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

14,029 words·~64 min read·/bill/114/hr/2/rds/section-101

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 and ending with 2025 after beginning with 2001 ; and by inserting or a subsequent paragraph after paragraph

(4); and in paragraph (4)— in the heading, by inserting after and ending with 2014 ; and years beginning with 2001 in subparagraph (A), by inserting and ending with 2014 after a year beginning with 2001 ; and in subsection (f)— in paragraph (1)(B), by inserting through 2014 after of each succeeding year ; and in paragraph (2), in the matter preceding subparagraph (A), by inserting and ending with 2014 after beginning with 2000 . Subsection

(d)of section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ) is amended— in paragraph (1)(A), by adding at the end the following: There shall be two separate conversion factors for each year beginning with 2026, one for items and services furnished by a qualifying APM participant (as defined in section 1833(z)(2)) (referred to in this subsection as the ; qualifying APM conversion factor ) and the other for other items and services (referred to in this subsection as the nonqualifying APM conversion factor ), equal to the respective conversion factor for the previous year (or, in the case of 2026, equal to the single conversion factor for 2025) multiplied by the update established under paragraph

(20)for such respective conversion factor for such year. in paragraph (1)(D), by inserting (or, beginning with 2026, applicable conversion factor) after single conversion factor ; and by striking paragraph

(16)and inserting the following new paragraphs: Subject to paragraphs (7)(B), (8)(B), (9)(B), (10)(B), (11)(B), (12)(B), (13)(B), (14)(B), and (15)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2015 for the period beginning on January 1, 2015, and ending on June 30, 2015, the update to the single conversion factor shall be 0.0 percent. The update to the single conversion factor established in paragraph (1)(C) for the period beginning on July 1, 2015, and ending on December 31, 2015, shall be 0.5 percent. The update to the single conversion factor established in paragraph (1)(C) for 2016 and each subsequent year through 2019 shall be 0.5 percent. The update to the single conversion factor established in paragraph (1)(C) for 2020 and each subsequent year through 2025 shall be 0.0 percent. For 2026 and each subsequent year, the update to the qualifying APM conversion factor established under paragraph (1)(A) is 0.75 percent, and the update to the nonqualifying APM conversion factor established under such paragraph is 0.25 percent. . Not later than July 1, 2017, 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, 2021, 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. Not later than July 1, 2019, the Medicare Payment Advisory Commission shall submit to Congress a report on— the payment update for professional services applied under the Medicare program under title XVIII of the Social Security Act for the period of years 2015 through 2019; the effect of such update on the efficiency, economy, and quality of care provided under such program; the effect of such update on ensuring a sufficient number of providers to maintain access to care by Medicare beneficiaries; and recommendations for any future payment updates for professional services under such program to ensure adequate access to care is maintained for Medicare beneficiaries. 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 2015 or any subsequent payment year and inserting each of 2015 through 2018 ; in clause (ii)(III), by striking each subsequent year and inserting 2018 ; and in clause (iii)— in the heading, by striking ; and subsequent years by striking and each subsequent year ; and by striking , but in no case shall the applicable percent be less than 95 percent . 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 2019 and each subsequent payment year, the Secretary shall, for purposes of subsection

(q)and in accordance with paragraph (1)(F) of such subsection, determine whether an eligible professional who is a MIPS eligible professional (as defined in subsection (q)(1)(C)) for such year is a meaningful EHR user under this paragraph for the performance period under subsection

(q)for such year. . 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 2015 or any subsequent year and inserting each of 2015 through 2018 ; and in clause (ii)(II), by striking and each subsequent year and inserting , 2017, and 2018 . 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 for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved. ; and in subsection (m)— by redesignating 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); and for eligible professionals who are not MIPS eligible professionals (as defined in subsection (q)(1)(C)) for the year involved. . 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, with respect to specific physicians and groups of physicians the Secretary determines appropriate, and for services furnished on or after January 1, 2017, with respect to all physicians and groups of physicians. Such payment modifier shall not be applied for items and services furnished on or after January 1, 2019. . 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 2019 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 Merit-based Incentive Payment System (in this subsection referred to as the MIPS ) under which the Secretary shall— develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph

(3)for a performance period (as established under paragraph (4)) for a year; 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 MIPS eligible professional for a performance period for a year to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) under paragraph

(6)to the professional for the year. Notwithstanding subparagraph (C)(ii), under the MIPS, the Secretary shall permit any eligible professional (as defined in subsection (k)(3)(B)) to report on applicable measures and activities described in paragraph (2)(B). The MIPS shall apply to payments for items and services furnished on or after January 1, 2019. For purposes of this subsection, subject to clauses

(ii)and (iv), the term MIPS eligible professional means— for the first and second years for which the MIPS applies to payments (and for the performance period for such first and second year), a physician (as defined in section 1861(r)), a physician assistant, nurse practitioner, and clinical nurse specialist (as such terms are defined in section 1861(aa)(5)), a certified registered nurse anesthetist (as defined in section 1861(bb)(2)), and a group that includes such professionals; and for the third year for which the MIPS applies to payments (and for the performance period for such third year) and for each succeeding year (and for the performance period for each such year), the professionals described in subclause (I), such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary, and a group that includes such professionals. For purposes of clause (i), the term MIPS eligible professional does not include, with respect to a year, an eligible professional (as defined in subsection (k)(3)(B)) who— is a qualifying APM participant (as defined in section 1833(z)(2)); subject to clause (vii), is a partial qualifying APM participant (as defined in clause (iii)) for the most recent period for which data are available and who, for the performance period with respect to such year, does not report on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS; or 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 2019 and 2020, the reference in subparagraph

(A)of such paragraph to 25 percent was instead a reference to 20 percent; with respect to 2021 and 2022— 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 2023 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 a low-volume threshold to apply for purposes of clause (ii)(III), which may include one or more or a combination of the following: The minimum number (as determined by the Secretary) of individuals enrolled under this part who are treated by the eligible professional for the performance period involved. 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 MIPS 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 MIPS eligible professional (including pursuant to clauses

(ii)and (v)) with respect to a year, in no case shall a MIPS adjustment factor (or additional MIPS adjustment factor) under paragraph

(6)apply to such individual for such year. In the case of an eligible professional who is a partial qualifying APM participant, with respect to a year, and who, for the performance period for such year, reports on applicable measures and activities described in paragraph (2)(B) that are required to be reported by such a professional under the MIPS, such eligible professional is considered to be a MIPS eligible professional with respect to such year. In no case shall an eligible professional who is a partial qualifying APM participant, with respect to a year, be considered a qualifying APM participant (as defined in paragraph

(2)of section 1833(z)) for such year or be eligible for the additional payment under paragraph

(1)of such section for such year. Under the MIPS: The Secretary shall establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing performance of such group with respect to the performance category described in clause

(i)of paragraph (2)(A). The Secretary may establish and apply a process that includes features of the provisions of subsection (m)(3)(C) for MIPS eligible professionals in a group practice with respect to assessing the performance of such group with respect to the performance categories described in clauses

(ii)through

(iv)of such paragraph. The process established under clause

(i)shall to the extent practicable reflect the range of items and services furnished by the MIPS eligible professionals in the group practice involved. Under the MIPS, the Secretary shall encourage the use of qualified clinical data registries pursuant to subsection (m)(3)(E) in carrying out this subsection. 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. Taking into account the relevant studies conducted and recommendations made in reports under section 2(d) of the Improving Medicare Post-Acute Care Transformation Act of 2014, and, as appropriate, other information, including information collected before completion of such studies and recommendations, the Secretary, on an ongoing basis, shall, as the Secretary determines appropriate and based on an individual’s health status and other risk factors— assess appropriate adjustments to quality measures, resource use measures, and other measures used under the MIPS; and assess and implement appropriate adjustments to payment adjustments, composite performance scores, scores for performance categories, or scores for measures or activities under the MIPS. Under the MIPS, the Secretary shall use the following performance categories (each of which is referred to in this subsection as a performance category) in determining the composite performance score under paragraph (5): 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 included in the final measures list published under subparagraph (D)(i) for such year and the list of quality measures described in subparagraph (D)(vi) used by qualified clinical data registries under subsection (m)(3)(E). For the performance category described in subparagraph (A)(ii), the measurement of resource use for such period under subsection (p)(3), using the methodology under subsection

(r)as appropriate, and, as feasible and applicable, accounting for the cost of drugs under part D. For the performance category described in subparagraph (A)(iii), clinical practice improvement activities (as defined in subparagraph (C)(v)(III)) under subcategories specified by the Secretary for such period, which shall include at least the following: The subcategory of expanded practice access, such as same day appointments for urgent needs and after hours access to clinician advice. The subcategory of population management, 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, 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, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision-making mechanisms. 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 15 or fewer professionals) and practices located in rural areas and in health professional shortage areas (as designated under section 332(a)(1)(A) of the Public Health Service Act). 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, such as measures for inpatient hospitals, for purposes of the performance categories described in clauses

(i)and

(ii)of subparagraph (A). For purposes of the previous sentence, the Secretary may not use measures for hospital outpatient departments, except in the case of items and services furnished by emergency physicians, radiologists, and anesthesiologists. 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 carrying out this paragraph, with respect to measures and activities specified in subparagraph

(B)for performance categories described in subparagraph (A), the Secretary— shall give consideration to the circumstances of professional types (or subcategories of those types determined by practice characteristics) who typically furnish services that do not involve face-to-face interaction with a patient; and may, to the extent feasible and appropriate, take into account such circumstances and apply under this subsection with respect to MIPS eligible professionals of such professional types or subcategories, alternative measures or activities that fulfill the goals of the applicable performance category. In carrying out the previous sentence, the Secretary shall consult with professionals of such professional types or subcategories. In initially applying subparagraph (B)(iii), the Secretary shall use a request for information to solicit recommendations from stakeholders to identify activities described in such subparagraph and specifying criteria for such activities. 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 MIPS eligible professional meets such criteria. For purposes of this subsection, the term clinical practice improvement activity means an activity that relevant eligible professional organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes. Under the MIPS, the Secretary, through notice and comment rulemaking and subject to the succeeding clauses of this subparagraph, shall, with respect to the performance period for a year, establish an annual final list of quality measures from which MIPS eligible professionals may choose for purposes of assessment under this subsection for such performance period. Pursuant to the previous sentence, the Secretary shall— not later than November 1 of the year prior to the first day of the first performance period under the MIPS, establish and publish in the Federal Register a final list of quality measures; and not later than November 1 of the year prior to the first day of each subsequent performance period, update the final list of quality measures from the previous year (and publish such updated final list in the Federal Register), by— removing from such list, as appropriate, quality measures, which may include the removal of measures that are no longer meaningful (such as measures that are topped out); adding to such list, as appropriate, new quality measures; and determining whether or not quality measures on such list that have undergone substantive changes should be included in the updated list. Eligible professional organizations and other relevant stakeholders shall be requested to identify and submit quality measures to be considered for selection under this subparagraph in the annual list of quality measures published under clause

(i)and to identify and submit updates to the measures on such list. For purposes of the previous sentence, measures may be submitted regardless of whether such measures were previously published in a proposed rule or endorsed by an entity with a contract under section 1890(a). In this subparagraph, the term eligible professional organization means a professional organization as defined by nationally recognized specialty boards of certification or equivalent certification boards. In selecting quality measures for inclusion in the annual final list under clause (i), the Secretary shall— provide that, to the extent practicable, all quality domains (as defined in subsection (s)(1)(B)) are addressed by such measures; and ensure that such selection is consistent with the process for selection of measures under subsections (k), (m), and (p)(2). Before including a new measure in the final list of measures published under clause

(i)for a year, the Secretary shall submit for publication in applicable specialty-appropriate, peer-reviewed journals such measure and the method for developing and selecting such measure, including clinical and other data supporting such measure. The final list of quality measures published under clause

(i)shall include, as applicable, measures under subsections (k), (m), and (p)(2), including quality measures from among— measures endorsed by a consensus-based entity; measures developed under subsection (s); and measures submitted under clause (ii)(I). Any measure selected for inclusion in such list that is not endorsed by a consensus-based entity shall have a focus that is evidence-based. Measures used by a qualified clinical data registry under subsection (m)(3)(E) shall not be subject to the requirements under clauses (i), (iv), and (v). The Secretary shall publish the list of measures used by such qualified clinical data registries on the Internet website of the Centers for Medicare & Medicaid Services. Any quality measure specified by the Secretary under subsection

(k)or (m), including under subsection (m)(3)(E), and any measure of quality of care established under subsection (p)(2) for the reporting period or performance period under the respective subsection beginning before the first performance period under the MIPS— shall not be subject to the requirements under clause

(i)(except under items

(aa)and

(cc)of subclause

(II)of such clause) or to the requirement under clause (iv); and shall be included in the final list of quality measures published under clause

(i)unless removed under clause (i)(II)(aa). Relevant eligible professional organizations and other relevant stakeholders, including State and national medical societies, shall be consulted in carrying out this subparagraph. The process under section 1890A is not required to apply to the selection of measures under this subparagraph. Under the MIPS, the Secretary shall establish performance standards with respect to measures and activities specified under paragraph (2)(B) for a performance period (as established under paragraph (4)) for a year. In establishing such performance standards with respect to measures and activities specified under paragraph (2)(B), the Secretary shall consider the following: Historical performance standards. Improvement. The opportunity for continued improvement. The Secretary shall establish a performance period (or periods) for a year (beginning with 2019). 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 and taking into account, as available and applicable, paragraph (1)(G), the Secretary shall develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph

(3)with respect to applicable measures and activities specified in paragraph (2)(B) with respect to each performance category applicable to such professional for a performance period (as established under paragraph (4)) for a year. Using such methodology, the Secretary shall provide for a composite assessment (using a scoring scale of 0 to 100) for each such professional for the performance period for such year. In this subsection such a composite assessment for such a professional with respect to a performance period shall be referred to as the composite performance score for such professional for such performance period. Under the methodology established under subparagraph (A), the Secretary shall provide that in the case of a MIPS eligible professional who fails to report on an applicable measure or activity that is required to be reported by the professional, the professional shall be treated as achieving the lowest potential score applicable to such measure or activity. Under the methodology established under subparagraph (A), the Secretary shall— encourage MIPS eligible professionals to report on applicable measures with respect to the performance category described in paragraph (2)(A)(i) through the use of certified EHR technology and qualified clinical data registries; and with respect to a performance period, with respect to a year, for which a MIPS eligible professional reports such measures through the use of such EHR technology, treat such professional as satisfying the clinical quality measures reporting requirement described in subsection (o)(2)(A)(iii) for such year. A MIPS eligible professional who is in a practice that is certified as a patient-centered medical home or comparable specialty practice, as determined by the Secretary, 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 MIPS eligible professional in an alternative payment model (as defined in section 1833(z)(3)(C)) with respect to a performance period shall earn such eligible professional a minimum score of one-half of the highest potential score for the performance category described in paragraph (2)(A)(iii) for such performance period. A MIPS eligible professional shall not be required to perform activities in each subcategory under paragraph (2)(B)(iii) or participate in an alternative payment model in order to achieve the highest potential score for the performance category described in paragraph (2)(A)(iii). Beginning with the second year to which the MIPS applies, in addition to the achievement of a MIPS eligible professional, if data sufficient to measure improvement is available, the methodology developed under subparagraph (A)— 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. Subject to clause (i), under the methodology developed under subparagraph (A), the Secretary may assign a higher scoring weight under subparagraph

(F)with respect to the achievement of a MIPS eligible professional than with respect to any improvement of such professional applied under clause

(i)with respect to a measure, activity, or category described in paragraph (2). Under the methodology developed under subparagraph (A), subject to subparagraph (F)(i) and clause (ii), the composite performance score shall be determined as follows: Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause

(i)of paragraph (2)(A). In applying the previous sentence, the Secretary shall, as feasible, encourage the application of outcome measures within such category. For the first and second years for which the MIPS applies to payments, the percentage applicable under item

(aa)shall be increased in a manner such that the total percentage points of the increase under this item for the respective year equals the total number of percentage points by which the percentage applied under subclause (II)(bb) for the respective year is less than 30 percent. Subject to item (bb), thirty percent of such score shall be based on performance with respect to the category described in clause

(ii)of paragraph (2)(A). For the first year for which the MIPS applies to payments, not more than 10 percent of such score shall be based on performance with respect to the category described in clause

(ii)of paragraph (2)(A). For the second year for which the MIPS applies to payments, not more than 15 percent of such score shall be based on performance with respect to the category described in clause

(ii)of paragraph (2)(A). 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, subject to subclauses (I)(bb) and (II)(bb) of clause (i), the percentages applicable under one or more of subclauses (I), (II), and

(III)of clause

(i)for such year shall be increased in a manner such that the total percentage points of the increase under this clause for such year equals the total number of percentage points reduced under the preceding sentence for such year. Under the methodology under subparagraph (A), if there are not sufficient measures and activities (described in paragraph (2)(B)) applicable and available to each type of eligible professional involved, the Secretary shall assign different scoring weights (including a weight of 0)— which may vary from the scoring weights specified in subparagraph (E), for each performance category based on the extent to which the category is applicable to the type of eligible professional involved; and for each measure and activity specified under paragraph (2)(B) with respect to each such category based on the extent to which the measure or activity is applicable and available to the type of eligible professional involved. 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 MIPS eligible professionals with respect to items and services furnished to individuals who are not individuals entitled to benefits under part A or enrolled under part B. In the case of MIPS eligible professionals electing to be a virtual group under clause

(ii)with respect to a performance period for a year, for purposes of applying the methodology under subparagraph

(A)with respect to the performance categories described in clauses

(i)and

(ii)of paragraph (2)(A)— the assessment of performance provided under such methodology with respect to such performance categories 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 with respect to the composite performance score provided under this paragraph for such performance period for each such MIPS eligible professional in such virtual group, the components of the composite performance score that assess performance with respect to such performance categories shall be based on the assessment of the combined performance under subclause

(I)for such performance categories and performance period. The Secretary shall, in accordance with the requirements under clause (iii), establish and have in place a process to allow an individual MIPS eligible professional or a group practice consisting of not more than 10 MIPS eligible professionals to elect, with respect to a performance period for a year to be a virtual group under this subparagraph with at least one other such individual MIPS eligible professional or group practice. Such a virtual group may be based on appropriate classifications of providers, such as by geographic areas or by provider specialties defined by nationally recognized specialty boards of certification or equivalent certification boards. The requirements for 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; provide that an individual MIPS eligible professional and a group practice described in clause

(ii)may elect to be in no more than one virtual group for a performance period and that, in the case of such a group practice that elects to be in such virtual group for such performance period, such election applies to all MIPS eligible professionals in such group practice; provide that a virtual group be a combination of tax identification numbers; provide for formal written agreements among MIPS eligible professionals electing to be a virtual group under this subparagraph; and include such other requirements as the Secretary determines appropriate. Taking into account paragraph (1)(G), the Secretary shall specify a MIPS adjustment factor for each MIPS eligible professional for a year. Such MIPS adjustment factor for a MIPS eligible professional for a year shall be in the form of a percent and shall be determined— by comparing the composite performance score of the eligible professional for such year to the performance threshold established under subparagraph (D)(i) for such year; in a manner such that the adjustment factors specified under this subparagraph for a year result in differential payments under this paragraph reflecting that— MIPS eligible professionals with composite performance scores for such year at or above such performance threshold for such year receive zero or positive payment adjustment factors for such year in accordance with clause (iii), with such professionals having higher composite performance scores receiving higher adjustment factors; and MIPS eligible professionals with composite performance scores for such year below such performance threshold for such year receive negative payment adjustment factors for such year in accordance with clause (iv), with such professionals having lower composite performance scores receiving lower adjustment factors; in a manner such that MIPS eligible professionals with composite scores described in clause (ii)(I) for such year, subject to clauses

(i)and

(ii)of subparagraph (F), receive a zero or positive adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the applicable percent specified in subparagraph

(B)is assigned for a score of 100; and in a manner such that— subject to subclause (II), MIPS eligible professionals with composite performance scores described in clause (ii)(II) for such year receive a negative payment adjustment factor on a linear sliding scale such that an adjustment factor of 0 percent is assigned for a score at the performance threshold and an adjustment factor of the negative of the applicable percent specified in subparagraph

(B)is assigned for a score of 0; and MIPS eligible professionals with composite performance scores that are equal to or greater than 0, but not greater than 1/4 of the performance threshold specified under subparagraph (D)(i) for such year, receive a negative payment adjustment factor that is equal to the negative of the applicable percent specified in subparagraph

(B)for such year. For purposes of this paragraph, the term applicable percent means— for 2019, 4 percent; for 2020, 5 percent; for 2021, 7 percent; and for 2022 and subsequent years, 9 percent. For 2019 and each subsequent year through 2024, in the case of a MIPS eligible professional with a composite performance score for a year at or above the additional performance threshold under subparagraph (D)(ii) for such year, in addition to the MIPS adjustment factor under subparagraph

(A)for the eligible professional for such year, subject to subparagraph (F)(iv), the Secretary shall specify an additional positive MIPS adjustment factor for such professional and year. Such additional MIPS adjustment factors shall be in the form of a percent and determined by the Secretary in a manner such that professionals having higher composite performance scores above the additional performance threshold receive higher additional MIPS adjustment factors. For each year of the MIPS, the Secretary shall compute a performance threshold with respect to which the composite performance score of MIPS eligible professionals shall be compared for purposes of determining adjustment factors under subparagraph

(A)that are positive, negative, and zero. Such performance threshold for a year shall be the mean or median (as selected by the Secretary) of the composite performance scores for all MIPS eligible professionals with respect to a prior period specified by the Secretary. The Secretary may reassess the selection of the mean or median under the previous sentence every 3 years. In addition to the performance threshold under clause (i), for each year of the MIPS, the Secretary shall compute an additional performance threshold for purposes of determining the additional MIPS adjustment factors under subparagraph (C). For each such year, the Secretary shall apply either of the following methods for computing such additional performance threshold for such a year: The threshold shall be the score that is equal to the 25th percentile of the range of possible composite performance scores above the performance threshold determined under clause (i). The threshold shall be the score that is equal to the 25th percentile of the actual composite performance scores for MIPS eligible professionals with composite performance scores at or above the performance threshold with respect to the prior period described in clause (i). With respect to each of the first two years to which the MIPS applies, the Secretary shall, prior to the performance period for such years, establish a performance threshold for purposes of determining MIPS adjustment factors under subparagraph

(A)and a threshold for purposes of determining additional MIPS adjustment factors under subparagraph (C). Each such performance threshold shall— be based on a period prior to such performance periods; and take into account— data available with respect to performance on measures and activities that may be used under the performance categories under subparagraph (2)(B); and other factors determined appropriate by the Secretary. In the case of items and services furnished by a MIPS eligible professional during a year (beginning with 2019), the amount otherwise paid under this part with respect to such items and services and MIPS eligible professional for such year, shall be multiplied by— 1, plus the sum of— the MIPS adjustment factor determined under subparagraph

(A)divided by 100, and as applicable, the additional MIPS adjustment factor determined under subparagraph

(C)divided by 100. With respect to positive MIPS adjustment factors under subparagraph (A)(ii)(I) for eligible professionals whose composite performance score is above the performance threshold under subparagraph (D)(i) for such year, subject to subclause (II), the Secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement of clause

(ii)is met. In no case may the scaling factor applied under this clause exceed 3.0. Subject to clause (iii), the Secretary shall ensure that the estimated amount described in subclause

(II)for a year is equal to the estimated amount described in subclause

(III)for such year. The amount described in this subclause is the estimated increase in the aggregate allowed charges resulting from the application of positive MIPS adjustment factors under subparagraph

(A)(after application of the scaling factor described in clause (i)) to MIPS eligible professionals whose composite performance score for a year is above the performance threshold under subparagraph (D)(i) for such year. The amount described in this subclause is the estimated decrease in the aggregate allowed charges resulting from the application of negative MIPS adjustment factors under subparagraph

(A)to MIPS eligible professionals whose composite performance score for a year is below the performance threshold under subparagraph (D)(i) for such year. In the case that all MIPS eligible professionals receive composite performance scores for a year that are below the performance threshold under subparagraph (D)(i) for such year, the negative MIPS adjustment factors under subparagraph

(A)shall apply with respect to such MIPS eligible professionals and the budget neutrality requirement of clause

(ii)and the additional adjustment factors under clause

(iv)shall not apply for such year. In the case that, with respect to a year, the application of clause

(i)results in a scaling factor equal to the maximum scaling factor specified in clause (i)(II), such scaling factor shall apply and the budget neutrality requirement of clause

(ii)shall not apply for such year. Subject to subclause (II), in specifying the MIPS additional adjustment factors under subparagraph

(C)for each applicable MIPS eligible professional for a year, the Secretary shall ensure that the estimated aggregate increase in payments under this part resulting from the application of such additional adjustment factors for MIPS eligible professionals in a year shall be equal (as estimated by the Secretary) to $500,000,000 for each year beginning with 2019 and ending with 2024. The MIPS additional adjustment factor under subparagraph

(C)for a year for an applicable MIPS eligible professional whose composite performance score is above the additional performance threshold under subparagraph (D)(ii) for such year shall not exceed 10 percent. The application of the previous sentence may result in an aggregate amount of additional incentive payments that are less than the amount specified in subclause (I). Under the MIPS, the Secretary shall, not later than 30 days prior to January 1 of the year involved, make available to MIPS eligible professionals the MIPS adjustment factor (and, as applicable, the additional MIPS adjustment factor) under paragraph

(6)applicable to the eligible professional for items and services furnished by the professional for such year. The Secretary may include such information in the confidential feedback under paragraph (12). The MIPS adjustment factors and additional MIPS adjustment factors under paragraph

(6)shall apply only with respect to the year involved, and the Secretary shall not take into account such adjustment factors in making payments to a MIPS eligible professional under this part in a subsequent year. The Secretary shall, in an easily understandable format, make available on the Physician Compare Internet website of the Centers for Medicare & Medicaid Services the following: Information regarding the performance of MIPS eligible professionals under the MIPS, which— shall include the composite score for each such MIPS eligible professional and the performance of each such MIPS eligible professional with respect to each performance category; and may include the performance of each such MIPS 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 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. 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 MIPS, including the range of composite scores for all MIPS eligible professionals and the range of the performance of all MIPS eligible professionals with respect to each performance category. The Secretary shall consult with stakeholders in carrying out the MIPS, including for the identification of measures and activities under paragraph (2)(B) and the methodologies developed under paragraphs (5)(A) and

(6)and regarding the use of qualified clinical data registries. Such consultation shall include the use of a request for information or other mechanisms determined appropriate. The Secretary shall enter into contracts or agreements with appropriate entities (such as quality improvement organizations, regional extension centers (as described in section 3012(c) of the Public Health Service Act), or regional health collaboratives) to offer guidance and assistance to MIPS eligible professionals in practices of 15 or fewer professionals (with priority given to such practices located in rural areas, health professional shortage areas (as designated under in section 332(a)(1)(A) of such Act), and medically underserved areas, and practices with low composite scores) with respect to— 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 $20,000,000 for each of fiscal years 2016 through 2020. Amounts transferred under this subparagraph for a fiscal year shall be available until expended. Beginning July 1, 2017, the Secretary— shall make available timely (such as quarterly) confidential feedback to MIPS eligible professionals on the performance of such professionals with respect to the performance categories under clauses

(i)and

(ii)of paragraph (2)(A); and may make available confidential feedback to such professionals on the performance of such professionals 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. With respect to the performance category described in paragraph (2)(A)(i), feedback under this subparagraph shall, to the extent an eligible professional chooses to participate in a data registry for purposes of this subsection (including registries under subsections

(k)and (m)), be provided based on performance on quality measures reported through the use of such registries. With respect to any other performance category described in paragraph (2)(A), the Secretary shall encourage provision of feedback through qualified clinical data registries as described in subsection (m)(3)(E)). For purposes of clause (i), the Secretary may use data, with respect to a MIPS eligible professional, from periods prior to the current performance period and may use rolling periods in order to make illustrative calculations about the performance of such professional. 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, 2018, the Secretary shall make available to MIPS eligible professionals information, with respect to individuals who are patients of such MIPS eligible professionals, about items and services for which payment is made under this title that are furnished to such individuals by other suppliers and providers of services, which may include information described in clause (ii). Such information may be made available under the previous sentence to such MIPS eligible professionals by mechanisms determined appropriate by the Secretary, which may include use of a web-based portal. Such information may be made available in accordance with the same or similar terms as data are made available to accountable care organizations participating in the shared savings program under section 1899. 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 MIPS eligible professional, by another supplier or provider of services during the most recent period for which data are available (such as the most recent three-month period), such as the name of such providers furnishing such items and services to such patients during such period, the types of such items and services so furnished, and the dates such items and services were so furnished. Historical data, such as averages and other measures of the distribution if appropriate, of the total, and components of, allowed charges (and other figures as determined appropriate by the Secretary). The Secretary shall establish a process under which a MIPS eligible professional may seek an informal review of the calculation of the MIPS adjustment factor (or factors) applicable to such eligible professional under this subsection for a year. The results of a review conducted pursuant to the previous sentence shall not be taken into account for purposes of paragraph

(6)with respect to a year (other than with respect to the calculation of such eligible professional’s MIPS adjustment factor for such year or additional MIPS adjustment factor for such year) after the factors determined in subparagraph

(A)and subparagraph

(C)of such paragraph have been determined for such year. 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 MIPS adjustment factor under paragraph (6)(A) and the amount of the additional MIPS adjustment factor under paragraph (6)(C) and the determination of such amounts. 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 (9). 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, 2021, the Comptroller General of the United States shall submit to Congress a report evaluating the eligible professional Merit-based Incentive Payment System under subsection

(q)of section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ), as added by paragraph (1). Such report shall— examine the distribution of the composite performance scores and MIPS adjustment factors (and additional MIPS adjustment factors) for MIPS eligible professionals (as defined in subsection (q)(1)(c) of such section) under such program, and patterns relating to such scores and adjustment factors, including based on type of provider, practice size, geographic location, and patient mix; provide recommendations for improving such program; evaluate the impact of technical assistance funding under section 1848(q)(11) of the Social Security Act, as added by paragraph (1), on the ability of professionals to improve within such program or successfully transition to an alternative payment model (as defined in section 1833(z)(3) of the Social Security Act, as added by subsection (e)), with priority for such evaluation given to practices located in rural areas, health professional shortage areas (as designated in section 332(a)(1)(A) of the Public Health Service Act), and medically underserved areas; and 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 MIPS incentive program under subsection

(q)of section 1848 of the Social Security Act ( 42 U.S.C. 1395w–4 ), as added by paragraph (1). Not later than January 1, 2017, the Comptroller General of the United States shall submit to Congress a report examining whether entities that pool financial risk for physician practices, such as independent risk managers, can play a role in supporting physician practices, particularly small physician practices, in assuming financial risk for the treatment of patients. Such report shall examine barriers that small physician practices currently face in assuming financial risk for treating patients, the types of risk management entities that could assist physician practices in participating in two-sided risk payment models, and how such entities could assist with risk management and with quality improvement activities. Such report shall also include an analysis of any existing legal barriers to such arrangements. Not later than 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)). Such report shall make recommendations for removing administrative barriers to practices, including small practices consisting of 15 or fewer professionals, in rural areas, health professional shortage areas, and medically underserved areas to participation in such models. For purposes of implementing the provisions of and the amendments made by this section, the Secretary of Health and Human Services shall provide for the transfer of $80,000,000 from the Supplementary Medical Insurance Trust Fund established under section 1841 of the Social Security Act ( 42 U.S.C. 1395t ) to the Centers for Medicare & Medicaid Program Management Account for each of the fiscal years 2015 through 2019. 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 2016 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 2016 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 2015 ; and by inserting and, for reporting periods occurring in 2016 and subsequent years, the Secretary may establish after 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, 2017. See subsection (q)(12) for reports under the eligible professionals Merit-based Incentive Payment System. . Section 1848(o)(2)(A)(iii) of the Social Security Act ( 42 U.S.C. 1395w–4(o)(2)(A)(iii) ) is amended by inserting and subsection (q)(5)(B)(ii)(II) after Subject to subparagraph (B)(ii) . Section 1868 of the Social Security Act ( 42 U.S.C. 1395ee ) is amended by adding at the end the following new subsection: There is established an ad hoc committee to be known as the Physician-Focused Payment Model Technical Advisory Committee (referred to in this subsection as the Committee ). The Committee shall be composed of 11 members appointed by the Comptroller General of the United States. The membership of the Committee shall include individuals with national recognition for their expertise in physician-focused payment models and related delivery of care. No more than 5 members of the Committee shall be providers of services or suppliers, or representatives of providers of services or suppliers. A member of the Committee shall not be an employee of the Federal Government. The Comptroller General shall establish a system for public disclosure by members of the Committee of financial and other potential conflicts of interest relating to such members. Members of the Committee shall be treated as employees of Congress for purposes of applying title I of the Ethics in Government Act of 1978 ( Public Law 95–521 ). The initial appointments of members of the Committee shall be made by not later than 180 days after the date of enactment of this subsection. The terms of members of the Committee shall be for 3 years except that the Comptroller General shall designate staggered terms for the members first appointed. Any member appointed to fill a vacancy occurring before the expiration of the term for which the member’s predecessor was appointed shall be appointed only for the remainder of that term. A member may serve after the expiration of that member’s term until a successor has taken office. A vacancy in the Committee shall be filled in the manner in which the original appointment was made. The Committee shall meet, as needed, to provide comments and recommendations to the Secretary, as described in paragraph (2)(C), on physician-focused payment models. Except as provided in clause (ii), a member of the Committee shall serve without compensation. A member of the Committee shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for an employee of an agency under subchapter I of chapter 57 of title 5, United States Code, while away from the home or regular place of business of the member in the performance of the duties of the Committee. The Assistant Secretary for Planning and Evaluation shall provide technical and operational support for the Committee, which may be by use of a contractor. The Office of the Actuary of the Centers for Medicare & Medicaid Services shall provide to the Committee actuarial assistance as needed. The Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, such amounts as are necessary to carry out this paragraph (not to exceed $5,000,000) for fiscal year 2015 and each subsequent fiscal year. Any amounts transferred under the preceding sentence for a fiscal year shall remain available until expended. Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Committee. Not later than November 1, 2016, the Secretary shall, through notice and comment rulemaking, following a request for information, establish criteria for physician-focused payment models, including models for specialist physicians, that could be used by the Committee for making comments and recommendations pursuant to paragraph (1)(D). During the comment period for the proposed rule described in clause (i), the Medicare Payment Advisory Commission may submit comments to the Secretary on the proposed criteria under such clause. The Secretary may update the criteria established under this subparagraph through rulemaking. On an ongoing basis, individuals and stakeholder entities may submit to the Committee proposals for physician-focused payment models that such individuals and entities believe meet the criteria described in subparagraph (A). The Committee shall, on a periodic basis, review models submitted under subparagraph (B), prepare comments and recommendations regarding whether such models meet the criteria described in subparagraph (A), and submit such comments and recommendations to the Secretary. The Secretary shall review the comments and recommendations submitted by the Committee under subparagraph

(C)and post a detailed response to such comments and recommendations on the Internet website of the Centers for Medicare & Medicaid Services. Nothing in this subsection shall be construed to impact the development or testing of models under this title or titles XI, XIX, or XXI. . 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 2019 and ending with 2024 and for which the professional is a qualifying APM participant with respect to such year, 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 estimated aggregate payment amounts for such 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 in which payment for covered professional services furnished by a qualifying APM participant in an alternative payment model— is made to an eligible alternative payment entity rather than directly to the qualifying APM participant; or is made on a basis other than a fee-for-service basis (such as payment on a capitated basis). 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 under this subsection or subsection

(m)shall be determined without regard to any additional payment under subsection

(m)and this subsection, respectively. The amount of the additional payment under this subsection or subsection

(x)shall be determined without regard to any additional payment under subsection

(x)and this subsection, respectively. The amount of the additional payment under this subsection or subsection

(y)shall be determined without regard to any additional payment under subsection

(y)and this subsection, respectively. For purposes of this subsection, the term qualifying APM participant means the following: With respect to 2019 and 2020, 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 eligible alternative payment entity. With respect to 2021 and 2022, 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 eligible alternative payment entity. 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 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 eligible alternative payment entity; 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 to an eligible alternative payment entity; 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 arrangements 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 participates in an entity that— bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures; or with respect to beneficiaries under title XIX, is a medical home that meets criteria comparable to medical homes expanded under section 1115A(c). With respect to 2023 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 eligible alternative payment entity. 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 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 to an eligible alternative payment entity; 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 arrangements 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 participates in an entity that— bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures; or with respect to beneficiaries under title XIX, is a medical home that meets criteria comparable to medical homes expanded under section 1115A(c). The Secretary may base the determination of whether an eligible professional is a qualifying APM participant under this subsection and the determination of whether an eligible professional is a partial qualifying APM participant under section 1848(q)(1)(C)(iii) by using counts of patients in lieu of using payments and using the same or similar percentage criteria (as specified in this subsection and such section, respectively), as the Secretary determines appropriate. 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) and includes a group that includes such professionals. The term alternative payment model means, other than for purposes of subparagraphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph (2), any of the following: A model under section 1115A (other than a health care innovation award). The shared savings program under section 1899. A demonstration under section 1866C. A demonstration required by Federal law. The term eligible alternative payment entity means, with respect to a year, an entity that— participates in an alternative payment model that— requires participants in such model to use certified EHR technology (as defined in subsection (o)(4)); and 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 bears financial risk for monetary losses under such alternative payment 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 entity is an eligible alternative payment entity 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 15 or fewer professionals. Focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment, and which examine risk-adjusted decreases in mortality rates, hospital readmissions rates, and other relevant and appropriate clinical measures. Focusing primarily on title XIX, working in conjunction with the Center for Medicaid and CHIP 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 title 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, 2016, the Secretary of Health and Human Services shall submit to Congress a study that examines the feasibility of integrating alternative payment models in the Medicare Advantage payment system. The study shall include the feasibility of including a value-based modifier and whether such modifier should be budget neutral. 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 subparagraph (A). Such report shall include recommendations for actions to be taken to reduce the vulnerability of such alternative payment models to fraudulent activity. Such report also shall include, as appropriate, recommendations of the Inspector General for changes in Federal fraud prevention laws to reduce such vulnerability. 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 Merit-based Incentive Payment System 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 care episode groups and patient condition groups, the Secretary shall undertake the steps described in the succeeding provisions of this paragraph. 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 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 120 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— care episode groups; and patient condition groups. Taking into account the information described in subparagraph

(B)and the information received under subparagraph (C), the Secretary shall— establish care episode groups and patient condition groups, which account for a target of an estimated ½ of expenditures under parts A and B (with such target increasing over time as appropriate); 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 occurs, and the principal procedures or services 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 a 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 270 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 120 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. Not later than 270 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 2018), 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. 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 one year 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 120 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, web-based forums, or other appropriate mechanisms. Not later than 240 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 2018), 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. Claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, 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, as the Secretary determines appropriate— 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). 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 charges for all services under part A and this part (and, if the Secretary determines appropriate, part D) for the analysis of patient resource use, by care episode codes and by patient condition codes; and may, as determined appropriate, use other measures of allowed charges (such as subtotals for categories of items and services) and measures of utilization of items and services (such as frequency of specific items and services and the ratio of specific items and services among attributed patients or episodes). 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, web-based forums, or other appropriate mechanisms. To the extent that the Secretary contracts with an entity to carry out any part of the provisions of this subsection, the Secretary may not contract with an entity or an entity with a subcontract if the entity or subcontracting entity currently makes recommendations to the Secretary on relative values for services under the fee schedule for physicians’ services under this section. 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 subsection: The term physician has the meaning given such term in section 1861(r)(1). 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 a certified registered nurse anesthetist (as defined in section 1861(bb)(2)); and beginning January 1, 2019, such other eligible professionals (as defined in subsection (k)(3)(B)) as specified by the Secretary. The provisions of sections 1890(b)(7) and 1890A shall not apply to this subsection. .

Connectionstraces to 5

Traces to 5 documents

U.S. Code

13 references not yet in our index