[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3961 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 3961

To amend title XVIII of the Social Security Act to reform the Medicare 
                   SGR payment system for physicians.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 29, 2009

Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of 
  California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the 
   following bill; which was referred to the Committee on Energy and 
  Commerce, and in addition to the Committee on Ways and Means, for a 
 period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to reform the Medicare 
                   SGR payment system for physicians.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Physician Payment Reform 
Act of 2009''.

SEC. 2. MEDICARE SUSTAINABLE GROWTH RATE REFORM.

    (a) Transitional Update for 2010.--Section 1848(d) of the Social 
Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the 
following new paragraph:
            ``(10) Update for 2010.--The update to the single 
        conversion factor established in paragraph (1)(C) for 2010 
        shall be the percentage increase in the MEI (as defined in 
        section 1842(i)(3)) for that year.''.
    (b) Rebasing SGR Using 2009; Limitation on Cumulative Adjustment 
Period.--Section 1848(d)(4) of such Act (42 U.S.C. 1395w-4(d)(4)) is 
amended--
            (1) in subparagraph (B), by striking ``subparagraph (D)'' 
        and inserting ``subparagraphs (D) and (G)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(G) Rebasing using 2009 for future update 
                adjustments.--In determining the update adjustment 
                factor under subparagraph (B) for 2011 and subsequent 
                years--
                            ``(i) the allowed expenditures for 2009 
                        shall be equal to the amount of the actual 
                        expenditures for physicians' services during 
                        2009; and
                            ``(ii) the reference in subparagraph 
                        (B)(ii)(I) to `April 1, 1996' shall be treated 
                        as a reference to `January 1, 2009 (or, if 
                        later, the first day of the fifth year before 
                        the year involved)'.''.
    (c) Limitation on Physicians' Services Included in Target Growth 
Rate Computation to Services Covered Under Physician Fee Schedule.--
Effective for services furnished on or after January 1, 2009, section 
1848(f)(4)(A) of such Act is amended by striking ``(such as clinical'' 
and all that follows through ``in a physician's office'' and inserting 
``for which payment under this part is made under the fee schedule 
under this section, for services for practitioners described in section 
1842(b)(18)(C) on a basis related to such fee schedule, or for services 
described in section 1861(p) (other than such services when furnished 
in the facility of a provider of services)''.
    (d) Establishment of Separate Target Growth Rates for Categories of 
Services.--
            (1) Establishment of service categories.--Subsection (j) of 
        section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is 
        amended by adding at the end the following new paragraph:
            ``(5) Service categories.--For services furnished on or 
        after January 1, 2009, each of the following categories of 
        physicians' services (as defined in paragraph (3)) shall be 
        treated as a separate `service category':
                    ``(A) Evaluation and management services that are 
                procedure codes (for services covered under this title) 
                for--
                            ``(i) services in the category designated 
                        Evaluation and Management in the Health Care 
                        Common Procedure Coding System (established by 
                        the Secretary under subsection (c)(5) as of 
                        December 31, 2009, and as subsequently modified 
                        by the Secretary); and
                            ``(ii) preventive services (as defined in 
                        section 1861(iii)) for which payment is made 
                        under this section.
                    ``(B) All other services not described in 
                subparagraph (A).
        Service categories established under this paragraph shall apply 
        without regard to the specialty of the physician furnishing the 
        service.''.
            (2) Establishment of separate conversion factors for each 
        service category.--Subsection (d)(1) of section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4) is amended--
                    (A) in subparagraph (A)--
                            (i) by designating the sentence beginning 
                        ``The conversion factor'' as clause (i) with 
                        the heading ``Application of single conversion 
                        factor.--'' and with appropriate indentation;
                            (ii) by striking ``The conversion factor'' 
                        and inserting ``Subject to clause (ii), the 
                        conversion factor''; and
                            (iii) by adding at the end the following 
                        new clause:
                            ``(ii) Application of multiple conversion 
                        factors beginning with 2011.--
                                    ``(I) In general.--In applying 
                                clause (i) for years beginning with 
                                2011, separate conversion factors shall 
                                be established for each service 
                                category of physicians' services (as 
                                defined in subsection (j)(5)) and any 
                                reference in this section to a 
                                conversion factor for such years shall 
                                be deemed to be a reference to the 
                                conversion factor for each of such 
                                categories.
                                    ``(II) Initial conversion 
                                factors.--Such factors for 2011 shall 
                                be based upon the single conversion 
                                factor for the previous year multiplied 
                                by the update established under 
                                paragraph (11) for such category for 
                                2011.
                                    ``(III) Updating of conversion 
                                factors.--Such factor for a service 
                                category for a subsequent year shall be 
                                based upon the conversion factor for 
                                such category for the previous year and 
                                adjusted by the update established for 
                                such category under paragraph (11) for 
                                the year involved.''; and
                    (B) in subparagraph (D), by striking ``other 
                physicians' services'' and inserting ``for physicians' 
                services described in the service category described in 
                subsection (j)(5)(B)''.
            (3) Establishing updates for conversion factors for service 
        categories.--Section 1848(d) of the Social Security Act (42 
        U.S.C. 1395w-4(d)), as amended by subsection (a), is amended--
                    (A) in paragraph (4)(C)(iii), by striking ``The 
                allowed'' and inserting ``Subject to paragraph (11)(B), 
                the allowed''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(11) Updates for service categories beginning with 
        2011.--
                    ``(A) In general.--In applying paragraph (4) for a 
                year beginning with 2011, the following rules apply:
                            ``(i) Application of separate update 
                        adjustments for each service category.--
                        Pursuant to paragraph (1)(A)(ii)(I), the update 
                        shall be made to the conversion factor for each 
                        service category (as defined in subsection 
                        (j)(5)) based upon an update adjustment factor 
                        for the respective category and year and the 
                        update adjustment factor shall be computed, for 
                        a year, separately for each service category.
                            ``(ii) Computation of allowed and actual 
                        expenditures based on service categories.--In 
                        computing the prior year adjustment component 
                        and the cumulative adjustment component under 
                        clauses (i) and (ii) of paragraph (4)(B), the 
                        following rules apply:
                                    ``(I) Application based on service 
                                categories.--The allowed expenditures 
                                and actual expenditures shall be the 
                                allowed and actual expenditures for the 
                                service category, as determined under 
                                subparagraph (B).
                                    ``(II) Application of category 
                                specific target growth rate.--The 
                                growth rate applied under clause 
                                (ii)(II) of such paragraph shall be the 
                                target growth rate for the service 
                                category involved under subsection 
                                (f)(5).
                    ``(B) Determination of allowed expenditures.--In 
                applying paragraph (4) for a year beginning with 2010, 
                notwithstanding subparagraph (C)(iii) of such 
                paragraph, the allowed expenditures for a service 
                category for a year is an amount computed by the 
                Secretary as follows:
                            ``(i) For 2010.--For 2010:
                                    ``(I) Total 2009 actual 
                                expenditures for all services included 
                                in sgr computation for each service 
                                category.--Compute total actual 
                                expenditures for physicians' services 
                                (as defined in subsection (f)(4)(A)) 
                                for 2009 for each service category.
                                    ``(II) Increase by growth rate to 
                                obtain 2010 allowed expenditures for 
                                service category.--Compute allowed 
                                expenditures for the service category 
                                for 2010 by increasing the allowed 
                                expenditures for the service category 
                                for 2009 computed under subclause (I) 
                                by the target growth rate for such 
                                service category under subsection (f) 
                                for 2010.
                            ``(ii) For subsequent years.--For a 
                        subsequent year, take the amount of allowed 
                        expenditures for such category for the 
                        preceding year (under clause (i) or this 
                        clause) and increase it by the target growth 
                        rate determined under subsection (f) for such 
                        category and year.''.
            (4) Application of separate target growth rates for each 
        category.--
                    (A) In general.--Section 1848(f) of the Social 
                Security Act (42 U.S.C. 1395w-4(f)) is amended by 
                adding at the end the following new paragraph:
            ``(5) Application of separate target growth rates for each 
        service category beginning with 2010.--The target growth rate 
        for a year beginning with 2010 shall be computed and applied 
        separately under this subsection for each service category (as 
        defined in subsection (j)(5)) and shall be computed using the 
        same method for computing the target growth rate except that 
        the factor described in paragraph (2)(C) for--
                    ``(A) the service category described in subsection 
                (j)(5)(A) shall be increased by 0.02; and
                    ``(B) the service category described in subsection 
                (j)(5)(B) shall be increased by 0.01.''.
                    (B) Use of target growth rates.--Section 1848 of 
                such Act is further amended--
                            (i) in subsection (d)--
                                    (I) in paragraph (1)(E)(ii), by 
                                inserting ``or target'' after 
                                ``sustainable''; and
                                    (II) in paragraph (4)(B)(ii)(II), 
                                by inserting ``or target'' after 
                                ``sustainable'';
                            (ii) in the heading of subsection (f), by 
                        inserting ``and Target Growth Rate'' after 
                        ``Sustainable Growth Rate'';
                            (iii) in subsection (f)(1)--
                                    (I) by striking ``and'' at the end 
                                of subparagraph (A);
                                    (II) in subparagraph (B), by 
                                inserting ``before 2010'' after ``each 
                                succeeding year'' and by striking the 
                                period at the end and inserting ``; 
                                and''; and
                                    (III) by adding at the end the 
                                following new subparagraph:
                    ``(C) November 1 of each succeeding year the target 
                growth rate for such succeeding year and each of the 2 
                preceding years.''; and
                            (iv) in subsection (f)(2), in the matter 
                        before subparagraph (A), by inserting after 
                        ``beginning with 2000'' the following: ``and 
                        ending with 2009''.
    (e) Application to Health Care Group Demonstration Program and 
Successor Accountable Care Organization Pilot Program.--In applying the 
target growth rate under subsections (d) and (f) of section 1848 of the 
Social Security Act to services furnished by a practitioner to 
beneficiaries who are attributable to a health care group under the 
demonstration program provided under section 1886A of such Act (or to 
an accountable care organization under a pilot program that is a 
succcessor to such demonstration program under a section of such Act), 
the Secretary of Health and Human Services shall develop, not later 
than January 1, 2012, for application beginning with 2012, a method 
that--
            (1) allows each such group or organization to have its own 
        expenditure targets and updates for such practitioners, with 
        respect to beneficiaries who are attributable to that group or 
        organization, that are consistent with the methodologies 
        described in such subsection (f); and
            (2) provides that the target growth rate applicable to 
        other physicians shall not apply to such physicians to the 
        extent that the physicians' services are furnished through the 
        group or organization.
In applying paragraph (1), the Secretary of Health and Human Services 
may apply the difference in the update under such paragraph on a claim-
by-claim or lump sum basis and such a payment shall be taken into 
account under the demonstration or pilot program.
                                 <all>