of such eligible
alternative payment models and
performance of such models.
(B) Disclosure.--The information made
available under this paragraph shall indicate,
where appropriate, that publicized information
may not be representative of the eligible
professional's entire patient population, the
variety of services furnished by the eligible
professional, or the health conditions of
individuals treated.
(C) Opportunity to review and submit
corrections.--The Secretary shall provide for
an opportunity for a professional described in
subparagraph (A) to review, and submit
corrections for, the information to be made
public with respect to the professional under
such subparagraph prior to such information
being made public.
(D) Aggregate information.--The Secretary
shall periodically post on the Physician
Compare Internet website aggregate information
on the VBP program, including the range of
composite scores for all VBP eligible
professionals and the range of the performance
of all VBP eligible professionals with respect
to each performance category.
(11) Consultation.--The Secretary shall consult with
stakeholders in carrying out the VBP program, including
for the identification of measures and activities under
paragraph (2)(B) and the methodologies developed under
paragraphs (5)(A) and (7). Such consultation shall
include the use of a request for information or other
mechanisms determined appropriate.
(12) Technical assistance to small practices and
practices in health professional shortage areas.--
(A) In general.--The Secretary shall enter
into contracts or agreements with appropriate
entities (such as quality improvement
organizations, regional extension centers (as
described in section 3012(c) of the Public
Health Service Act), or regional health
collaboratives) to offer guidance and
assistance to VBP eligible professionals in
practices of fewer than 20 professionals (with
priority given to such practices located in
rural areas, health professional shortage areas
(as designated under in section 332(a)(1)(A) of
the Public Health Service Act), or practices
with low composite scores) with respect to--
(i) the performance categories
described in clauses (i) through (iv)
of paragraph (2)(A); or
(ii) how to transition to the
implementation of and participation in
an alternative payment model as
described in section 1833(z)(3)(C).
(B) Funding for implementation.--For purposes
of implementing subparagraph (A), the Secretary
shall provide for the transfer from the Federal
Supplementary Medical Insurance Trust Fund
established under section 1841 to the Centers
for Medicare & Medicaid Services Program
Management Account of $50,000,000 for each of
fiscal years 2014 through 2018. Amounts
transferred under this subparagraph for a
fiscal year shall be available until expended.
(13) Feedback and information to improve
performance.--
(A) Performance feedback.--
(i) In general.--Beginning July 1,
2015, the Secretary--
(I) shall make available
timely (such as quarterly)
confidential feedback to each
VBP eligible professional on
the performance of such
professional with respect to
the performance categories
under clauses (i) and (ii) of
paragraph (2)(A); and
(II) may make available
confidential feedback to each
such professional on the
performance of such
professional with respect to
the performance categories
under clauses (iii) and (iv) of
such paragraph.
(ii) Mechanisms.--The Secretary may
use one or more mechanisms to make
feedback available under clause (i),
which may include use of a web-based
portal or other mechanisms determined
appropriate by the Secretary. The
Secretary shall encourage provision of
feedback through qualified clinical
data registries as described in
subsection (m)(3)(E)).
(iii) Use of data.--For purposes of
clause (i), the Secretary may use data,
with respect to a VBP eligible
professional, from periods prior to the
current performance period and may use
rolling periods in order to make
illustrative calculations about the
performance of such professional.
(iv) Disclosure exemption.--Feedback
made available under this subparagraph
shall be exempt from disclosure under
section 552 of title 5, United States
Code.
(v) Receipt of information.--The
Secretary may use the mechanisms
established under clause (ii) to
receive information from professionals,
such as information with respect to
this subsection.
(B) Additional information.--
(i) In general.--Beginning July 1,
2016, the Secretary shall make
available to each VBP eligible
professional information, with respect
to individuals who are patients of such
VBP eligible professional, about items
and services for which payment is made
under this title that are furnished to
such individuals by other suppliers and
providers of services, which may
include information described in clause
(ii). Such information shall be made
available under the previous sentence
to such VBP eligible professionals by
mechanisms determined appropriate by
the Secretary, which may include use of
a web-based portal. Such information
shall be made available in accordance
with the same or similar terms as data
are made available to accountable care
organizations under section 1899,
including a beneficiary opt-out.
(ii) Type of information.--For
purposes of clause (i), the information
described in this clause, is the
following:
(I) With respect to selected
items and services (as
determined appropriate by the
Secretary) for which payment is
made under this title and that
are furnished to individuals,
who are patients of a VBP
eligible professional, by
another supplier or provider of
services during the most recent
period for which data are
available (such as the most
recent three-month period), the
name of such providers
furnishing such items and
services to such patients
during such period, the types
of such items and services so
furnished, and the dates such
items and services were so
furnished.
(II) Historical averages (and
other measures of the
distribution if appropriate) of
the total, and components of,
allowed charges (and other
figures as determined
appropriate by the Secretary)
for care episodes for such
period.
(14) Review.--
(A) Targeted review.--The Secretary shall
establish a process under which a VBP eligible
professional may seek an informal review of the
calculation of the VBP program incentive
payment adjustment factor applicable to such
eligible professional under this subsection for
a year. The results of a review conducted
pursuant to the previous sentence shall not be
taken into account for purposes of paragraph
(7) with respect to a year (other than with
respect to the calculation of such eligible
professional's VBP program incentive payment
adjustment factor for such year) after the
factors determined in subparagraph (A) of such
paragraph have been determined for such year.
(B) Limitation.--Except as provided for in
subparagraph (A), there shall be no
administrative or judicial review under section
1869, section 1878, or otherwise of the
following:
(i) The methodology used to determine
the amount of the VBP program incentive
payment adjustment factor under
paragraph (7) and the determination of
such amount.
(ii) The determination of the amount
of funding available for such VBP
program incentive payments under
paragraph (6)(A) and the payment
reduction under paragraph (6)(B)(i).
(iii) The establishment of the
performance standards under paragraph
(3) and the performance period under
paragraph (4).
(iv) The identification of measures
and activities specified under
paragraph (2)(B) and information made
public or posted on the Physician
Compare Internet website of the Centers
for Medicare & Medicaid Services under
paragraph (10).
(v) The methodology developed under
paragraph (5) that is used to calculate
performance scores and the calculation
of such scores, including the weighting
of measures and activities under such
methodology.
(r) Collaborating With the Physician, Practitioner, and Other
Stakeholder Communities to Improve Resource Use Measurement.--
(1) In general.--In order to involve the physician,
practitioner, and other stakeholder communities in
enhancing the infrastructure for resource use
measurement, including for purposes of the value-based
performance incentive program under subsection (q) and
alternative payment models under section 1833(z), the
Secretary shall undertake the steps described in the
succeeding provisions of this subsection.
(2) Development of care episode and patient condition
groups and classification codes.--
(A) In general.--In order to classify similar
patients into distinct care episode groups and
distinct patient condition groups, the
Secretary shall undertake the steps described
in the succeeding provisions of this paragraph.
(B) Public availability of existing efforts
to design an episode grouper.--Not later than
60 days after the date of the enactment of this
subsection, the Secretary shall post on the
Internet website of the Centers for Medicare &
Medicaid Services a list of the episode groups
developed pursuant to subsection (n)(9)(A) and
related descriptive information.
(C) Stakeholder input.--The Secretary shall
accept, through the date that is 60 days after
the day the Secretary posts the list pursuant
to subparagraph (B), suggestions from physician
specialty societies, applicable practitioner
organizations, and other stakeholders for
episode groups in addition to those posted
pursuant to such subparagraph, and specific
clinical criteria and patient characteristics
to classify patients into--
(i) distinct care episode groups; and
(ii) distinct patient condition
groups.
(D) Development of proposed classification
codes.--
(i) In general.--Taking into account
the information described in
subparagraph (B) and the information
received under subparagraph (C), the
Secretary shall--
(I) establish distinct care
episode groups and distinct
patient condition groups, which
account for at least an
estimated two-thirds of
expenditures under parts A and
B; and
(II) assign codes to such
groups.
(ii) Care episode groups.--In
establishing the care episode groups
under clause (i), the Secretary shall
take into account--
(I) the patient's clinical
problems at the time items and
services are furnished during
an episode of care, such as the
clinical conditions or
diagnoses, whether or not
inpatient hospitalization is
anticipated or occurs, and the
principal procedures or
services planned or furnished;
and
(II) other factors determined
appropriate by the Secretary.
(iii) Patient condition groups.--In
establishing the patient condition
groups under clause (i), the Secretary
shall take into account--
(I) the patient's clinical
history at the time of each
medical visit, such as the
patient's combination of
chronic conditions, current
health status, and recent
significant history (such as
hospitalization and major
surgery during a previous
period, such as 3 months); and
(II) other factors determined
appropriate by the Secretary,
such as eligibility status
under this title (including
eligibility under section
226(a), 226(b), or 226A, and
dual eligibility under this
title and title XIX).
(E) Draft care episode and patient condition
groups and classification codes.--Not later
than 120 days after the end of the comment
period described in subparagraph (C), the
Secretary shall post on the Internet website of
the Centers for Medicare & Medicaid Services a
draft list of the care episode and patient
condition codes established under subparagraph
(D) (and the criteria and characteristics
assigned to such code).
(F) Solicitation of input.--The Secretary
shall seek, through the date that is 60 days
after the Secretary posts the list pursuant to
subparagraph (E), comments from physician
specialty societies, applicable practitioner
organizations, and other stakeholders,
including representatives of individuals
entitled to benefits under part A or enrolled
under this part, regarding the care episode and
patient condition groups (and codes) posted
under subparagraph (E). In seeking such
comments, the Secretary shall use one or more
mechanisms (other than notice and comment
rulemaking) that may include use of open door
forums, town hall meetings, or other
appropriate mechanisms.
(G) Operational list of care episode and
patient condition groups and codes.--Not later
than 120 days after the end of the comment
period described in subparagraph (F), taking
into account the comments received under such
subparagraph, the Secretary shall post on the
Internet website of the Centers for Medicare &
Medicaid Services an operational list of care
episode and patient condition codes (and the
criteria and characteristics assigned to such
code).
(H) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2016),
the Secretary shall, through rulemaking, make
revisions to the operational lists of care
episode and patient condition codes as the
Secretary determines may be appropriate. Such
revisions may be based on experience, new
information developed pursuant to subsection
(n)(9)(A), and input from the physician
specialty societies, applicable practitioner
organizations, and other stakeholders,
including representatives of individuals
entitled to benefits under part A or enrolled
under this part.
(3) Attribution of patients to physicians or
practitioners.--
(A) In general.--In order to facilitate the
attribution of patients and episodes (in whole
or in part) to one or more physicians or
applicable practitioners furnishing items and
services, the Secretary shall undertake the
steps described in the succeeding provisions of
this paragraph.
(B) Development of patient relationship
categories and codes.--The Secretary shall
develop patient relationship categories and
codes that define and distinguish the
relationship and responsibility of a physician
or applicable practitioner with a patient at
the time of furnishing an item or service. Such
patient relationship categories shall include
different relationships of the physician or
applicable practitioner to the patient (and the
codes may reflect combinations of such
categories), such as a physician or applicable
practitioner who--
(i) considers themself to have the
primary responsibility for the general
and ongoing care for the patient over
extended periods of time;
(ii) considers themself to be the
lead physician or practitioner and who
furnishes items and services and
coordinates care furnished by other
physicians or practitioners for the
patient during an acute episode;
(iii) furnishes items and services to
the patient on a continuing basis
during an acute episode of care, but in
a supportive rather than a lead role;
(iv) furnishes items and services to
the patient on an occasional basis,
usually at the request of another
physician or practitioner; or
(v) furnishes items and services only
as ordered by another physician or
practitioner.
(C) Draft list of patient relationship
categories and codes.--Not later than 180 days
after the date of the enactment of this
subsection, the Secretary shall post on the
Internet website of the Centers for Medicare &
Medicaid Services a draft list of the patient
relationship categories and codes developed
under subparagraph (B).
(D) Stakeholder input.--The Secretary shall
seek, through the date that is 60 days after
the Secretary posts the list pursuant to
subparagraph (C), comments from physician
specialty societies, applicable practitioner
organizations, and other stakeholders,
including representatives of individuals
entitled to benefits under part A or enrolled
under this part, regarding the patient
relationship categories and codes posted under
subparagraph (C). In seeking such comments, the
Secretary shall use one or more mechanisms
(other than notice and comment rulemaking) that
may include open door forums, town hall
meetings, or other appropriate mechanisms.
(E) Operational list of patient relationship
categories and codes.--Not later than 120 days
after the end of the comment period described
in subparagraph (D), taking into account the
comments received under such subparagraph, the
Secretary shall post on the Internet website of
the Centers for Medicare & Medicaid Services an
operational list of patient relationship
categories and codes.
(F) Subsequent revisions.--Not later than
November 1 of each year (beginning with 2016),
the Secretary shall, through rulemaking, make
revisions to the operational list of patient
relationship categories and codes as the
Secretary determines appropriate. Such
revisions may be based on experience, new
information developed pursuant to subsection
(n)(9)(A), and input from the physician
specialty societies, applicable practitioner
organizations, and other stakeholders,
including representatives of individuals
entitled to benefits under part A or enrolled
under this part.
(4) Reporting of information for resource use
measurement.--Claims submitted for items and services
furnished by a physician or applicable practitioner on
or after January 1, 2016, shall, as determined
appropriate by the Secretary, include--
(A) applicable codes established under
paragraphs (2) and (3); and
(B) the national provider identifier of the
ordering physician or applicable practitioner
(if different from the billing physician or
applicable practitioner).
(5) Methodology for resource use analysis.--
(A) In general.--In order to evaluate the
resources used to treat patients (with respect
to care episode and patient condition groups),
the Secretary shall--
(i) use the patient relationship
codes reported on claims pursuant to
paragraph (4) to attribute patients (in
whole or in part) to one or more
physicians and applicable
practitioners;
(ii) use the care episode and patient
condition codes reported on claims
pursuant to paragraph (4) as a basis to
compare similar patients and care
episodes and patient condition groups;
and
(iii) conduct an analysis of resource
use (with respect to care episodes and
patient condition groups of such
patients), as the Secretary determines
appropriate.
(B) Analysis of patients of physicians and
practitioners.--In conducting the analysis
described in subparagraph (A)(iii) with respect
to patients attributed to physicians and
applicable practitioners, the Secretary shall,
as feasible--
(i) use the claims data experience of
such patients by patient condition
codes during a common period, such as
12 months; and
(ii) use the claims data experience
of such patients by care episode
codes--
(I) in the case of episodes
without a hospitalization,
during periods of time (such as
the number of days) determined
appropriate by the Secretary;
and
(II) in the case of episodes
with a hospitalization, during
periods of time (such as the
number of days) before, during,
and after the hospitalization.
(C) Measurement of resource use.--In
measuring such resource use, the Secretary--
(i) shall use per patient total
allowed amounts for all services under
part A and this part (and, if the
Secretary determines appropriate, part
D) for the analysis of patient resource
use, by care episode codes and by
patient condition codes; and
(ii) may, as determined appropriate,
use other measures of allowed amounts
(such as subtotals for categories of
items and services) and measures of
utilization of items and services (such
as frequency of specific items and
services and the ratio of specific
items and services among attributed
patients or episodes).
(D) Stakeholder input.--The Secretary shall
seek comments from the physician specialty
societies, applicable practitioner
organizations, and other stakeholders,
including representatives of individuals
entitled to benefits under part A or enrolled
under this part, regarding the resource use
methodology established pursuant to this
paragraph. In seeking comments the Secretary
shall use one or more mechanisms (other than
notice and comment rulemaking) that may include
open door forums, town hall meetings, or other
appropriate mechanisms.
(6) Limitation.--There shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of--
(A) care episode and patient condition groups
and codes established under paragraph (2);
(B) patient relationship categories and codes
established under paragraph (3); and
(C) measurement of, and analyses of resource
use with respect to, care episode and patient
condition codes and patient relationship codes
pursuant to paragraph (5).
(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
(8) Definitions.--In this section:
(A) Physician.--The term ``physician'' has
the meaning given such term in section
1861(r)(1).
(B) Applicable practitioner.--The term
``applicable practitioner'' means--
(i) a physician assistant, nurse
practitioner, and clinical nurse
specialist (as such terms are defined
in section 1861(aa)(5)); and
(ii) beginning January 1, 2017, such
other eligible professionals (as
defined in subsection (k)(3)(B)) as
specified by the Secretary.
(9) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this
subsection.
(s) Priorities and Funding for Quality Measure Development.--
(1) Plan identifying measure development priorities
and timelines.--
(A) Draft measure development plan.--
(i) Draft plan.--
(I) In general.--Not later
than October 1, 2014, the
Secretary shall develop, and
post on the Internet website of
the Centers for Medicare &
Medicaid Services, a draft plan
for the development of quality
measures for application under
the applicable provisions.
(II) Requirement.--Such plan
shall address how measures used
by private payers and
integrated delivery systems
could be incorporated under
such subsection.
(ii) Consideration.--In developing
the draft plan under subparagraph (A),
the Secretary shall consider--
(I) gap analyses conducted by
the entity with a contract
under section 1890(a) or other
contractors or entities; and
(II) whether measures are
applicable across health care
settings.
(iii) Priorities.--In developing the
draft plan under subparagraph (A), the
Secretary shall give priority to the
following types of measures:
(I) Outcome measures
including patient reported
outcome and functional status
measures.
(II) Patient experience
measures.
(III) Care coordination
measures.
(IV) Measures of appropriate
use of services, including
measures of over use.
(iv) Definition of applicable
provisions.--In this subsection, the
term ``applicable provisions'' means
the following provisions:
(I) Subsection (q)(2)(B)(i).
(II) Section 1833(z)(2)(C).
(B) Stakeholder input.--The Secretary shall
accept through December 1, 2014, comments on
the draft plan posted under paragraph (1)(A)
from the public, including health care
providers, payers, consumers, and other
stakeholders.
(C) Operational measure development plan.--
Not later than February 1, 2015, taking into
account the comments received under
subparagraph (B), the Secretary shall post on
the Internet website of the Centers for
Medicare & Medicaid Services an operational
plan for the development of quality measures
for use under subsection (q)(2)(A)(i).
(2) Contracts and other arrangements for quality
measure development.--
(A) In general.--The Secretary shall enter
into contracts or other arrangements with
entities for the purpose of developing,
improving, updating, or expanding quality
measures for application under the applicable
provisions. Such entities may include physician
specialty societies and other practitioner
organizations.
(B) Prioritization.--
(i) In general.--In entering into
contracts or other arrangements under
subparagraph (A), the Secretary shall
give priority to the development of the
types of measures described in
paragraph (1)(A)(iii).
(ii) Consideration.--In selecting
measures for development under this
subsection, the Secretary shall
consider whether such measures would be
electronically specified.
(3) Annual report by the secretary.--
(A) In general.--Not later than February 1,
2016, and annually thereafter, the Secretary
shall post on the Internet website of the
Centers for Medicare & Medicaid Services a
report on the progress made in developing
quality measures for application under the
applicable provisions.
(B) Requirements.--Each report submitted
pursuant to paragraph (1) shall include the
following:
(i) A description of the Secretary's
efforts to implement this subsection.
(ii) With respect to the measures
developed during the previous year--
(I) a description of the
total number of quality
measures developed and the
types of such measures, such as
an outcome or patient
experience measure;
(II) the name of each measure
developed;
(III) the name of the
developer and steward of each
measure;
(IV) with respect to each
type of measure, an estimate of
the total amount expended under
this title to develop all
measures of such type; and
(V) whether the measure would
be electronically specified.
(iii) With respect to measures in
development at the time of the report--
(I) the information described
in clause (ii), if available;
and
(II) a timeline for
completion of the development
of such measures.
(iv) An update on the progress in
developing the types of measures
described in paragraph (1)(A)(iii),
including a description of issues
affecting such progress.
(v) A list of quality topics and
concepts that are being considered for
development of measures and the
rationale for the selection of topics
and concepts including their
relationship to gap analyses.
(vi) A description of any updates to
the plan under paragraph (1) (including
newly identified gaps and the status of
previously identified gaps) and the
inventory of measures applicable under
the applicable provisions.
(vii) Other information the Secretary
determines to be appropriate.
(4) Stakeholder input.--With respect to measures
applicable under the applicable provisions, the
Secretary shall seek stakeholder input with respect
to--
(A) the identification of gaps where no
quality measures exist, particularly with
respect to the types of measures described in
paragraph (1)(A)(iii);
(B) prioritizing quality measure development
to address such gaps; and
(C) other areas related to quality measure
development determined appropriate by the
Secretary.
(5) Funding.--For purposes of carrying out this
subsection, the Secretary shall provide for the
transfer, from the Federal Supplementary Medical
Insurance Trust Fund under section 1841, of $15,000,000
to the Centers for Medicare & Medicaid Services Program
Management Account for each of fiscal years 2014
through 2018. Amounts transferred under this paragraph
shall remain available through the end of fiscal year
2021.
(t) Public Reporting of Performance and Other Information on
Physician Compare.--
(1) In general.--
(A) Development.--Not later than January 1,
2011, the Secretary shall develop a Physician
Compare Internet website with information on
physicians enrolled in the program under this
title under section 1866(j) and other eligible
professionals who participate in the Physician
Quality Reporting Initiative under section
1848.
(B) Plan.--Not later than January 1, 2013,
and with respect to reporting periods that
begin no earlier than January 1, 2012, the
Secretary shall also implement a plan for
making publicly available through Physician
Compare, consistent with paragraph (3),
information on physician performance that
provides comparable information for the public
on quality and patient experience measures with
respect to physicians enrolled in the program
under this title under section 1866(j). To the
extent scientifically sound measures that are
developed consistent with the requirements of
this subsection are available, such
information, to the extent practicable, shall
include--
(i) measures collected under the
Physician Quality Reporting Initiative;
(ii) an assessment of patient health
outcomes and the functional status of
patients;
(iii) an assessment of the continuity
and coordination of care and care
transitions, including episodes of care
and risk-adjusted resource use;
(iv) an assessment of efficiency;
(v) an assessment of patient
experience and patient, caregiver, and
family engagement;
(vi) an assessment of the safety,
effectiveness, and timeliness of care;
and
(vii) other information as determined
appropriate by the Secretary.
(2) Other required considerations.--In developing and
implementing the plan described in paragraph (1)(B),
the Secretary shall, to the extent practicable,
include--
(A) processes to assure that data made
public, either by the Centers for Medicare &
Medicaid Services or by other entities, is
statistically valid and reliable, including
risk adjustment mechanisms used by the
Secretary;
(B) processes by which a physician or other
eligible professional whose performance on
measures is being publicly reported has a
reasonable opportunity, as determined by the
Secretary, to review his or her individual
results before they are made public;
(C) processes by the Secretary to assure that
the implementation of the plan and the data
made available on Physician Compare provide a
robust and accurate portrayal of a physician's
performance;
(D) data that reflects the care provided to
all patients seen by physicians, under both the
program under this title and, to the extent
practicable, other payers, to the extent such
information would provide a more accurate
portrayal of physician performance;
(E) processes to ensure appropriate
attribution of care when multiple physicians
and other providers are involved in the care of
a patient;
(F) processes to ensure timely statistical
performance feedback is provided to physicians
concerning the data reported under any program
subject to public reporting under this
subsection; and
(G) implementation of computer and data
systems of the Centers for Medicare & Medicaid
Services that support valid, reliable, and
accurate public reporting activities authorized
under this subsection.
(3) Ensuring patient privacy.--The Secretary shall
ensure that information on physician performance and
patient experience is not disclosed under this
subsection in a manner that violates sections 552 or
552a of title 5, United States Code, with regard to the
privacy of individually identifiable health
information.
(4) Feedback from multi-stakeholder groups.--The
Secretary shall take into consideration input provided
by multi-stakeholder groups, consistent with sections
1890(b)(7) and 1890A, in selecting quality measures for
use under this subsection.
(5) Consideration of transition to value-based
purchasing.--In developing the plan under paragraph
(1)(B), the Secretary shall, as the Secretary
determines appropriate, consider the plan to transition
to a value-based purchasing program for physicians and
other practitioners developed under section 131 of the
Medicare Improvements for Patients and Providers Act of
2008.
(6) Report to congress.--Not later than January 1,
2015, the Secretary shall submit to Congress a report
on the Physician Compare Internet website developed
under paragraph (1)(A). Such report shall include
information on the efforts of and plans made by the
Secretary to collect and publish data on physician
quality and efficiency and on patient experience of
care in support of value-based purchasing and consumer
choice, together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(7) Expansion.--At any time before the date on which
the report is submitted under paragraph (6), the
Secretary may expand (including expansion to other
providers of services and suppliers under this title)
the information made available on such website.
(8) Financial incentives to encourage consumers to
choose high quality providers.--The Secretary may
establish a demonstration program, not later than
January 1, 2019, to provide financial incentives to
Medicare beneficiaries who are furnished services by
high quality physicians, as determined by the Secretary
based on factors in clauses (i) through (vii) of
paragraph (1)(B). In no case may Medicare beneficiaries
be required to pay increased premiums or cost sharing
or be subject to a reduction in benefits under this
title as a result of such demonstration program. The
Secretary shall ensure that any such demonstration
program does not disadvantage those beneficiaries
without reasonable access to high performing physicians
or create financial inequities under this title.
(9) Public availability of eligible professional
claims data.--
(A) In general.--The Secretary shall make
publicly available on Physician Compare the
information described in subparagraph (B) with
respect to eligible professionals.
(B) Information described.--The following
information, with respect to an eligible
professional, is described in this
subparagraph:
(i) Information on the number of
services furnished by the eligible
professional, which may include
information on the most frequent
services furnished or groupings of
services.
(ii) Information on submitted charges
and payments for services under this
part.
(iii) A unique identifier for the
eligible professional that is available
to the public, such as a national
provider identifier.
(C) Searchability.--The information made
available under this paragraph shall be
searchable by at least the following:
(i) The specialty or type of the
eligible professional.
(ii) Characteristics of the services
furnished, such as volume or groupings
of services.
(iii) The location of the eligible
professional.
(D) Disclosure.--The information made
available under this paragraph shall indicate,
where appropriate, that publicized information
may not be representative of the eligible
professional's entire patient population, the
variety of services furnished by the eligible
professional, or the health conditions of
individuals treated.
(E) Implementation.--
(i) Initial implementation.--
Physician Compare shall include the
information described in subparagraph
(B)--
(I) with respect to
physicians, by not later than
July 1, 2015; and
(II) with respect to other
eligible professionals, by not
later than July 1, 2016.
(ii) Annual updating.--The
information made available under this
paragraph shall be updated on Physician
Compare not less frequently than on an
annual basis.
(F) Opportunity to review and submit
corrections.--The Secretary shall provide for
an opportunity for an eligible professional to
review, and submit corrections for, the
information to be made public with respect to
the eligible professional under this paragraph
prior to such information being made public.
(10) Definitions.--In this subsection:
(A) Eligible professional.--The term
``eligible professional'' has the meaning given
that term for purposes of the Physician Quality
Reporting Initiative under section 1848.
(B) Physician.--The term ``physician'' has
the meaning given that term in section 1861(r).
(C) Physician compare.--The term ``Physician
Compare'' means the Internet website developed
under paragraph (1)(A) (or a successor
website).
* * * * * * *
Part E--Miscellaneous Provisions
* * * * * * *
administration
Sec. 1874. (a) * * *
* * * * * * *
(e) Availability of [Medicare] Data.--
(1) * * *
* * * * * * *
(3) Data described.--The data described in this
paragraph are standardized extracts (as determined by
the Secretary) of claims data under parts A, B, and D
for items and services furnished under such parts for
one or more specified geographic areas and time periods
requested by a qualified entity. Effective July 1,
2014, if the Secretary determines appropriate, the data
described in this paragraph may also include
standardized extracts (as determined by the Secretary)
of claims data under titles XIX and XXI for assistance
provided under such titles for one or more specified
geographic areas and time periods requested by a
qualified entity. The Secretary shall take such actions
as the Secretary deems necessary to protect the
identity of individuals entitled to or enrolled for
benefits under such parts or under titles XIX or XXI.
(4) Requirements.--
(A) Fee.--Data described in paragraph (3)
shall be made available to a qualified entity
under this subsection at a fee equal to the
cost of making such data available. Any fee
collected pursuant to the preceding sentence
shall be deposited, for periods prior to July
1, 2014, into the Federal Supplementary Medical
Insurance Trust Fund under section 1841, and,
beginning July 1, 2014, into the Centers for
Medicare & Medicaid Services Program Management
Account.
* * * * * * *
(5) Expansion of uses of claims data by qualified
entities.--
(A) Expansion.--To the extent consistent with
applicable information, privacy, security, and
disclosure laws, beginning July 1, 2014,
notwithstanding paragraph (4)(B) (other than
clause (iii) of such paragraph) and the second
sentence of paragraph (4)(D), a qualified
entity may, as determined appropriate by the
Secretary, do any or all of the following:
(i)(I) Use the combined data
described in paragraph (4)(B)(iii) to
conduct analyses, other than for
reports described in paragraph (4), for
entities described in subparagraph (B)
for non-public uses, as determined
appropriate by the Secretary, such as
for the purposes described in subclause
(II).
(II) The purposes described in this
subclause are assisting providers of
services and suppliers in developing
and participating in quality and
patient care improvement activities
(including developing new models of
care), population health management,
and disease monitoring, and the
purposes described in subparagraph (C).
(ii) Provide or sell such analyses to
entities described in subparagraph (B).
(iii) Provide entities described in
clauses (i), (ii), (v), and (vi) of
subparagraph (B) with access to the
combined data described in paragraph
(4)(B)(iii) through a qualified data
enclave (as defined in subparagraph
(F)) that is maintained by the
qualified entity in order for entities
described in such clauses to conduct
analyses for non-public uses, such as
for the purposes described in clause
(i)(II).
(B) Entities described.--For the purpose of
subparagraph (A) clauses (i) and (ii), the
entities described in this subparagraph are the
following:
(i) A provider of services.
(ii) A supplier.
(iii) Subject to subparagraph (C), an
employer (as defined in section 3(5) of
the Employee Retirement Insurance
Security Act of 1974).
(iv) A health insurance issuer (as
defined in section 2791 of the Public
Health Service Act) that provides data
under paragraph (4)(B)(iii).
(v) A medical society or hospital
association.
(vi) Other entities approved by the
Secretary (other than an employer (as
so defined) and a health insurance
issuer (as so defined)).
(C) Limitation with respect to employers.--
Any analyses provided or sold under this
paragraph to an employer (as so defined) may
only be used by such employer for purposes of
providing health insurance to employees and
retirees of the employer.
(D) Protection of patient identification.--
(i) In general.--Except as provided
in clause (ii), an analysis provided or
sold under this paragraph shall not
contain information that individually
identifies a patient.
(ii) Information on patients of the
provider of services or supplier.--An
analysis that is provided or sold under
this paragraph to a provider of
services or supplier may contain data
that individually identifies a patient
of such provider or supplier but only
with respect to items and services
furnished by such provider or supplier
to such patient.
(iii) Opportunity for providers of
services and suppliers to review.--
Prior to a qualified entity providing
or selling an analysis under this
paragraph to an entity described in
subparagraph (B), to the extent that
such analysis would individually
identify a provider of services or
supplier who is not being provided or
sold such analysis, such qualified
entity shall provide an opportunity for
such provider or supplier to review and
submit corrections to such analysis.
(E) No redisclosure.--An entity described in
subparagraph (B) that is provided or sold an
analysis under this paragraph shall not
redisclose or make public such an analysis.
(F) Requirements for a qualified data
enclave.--
(i) Definition.--For purposes of this
paragraph, the term ``qualified data
enclave'' means a data enclave that the
Secretary determines meets the
following:
(I) The data enclave is a
web-based portal or comparable
mechanism.
(II) Subject to the
requirements described in
clause (ii) and such other
requirements as the Secretary
may specify, the data enclave
is capable of providing access
to the combined data described
in subparagraph (A)(iii).
(ii) Enclave access requirements.--
The requirements described in this
clause are the following:
(I) A qualified data enclave
shall preclude any entity that
obtains access to the data from
removing or extracting the data
from such enclave.
(II) Subject to the
succeeding sentence, the
enclave shall preclude access
to data that individually
identifies a patient, including
data on the patient's name and
date of birth and such other
data as the Secretary shall
specify. Such data enclave may
provide providers of services
and suppliers with access to
such individually identifiable
patient data but only with
respect to items and services
furnished by such provider or
supplier to such patient.
(III) Access to data in the
enclave shall not be provided
to any entity unless the
qualified entity and the entity
have entered into a data use
agreement, the terms of which
contain the requirements of
this paragraph and such other
terms the Secretary may
specify.
(G) Annual reports.--Any qualified entity
that provides or sells analyses pursuant to
subparagraph (A)(ii) or provides access to a
qualified data enclave pursuant to subparagraph
(A)(iii) shall annually submit to the Secretary
a report that includes--
(i) a summary of the analyses
provided or sold, including the number
of such analyses, the number of
purchasers of such analyses, and the
total amount of fees received for such
analyses;
(ii) a description of the topics and
purposes of such analyses;
(iii) information on the entities who
obtained access to the qualified data
enclave, the uses of the data, and the
total amount of fees received for
providing such access; and
(iv) other information determined
appropriate by the Secretary.
* * * * * * *
payment to hospitals for inpatient hospital services
Sec. 1886. (a) * * *
* * * * * * *
(n) Incentives for Adoption and Meaningful Use of Certified
EHR Technology.--
(1) * * *
* * * * * * *
(3) Meaningful ehr user.--
(A) In general.--For purposes of paragraph
(1), an eligible hospital shall be treated as a
meaningful EHR user for an EHR reporting period
for a payment year (or, for purposes of
subsection (b)(3)(B)(ix), for an EHR reporting
period under such subsection for a fiscal year)
if each of the following requirements are met:
(i) * * *
(ii) Information exchange.--The
eligible hospital demonstrates to the
satisfaction of the Secretary, in
accordance with subparagraph (C)(i),
that during such period such certified
EHR technology is connected in a manner
that provides, in accordance with law
and standards applicable to the
exchange of information, for the
electronic exchange of health
information to improve the quality of
health care, such as promoting care
coordination, and the hospital
demonstrates (through a process
specified by the Secretary, such as the
use of an attestation referred to in
section 1848(o)(2)(A)(ii)) that the
hospital has not and will not take any
deliberate action to limit or restrict
the use, compatibility, or
interoperability of the certified EHR
technology.
* * * * * * *
----------
PATIENT PROTECTION AND AFFORDABLE HEALTH CARE ACT
(Public Law 111-148)
* * * * * * *
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
* * * * * * *
Subtitle C--Provisions Relating to Title III
* * * * * * *
[SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
[(a) In general.--
[(1) Development.--Not later than January 1, 2011,
the Secretary shall develop a Physician Compare
Internet website with information on physicians
enrolled in the Medicare program under section 1866(j)
of the Social Security Act (42 U.S.C. 1395cc(j)) and
other eligible professionals who participate in the
Physician Quality Reporting Initiative under section
1848 of such Act (42 U.S.C. 1395w-4).
[(2) Plan.--Not later than January 1, 2013, and with
respect to reporting periods that begin no earlier than
January 1, 2012, the Secretary shall also implement a
plan for making publicly available through Physician
Compare, consistent with subsection (c), information on
physician performance that provides comparable
information for the public on quality and patient
experience measures with respect to physicians enrolled
in the Medicare program under such section 1866(j). To
the extent scientifically sound measures that are
developed consistent with the requirements of this
section are available, such information, to the extent
practicable, shall include--
[(A) measures collected under the Physician
Quality Reporting Initiative;
[(B) an assessment of patient health outcomes
and the functional status of patients;
[(C) an assessment of the continuity and
coordination of care and care transitions,
including episodes of care and risk-adjusted
resource use;
[(D) an assessment of efficiency;
[(E) an assessment of patient experience and
patient, caregiver, and family engagement;
[(F) an assessment of the safety,
effectiveness, and timeliness of care; and
[(G) other information as determined
appropriate by the Secretary.
[(b) Other required considerations.--In developing and
implementing the plan described in subsection (a)(2), the
Secretary shall, to the extent practicable, include--
[(1) processes to assure that data made public,
either by the Centers for Medicare & Medicaid Services
or by other entities, is statistically valid and
reliable, including risk adjustment mechanisms used by
the Secretary;
[(2) processes by which a physician or other eligible
professional whose performance on measures is being
publicly reported has a reasonable opportunity, as
determined by the Secretary, to review his or her
individual results before they are made public;
[(3) processes by the Secretary to assure that the
implementation of the plan and the data made available
on Physician Compare provide a robust and accurate
portrayal of a physician's performance;
[(4) data that reflects the care provided to all
patients seen by physicians, under both the Medicare
program and, to the extent practicable, other payers,
to the extent such information would provide a more
accurate portrayal of physician performance;
[(5) processes to ensure appropriate attribution of
care when multiple physicians and other providers are
involved in the care of a patient;
[(6) processes to ensure timely statistical
performance feedback is provided to physicians
concerning the data reported under any program subject
to public reporting under this section; and
[(7) implementation of computer and data systems of
the Centers for Medicare & Medicaid Services that
support valid, reliable, and accurate public reporting
activities authorized under this section.
[(c) Ensuring patient privacy.--The Secretary shall ensure
that information on physician performance and patient
experience is not disclosed under this section in a manner that
violates sections 552 or 552a of title 5, United States Code,
with regard to the privacy of individually identifiable health
information.
[(d) Feedback from multi-stakeholder groups.--The Secretary
shall take into consideration input provided by multi-
stakeholder groups, consistent with sections 1890(b)(7) and
1890A of the Social Security Act, as added by section 3014 of
this Act, in selecting quality measures for use under this
section.
[(e) Consideration of transition to value-based purchasing.--
In developing the plan under this subsection (a)(2), the
Secretary shall, as the Secretary determines appropriate,
consider the plan to transition to a value-based purchasing
program for physicians and other practitioners developed under
section 131 of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275).
[(f) Report to Congress.--Not later than January 1, 2015, the
Secretary shall submit to Congress a report on the Physician
Compare Internet website developed under subsection (a)(1).
Such report shall include information on the efforts of and
plans made by the Secretary to collect and publish data on
physician quality and efficiency and on patient experience of
care in support of value-based purchasing and consumer choice,
together with recommendations for such legislation and
administrative action as the Secretary determines appropriate.
[(g) Expansion.--At any time before the date on which the
report is submitted under subsection (f), the Secretary may
expand (including expansion to other providers of services and
suppliers under title XVIII of the Social Security Act) the
information made available on such website.
[(h) Financial incentives to encourage consumers to choose
high quality providers.--The Secretary may establish a
demonstration program, not later than January 1, 2019, to
provide financial incentives to Medicare beneficiaries who are
furnished services by high quality physicians, as determined by
the Secretary based on factors in subparagraphs (A) through (G)
of subsection (a)(2). In no case may Medicare beneficiaries be
required to pay increased premiums or cost sharing or be
subject to a reduction in benefits under title XVIII of the
Social Security Act as a result of such demonstration program.
The Secretary shall ensure that any such demonstration program
does not disadvantage those beneficiaries without reasonable
access to high performing physicians or create financial
inequities under such title.
[(i) Definitions.--In this section:
[(1) Eligible professional.--The term ``eligible
professional'' has the meaning given that term for
purposes of the Physician Quality Reporting Initiative
under section 1848 of the Social Security Act (42
U.S.C. 1395w-4).
[(2) Physician.--The term ``physician'' has the
meaning given that term in section 1861(r) of such Act
(42 U.S.C. 1395x(r)).
[(3) Physician compare.--The term ``Physician
Compare'' means the Internet website developed under
subsection (a)(1).
[(4) Secretary.--The term ``Secretary'' means the
Secretary of Health and Human Services.]
* * * * * * *