Sec. 101. Repealing the sustainable growth rate (SGR) and improving Medicare payment for physicians’ services

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ) is amended— in subsection (d)— in paragraph (1)(A), by inserting or a subsequent paragraph after paragraph

(4); and in paragraph (4)— in the heading, by inserting after and ending with 2013 ; and years beginning with 2001 in subparagraph (A), by inserting and ending with 2013 after a year beginning with 2001 ; and in subsection (f)— in paragraph (1)(B), by inserting through 2013 after of each succeeding year ; and in paragraph (2), by inserting and ending with 2013 after beginning with 2000 . 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: The update to the single conversion factor established in paragraph (1)(C) for each of 2014 through 2023 shall be zero percent. The update to the single conversion factor established in paragraph (1)(C) for 2024 and each subsequent year shall be— for items and services furnished by a qualifying APM participant (as defined in section 1833(z)(2)) for such year, 2 percent; and for other items and services, 1 percent. . Not later than July 1, 2016, the Medicare Payment Advisory Commission shall submit to Congress a report on the relationship between— 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 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. 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. Section 1848(a)(7)(A) of the Social Security Act ( 42 U.S.C. 1395w–4(a)(7)(A) ) is amended— in clause (i), by striking or any subsequent payment year and inserting or 2016 ; in clause (ii)— in the matter preceding subclause (I), by striking Subject to clause (iii), for and inserting For ; in subclause (I), by adding at the end and ; in subclause (II), by striking ; and and inserting a period; and by striking subclause (III); and by striking clause (iii). Section 1848(o)(2) of the Social Security Act ( 42 U.S.C. 1395w–4(o)(2) ) is amended— in subparagraph (A), in the matter preceding clause (i)— by striking For purposes of paragraph (1), an and inserting An ; and 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 by adding at the end the following new subparagraph: 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. . Section 1848(a)(8)(A) of the Social Security Act ( 42 U.S.C. 1395w–4(a)(8)(A) ) is amended— in clause (i), by striking or any subsequent year and inserting or 2016 ; and in clause (ii)(II), by striking and each subsequent year . Section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ) is amended— in subsection (k), by adding at the end the following new paragraph: The Secretary shall, in accordance with subsection (q)(1)(F), carry out the provisions of this subsection for purposes of subsection (q). ; and in subsection (m)— by redesignating the paragraph

(7)added by section 10327(a) of Public Law 111–148 as paragraph (8); and by adding at the end the following new paragraph: The Secretary shall, in accordance with subsection (q)(1)(F), carry out the processes under this subsection for purposes of subsection (q). . 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: 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. . Section 1848(p) of the Social Security Act ( 42 U.S.C. 1395w–4(p) ) is amended— in paragraph (2), by adding at the end the following new subparagraph: The Secretary shall, in accordance with subsection (q)(1)(F), carry out subparagraph

(B)for purposes of subsection (q). ; and 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). . Section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ) is amended by adding at the end the following new subsection: 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— 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; using such methodology, provide for a composite performance score in accordance with paragraph

(5)for each such professional for each performance period; and 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. The VBP program shall apply to payments for items and services furnished on or after January 1, 2017. For purposes of this subsection, subject to clauses

(ii)and (iv), the term VBP eligible professional means— 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)), 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 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. 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))— who is a qualifying APM participant (as defined in section 1833(z)(2)); 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 who, for the performance period with respect to such year, does not exceed the low-volume threshold measurement selected under clause (iv). 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— with respect to 2017 and 2018, the reference in subparagraph

(A)of such paragraph to 25 percent was instead a reference to 20 percent; with respect to 2019 and 2020— the reference in subparagraph (B)(i) of such paragraph to 50 percent was instead a reference to 40 percent; and 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 with respect to 2021 and subsequent years— the reference in subparagraph (C)(i) of such paragraph to 75 percent was instead a reference to 50 percent; and 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. The Secretary shall select one of the following low-volume threshold measurements to apply for purposes of clause (ii)(III): 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. 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. The minimum amount (as determined by the Secretary) of allowed charges billed by such professional under this part for such performance period. 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. 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. 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. Under the VBP program: 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). 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. 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. 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. 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. In applying a provision of subsection (k), (m), (o), or

(p)for purposes of this subsection, the Secretary shall— adjust the application of such provision to ensure the provision is consistent with the provisions of this subsection; and not apply such provision to the extent that the provision is duplicative with a provision of this subsection. 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): Quality. Resource use. Clinical practice improvement activities. Meaningful use of certified EHR technology. 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: 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). 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. 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: 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. 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. 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. 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. The subcategory of patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification. 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 10 or fewer professionals) and practices located in rural areas and in health professional shortage areas (as designated under section 332(a)(1)(A) of the Public Health Service Act). 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. In applying subparagraph (B)(i), the Secretary shall, as feasible, emphasize the application of outcome 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). 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). 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. In applying subparagraph (B)(iii), the Secretary may contract with entities to assist the Secretary in— identifying activities described in subparagraph (B)(iii); specifying criteria for such activities; and determining whether a VBP eligible professional meets such criteria. 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. In establishing such performance standards with respect to measures and activities specified under paragraph (2)(B), the Secretary shall take into account the following: Historical performance standards. Improvement rates. The opportunity for continued improvement. 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. Subject to the succeeding provisions of this paragraph, 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. Under the methodology under subparagraph (A), the Secretary— may assign different scoring weights (including a weight of 0) for— each performance category based on the extent to which the category is applicable to the type of eligible professional involved; and 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 with respect to the performance category described in paragraph (2)(A)(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 may assign a higher scoring weight to patient experience measures. 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. Under the methodology established under subparagraph (A), the Secretary shall— 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 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. 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. 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. 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). 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). 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)— 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 in the case of performance scores for other performance categories, may take into account the improvement of the professional. Beginning with the fourth year to which the VBP program applies, under the methodology developed under subparagraph (A), the Secretary shall 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). Under the methodology developed under subparagraph (A), subject to clauses

(ii)and (iii), the composite performance score shall be determined as follows: Thirty percent of such score shall be based on performance with respect to the category described in clause

(i)of paragraph (2)(A). Thirty percent of such score shall be based on performance with respect to the category described in clause

(ii)of paragraph (2)(A). Fifteen percent of such score shall be based on performance with respect to the category described in clause

(iii)of paragraph (2)(A). Twenty-five percent of such score shall be based on performance with respect to the category described in clause

(iv)of paragraph (2)(A). 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 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. Subject to subclause (II), the percentages described in subclauses

(I)and

(II)of clause (i), including after application of clause (ii), shall be equal. For the first 2 years for which the VBP program applies, after application of clause (ii), the Secretary may increase the percentage applicable under subclause

(I)or

(II)of clause

(i)as long as the Secretary decreases the percentage applicable under the other subclause by an equal number of percentage points and the number of percentage points applicable under each of subclauses

(I)and

(II)is not less than 15. Analysis of the performance category described in paragraph (2)(A)(ii) shall include results from the methodology described in subsection (r)(5), as appropriate. 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. 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)— 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 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. 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. The process under clause

(ii)shall provide that— 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 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. 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. 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. For purposes of clause (i), the term applicable percent means— for 2017, 4 percent; for 2018, 6 percent; for 2019, 8 percent; for 2020, 10 percent; and for 2021 and subsequent years, a percent specified by the Secretary (but in no case less than 10 percent or more than 12 percent). 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. 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— by the composite performance score of the eligible professional for such year; 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 in a manner such that the adjustment factors specified under this subparagraph for a year— do 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 do 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. 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— the product of— the VBP program incentive payment adjustment factor determined under subparagraph

(A)for such VBP eligible professional for such year; and 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 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. 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. 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. 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). 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. The Secretary shall, in an easily understandable format, make available on the Physician Compare Internet website under subsection

(t)the following: Information regarding the performance of VBP eligible professionals under the VBP program, which— 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 may include the performance of each such VBP eligible professional with respect to each measure or activity specified in paragraph (2)(B). 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. 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. 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. 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. 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 10 or fewer professionals (with priority given to such practices located in rural areas, health professional shortage areas (as designated in section 332(a)(1)(A) of the Public Health Service Act), medically underserved areas, or practices with low composite scores) with respect to— the performance categories described in clauses

(i)through

(iv)of paragraph (2)(A); or how to transition to the implementation of and participation in an alternative payment model as described in section 1833(z)(3)(C). 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 $25,000,000 for each of fiscal years 2014 through 2018. Of amounts transferred under the preceding sentence, not less than $10,000,000 shall be available for technical assistance to small practices (consisting of 10 or fewer professionals) in health professional shortage areas (as so designated). Amounts transferred under this subparagraph for a fiscal year shall be available until expended. Beginning July 1, 2015, the Secretary— 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 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. 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). 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. Feedback made available under this subparagraph shall be exempt from disclosure under section 552 of title 5, United States Code. The Secretary may use the mechanisms established under clause

(ii)to receive information from professionals, such as information with respect to this subsection. 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. For purposes of clause (i), the information described in this clause, is the following: 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. 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. 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. 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: The methodology used to determine the amount of the VBP program incentive payment adjustment factor under paragraph

(7)and the determination of such amount. 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). The establishment of the performance standards under paragraph

(3)and the performance period under paragraph (4). 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). 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. . 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— 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 those based on type of provider, practice size, geographic location, and patient mix; provide recommendations for improving such program; evaluate the impact of technical assistance funding under section 1848(q)(12) of the Social Security Act, as added by paragraph (1), on the ability of professionals to improve within such program or successfully transition to an alternative payment model (as defined in section 1833(z)(3) of the Social Security Act, as added by subsection (e)(1)), with priority for such evaluation given to practices located in rural areas, health professional shortage areas (as designated in section 332(a)(1)(A) of the Public Health Service Act), and medically underserved areas; and provide recommendations for optimizing the use of such technical assistance funds. 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— compares the similarities and differences in the use of quality measures under the original medicare fee-for-service program under parts A and B of title XVIII of the Social Security Act, the Medicare Advantage program under part C of such title, selected State Medicaid programs under title XIX of such Act, and private payer arrangements; and makes recommendations on how to reduce the administrative burden involved in applying such quality measures. The report under clause

(i)shall— consider those measures applicable to individuals entitled to, or enrolled for, benefits under such part A, or enrolled under such part B and individuals under the age of 65; and focus on those measures that comprise the most significant component of the quality performance category of 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). Not later than October 1, 2019, and October 1, 2021, the Comptroller General of the United States shall submit to Congress a report that examines the transition of professionals in rural areas, health professional shortage areas (as designated in section 332(a)(1)(A) of the Public Health Service Act), or medically underserved areas to an alternative payment model (as defined in section 1833(z)(3) of the Social Security Act, as added by subsection (e)(1)). Such report shall make recommendations for removing administrative barriers to practices in rural areas, health professional shortage areas, and medically underserved areas to participation in such models. 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. 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 . 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). Section 1848(m)(5)(F) of the Social Security Act ( 42 U.S.C. 1395w–4(m)(5)(F) ) is amended— by striking and subsequent years and inserting through reporting periods occurring in 2013 ; and by inserting and, for reporting periods occurring in 2014 and subsequent years, the Secretary may establish following shall establish . 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: Reports under the Program shall not be provided after December 31, 2016. See subsection (q)(13) for reports beginning with 2017. . 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) . Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ) is amended by adding at the end the following new subsection: 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. Payments under this subsection shall be made in a lump sum, on an annual basis, as soon as practicable. 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. 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. For purposes of this subsection, the term qualifying APM participant means the following: 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. With respect to 2019 and 2020, an eligible professional described in either of the following clauses: 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. An eligible professional— 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— payments described in clause (i); and all other payments, regardless of payer (other than payments made by the Secretary of Defense or the Secretary of Veterans Affairs under chapter 55 of title 10, United States Code, or title 38, United States Code, or any other provision of law, and other than payments made under title XIX in a State in which no medical home or alternative payment model is available under the State program under that title). meet the requirement described in clause (iii)(I) with respect to payments described in item

(aa)and meet the requirement described in clause (iii)(II) with respect to payments described in item (bb); 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 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. For purposes of clause (ii)(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 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— quality measures comparable to measures under the performance category described in section 1848(q)(2)(B)(i) apply; certified EHR technology is used; and the eligible professional

(AA)bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures; or

(BB)is a medical home (with respect to beneficiaries under title XIX) that meets criteria comparable to medical homes expanded under section 1115A(c). With respect to 2021 and each subsequent year, an eligible professional described in either of the following clauses: 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. An eligible professional— 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— payments described in clause (i); and all other payments, regardless of payer (other than payments made by the Secretary of Defense or the Secretary of Veterans Affairs under chapter 55 of title 10, United States Code, or title 38, United States Code, or any other provision of law, and other than payments made under title XIX in a State in which no medical home or alternative payment model is available under the State program under that title. meet the requirement described in clause (iii)(I) with respect to payments described in item

(aa)of such clause, is that such payments are made under an eligible alternative payment model; and the requirement described in this subclause, with respect to payments described in item

(AA)bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures; or

(BB)is a medical home (with respect to beneficiaries under title XIX) that meets criteria comparable to medical homes expanded under section 1115A(c). In this subsection: The term covered professional services has the meaning given that term in section 1848(k)(3)(A). The term eligible professional has the meaning given that term in section 1848(k)(3)(B). The term alternative payment model means any of the following: A model under section 1115A (other than a health care innovation award). An accountable care organization under section 1899. A demonstration under section 1866C. A demonstration required by Federal law. The term eligible alternative payment model means, with respect to a year, an alternative payment model— that requires use of certified EHR technology (as defined in subsection (o)(4)); 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 that satisfies the requirement described in clause (ii). 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— 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 is a medical home expanded under section 1115A(c). There shall be no administrative or judicial review under section 1869, 1878, or otherwise, of the following: 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). The determination of the amount of the 5 percent payment incentive under paragraph (1)(A), including any estimation as part of such determination. . Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ) is further amended— 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 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. . Section 1115A(b)(2) of the Social Security Act ( 42 U.S.C. 1315a(b)(2) ) is amended— in subparagraph (B), by adding at the end the following new clauses: Focusing primarily on physicians’ services (as defined in section 1848(j)(3)) furnished by physicians who are not primary care practitioners. Focusing on practices of 10 or fewer professionals. Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP Services within the Centers for Medicare & Medicaid Services. ; and 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 . Nothing in the provisions of, or amendments made by, this Act shall be construed as precluding an alternative payment model or a qualifying APM participant (as those terms are defined in section 1833(z) of the Social Security Act, as added by paragraph (1)) from furnishing a telehealth service for which payment is not made under section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ). Not later than July 1, 2015, the Secretary of Health and Human Services shall submit to Congress a plan to integrate Medicare Advantage alternative payment models that take into account a budget neutral value-based modifier. 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— 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) )); identifies aspects of such alternative payment models that are vulnerable to fraudulent activity; and examines the implications of waivers to such laws granted in support of such alternative payment models, including under any potential expansion of such models. 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. 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. 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. 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). 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. In conducting such study the Secretary may use existing Federal data and collect such additional data as may be necessary to complete the study. 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). 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. 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— 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 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. 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. 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. 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. The Secretary shall collect or otherwise obtain access to the data necessary to carry out this paragraph through existing and new data sources. 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. 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. 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 Medicare program. 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: 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. 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. 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. 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— distinct care episode groups; and distinct patient condition groups. Taking into account the information described in subparagraph

(B)and the information received under subparagraph (C), the Secretary shall— 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 assign codes to such groups. In establishing the care episode groups under clause (i), the Secretary shall take into account— 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 other factors determined appropriate by the Secretary. In establishing the patient condition groups under clause (i), the Secretary shall take into account— 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 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). 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). 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 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. 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). 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 individuals entitled to benefits under part A or enrolled under this part. 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. 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— considers themself to have the primary responsibility for the general and ongoing care for the patient over extended periods of time; 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; 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; furnishes items and services to the patient on an occasional basis, usually at the request of another physician or practitioner; or furnishes items and services only as ordered by another physician or practitioner. 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). 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 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. 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. 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 individuals entitled to benefits under part A or enrolled under this part. 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— applicable codes established under paragraphs

(2)and (3); and the national provider identifier of the ordering physician or applicable practitioner (if different from the billing physician or applicable practitioner). In order to evaluate the resources used to treat patients (with respect to care episode and patient condition groups), the Secretary shall— 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; 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 conduct an analysis of resource use (with respect to care episodes and patient condition groups of such patients), as the Secretary determines appropriate. In conducting the analysis described in subparagraph (A)(iii) with respect to patients attributed to physicians and applicable practitioners, the Secretary shall, as feasible— use the claims data experience of such patients by patient condition codes during a common period, such as 12 months; and use the claims data experience of such patients by care episode codes— in the case of episodes without a hospitalization, during periods of time (such as the number of days) determined appropriate by the Secretary; and in the case of episodes with a hospitalization, during periods of time (such as the number of days) before, during, and after the hospitalization. In measuring such resource use, the Secretary— 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 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). The Secretary shall seek comments from the physician specialty societies, applicable practitioner organizations, and other stakeholders, including 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. There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of— care episode and patient condition groups and codes established under paragraph (2); patient relationship categories and codes established under paragraph (3); and measurement of, and analyses of resource use with respect to, care episode and patient condition codes and patient relationship codes pursuant to paragraph (5). Chapter 35 of title 44, United States Code, shall not apply to this section. In this section: The term physician has the meaning given such term in section 1861(r). The term applicable practitioner means— a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1861(aa)(5)); and beginning January 1, 2017, such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary. The provisions of sections 1890A(b)(2) and 1890B shall not apply to this subsection. .

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