[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2810 Reported in House (RH)]

                                                 Union Calendar No. 283
113th CONGRESS
  2d Session
                                H. R. 2810

                  [Report No. 113-257, Parts I and II]

     To amend title XVIII of the Social Security Act to reform the 
sustainable growth rate and Medicare payment for physicians' services, 
                        and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 24, 2013

   Mr. Burgess (for himself, Mr. Pallone, Mr. Upton, Mr. Waxman, Mr. 
   Pitts, and Mr. Dingell) introduced the following bill; which was 
 referred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means and the Judiciary, 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

                           November 12, 2013

  Reported from the Committee on Energy and Commerce with an amendment
 [Strike out all after the enacting clause and insert the part printed 
                               in italic]

                           November 12, 2013

               The Committee on the Judiciary discharged

                           November 12, 2013

   Referral to the Committee on Ways and Means extended for a period 
                 ending not later than December 2, 2013

                            December 2, 2013

   Referral to the Committee on Ways and Means extended for a period 
                 ending not later than January 10, 2014

                            January 10, 2014

   Referral to the Committee on Ways and Means extended for a period 
                  ending not later than March 14, 2014

                             March 14, 2014

 Additional sponsors: Mr. Cassidy, Mr. Bucshon, Mrs. Christensen, Mr. 
  Gingrey of Georgia, Mr. Stockman, Mr. Thornberry, Mr. Benishek, Mr. 
 Murphy of Pennsylvania, Mr. Gosar, Ms. Matsui, Ms. Castor of Florida, 
  Mr. Engel, Mr. Cuellar, Mr. Sessions, Mr. Young of Alaska, Mr. Gene 
  Green of Texas, Mr. Olson, Mrs. Ellmers, Mr. Roe of Tennessee, Mrs. 
 Blackburn, Mr. Latta, Mrs. McMorris Rodgers, Mr. Terry, Mr. Rogers of 
  Michigan, Mr. Walden, Mr. Bilirakis, Ms. Schakowsky, Mr. Braley of 
Iowa, Mrs. Capps, Mr. Carter, Mr. Barton, Mr. Whitfield, Mr. Lance, Mr. 
  Holding, Mr. Westmoreland, Mr. Latham, Mrs. Brooks of Indiana, Mr. 
  Walberg, Mr. Rice of South Carolina, Mr. Loebsack, Mr. Coffman, Mr. 
 Bera of California, Mr. Ruiz, Mr. Stivers, Mr. McKinley, Mr. Kennedy, 
 Mr. Ben Ray Lujan of New Mexico, Mr. Rush, Mr. Yoder, Mr. Marino, Mr. 
                       McNerney, and Mr. Langevin

                             March 14, 2014

   Reported from the Committee on Ways and Means with an amendment, 
   committed to the Committee of the Whole House on the State of the 
                    Union, and ordered to be printed
 [Strike out all after the enacting clause and insert the part printed 
                           in boldface roman]
 [For text of introduced bill, see copy of bill as introduced on July 
                               24, 2013]

_______________________________________________________________________

                                 A BILL


 
     To amend title XVIII of the Social Security Act to reform the 
sustainable growth rate and Medicare payment for physicians' services, 
                        and for other purposes.


 


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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Medicare Patient 
Access and Quality Improvement Act of 2013''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Reform of sustainable growth rate (SGR) and Medicare payment 
                            for physicians' services.
Sec. 3. Expanding availability of Medicare data.
Sec. 4. Encouraging care coordination and medical homes.
Sec. 5. Miscellaneous.

SEC. 2. REFORM OF SUSTAINABLE GROWTH RATE (SGR) AND MEDICARE PAYMENT 
              FOR PHYSICIANS' SERVICES.

    (a) Stabilizing Fee Updates (phase I).--
            (1) Repeal of sgr payment methodology.--Section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4) is amended--
                    (A) in subsection (d)--
                            (i) in paragraph (1)(A), by inserting ``or 
                        a subsequent paragraph or section 1848A'' after 
                        ``paragraph (4)''; and
                            (ii) in paragraph (4)--
                                    (I) in the heading, by striking 
                                ``years beginning with 2001'' and 
                                inserting ``2001, 2002, and 2003''; and
                                    (II) in subparagraph (A), by 
                                striking ``a year beginning with 2001'' 
                                and inserting ``2001, 2002, and 2003''; 
                                and
                    (B) in subsection (f)--
                            (i) in paragraph (1)(B), by inserting 
                        ``through 2013'' after ``of each succeeding 
                        year''; and
                            (ii) in paragraph (2), by inserting ``and 
                        ending with 2013'' after ``beginning with 
                        2000''.
            (2) Update of rates for 2014 through 2018.--Subsection (d) 
        of section 1848 of the Social Security Act (42 U.S.C. 1395w-4) 
        is amended by adding at the end the following new paragraph:
            ``(15) Update for 2014 through 2018.--The update to the 
        single conversion factor established in paragraph (1)(C) for 
        each of 2014 through 2018 shall be 0.5 percent.''.
    (b) Quality Update Incentive Program (phase II).--
            (1) In general.--Section 1848 of the Social Security Act 
        (42 U.S.C. 1395w-4), as amended by subsection (a), is further 
        amended--
                    (A) in subsection (d), by adding at the end the 
                following new paragraph:
            ``(16) Update beginning with 2019.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                update to the single conversion factor established in 
                paragraph (1)(C) for each year beginning with 2019 
                shall be 0.5 percent.
                    ``(B) Adjustment.--In the case of an eligible 
                professional (as defined in subsection (k)(3)) who does 
                not have a payment arrangement described in section 
                1848A(a) in effect, the update under subparagraph (A) 
                for a year beginning with 2019 shall be adjusted by the 
                applicable quality adjustment determined under 
                subsection (q)(3) for the year involved.''; and
                    (B) in subsection (i)(1)--
                            (i) by striking ``and'' at the end of 
                        subparagraph (D);
                            (ii) by striking the period at the end of 
                        subparagraph (E) and inserting ``, and''; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(F) the implementation of subsection (q).''.
            (2) Enhancing physician quality reporting system to support 
        quality update incentive program.--Section 1848 of the Social 
        Security Act (42 U.S.C. 1395w-4) is amended--
                    (A) in subsection (k)(1), in the first sentence, by 
                inserting ``and, if applicable, clinical practice 
                improvement activities,'' after ``quality measures'';
                    (B) in subsection (k)(2)--
                            (i) in subparagraph (C)--
                                    (I) in the subparagraph heading, by 
                                striking ``and subsequent years'' and 
                                inserting ``through 2018''; and
                                    (II) in clause (i), by inserting 
                                ``(before 2019)'' after ``subsequent 
                                year'';
                            (ii) by redesignating subparagraph (D) as 
                        subparagraph (E);
                            (iii) by inserting after subparagraph (C) 
                        the following new subparagraph:
                    ``(D) For 2019 and subsequent years.--For purposes 
                of reporting data on quality measures and, as 
                applicable clinical practice improvement activities, 
                for covered professional services furnished during the 
                performance period (as defined in subsection (q)(2)(B)) 
                with respect to 2019 and the performance period with 
                respect to each subsequent year, subject to subsection 
                (q)(1)(D), the quality measures and clinical practice 
                improvement activities specified under this paragraph 
                shall be, with respect to an eligible professional, the 
                quality measures and, as applicable, clinical practice 
                improvement activities within the final core measure 
                set under paragraph (9)(F) applicable to the peer 
                cohort of such provider and year involved.''; and
                            (iv) in subparagraph (E), as redesignated 
                        by subparagraph (B)(ii) of this paragraph, by 
                        striking ``and subsequent years'';
                    (C) in subsection (k)(3)--
                            (i) in the paragraph heading, by striking 
                        ``Covered professional services and eligible 
                        professionals defined'' and inserting 
                        ``Definitions''; and
                            (ii) by adding at the end the following new 
                        subparagraphs:
                    ``(C) Clinical practice improvement activities.--
                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.
                    ``(D) Eligible professional organization.--The term 
                `eligible professional organization' means a 
                professional organization as defined by nationally 
                recognized multispecialty boards of certification or 
                equivalent certification boards.
                    ``(E) Peer cohort.--The term `peer cohort' means a 
                peer cohort identified on the list under paragraph 
                (9)(B), as updated under clause (ii) of such 
                paragraph.'';
                    (D) in subsection (k)(7), by striking `` and the 
                application of paragraphs (4) and (5)'' and inserting 
                ``, the application of paragraphs (4) and (5), and the 
                implementation of paragraph (9)'';
                    (E) by adding at the end of subsection (k) the 
                following new paragraph:
            ``(9) Establishment of final core measure sets.--
                    ``(A) In general.--Under the system under this 
                subsection--
                            ``(i) for each peer cohort identified under 
                        subparagraph (B) and in accordance with this 
                        paragraph, there shall be published a final 
                        core measure set under subparagraph (F), which 
                        shall consist of quality measures and may also 
                        consist of clinical practice improvement 
                        activities, with respect to which eligible 
                        professionals shall, subject to subsection 
                        (m)(3)(C), be assessed for purposes of 
                        determining, for years beginning with 2019, the 
                        quality adjustment under subsection (q)(3) 
                        applicable to such professionals; and
                            ``(ii) each eligible professional shall 
                        self-identify, in accordance with subparagraph 
                        (B), within such a peer cohort for purposes of 
                        such assessments.
                    ``(B) Peer cohorts.--The Secretary shall identify 
                (and publish a list of) peer cohorts by which eligible 
                professionals shall self-identify for purposes of this 
                subsection and subsection (q) with respect to a 
                performance period (as defined in subsection (q)(2)(B)) 
                for a year beginning with 2019. For purposes of this 
                subsection and subsection (q), the Secretary shall 
                develop one or more peer cohorts for multispecialty 
                groups, each of which shall be included as a peer 
                cohort under this subparagraph. Such self-
                identification will be made through such a process and 
                at such time as specified under the system under this 
                subsection. Such list--
                            ``(i) shall include, as peer cohorts, 
                        provider specialties defined by nationally 
                        recognized multispecialty boards of 
                        certification or equivalent certification 
                        boards and such other cohorts as established 
                        under this section in order to capture 
                        classifications of providers across eligible 
                        professional organizations and other practice 
                        areas, groupings, or categories; and
                            ``(ii) shall be updated from time to time.
                    ``(C) Quality measures for core measure sets.--
                            ``(i) Development.--Under the system under 
                        this subsection there shall be established a 
                        process for the development of quality measures 
                        under this subparagraph for purposes of 
                        potential inclusion of such measures in core 
                        measure sets under this paragraph. Under such 
                        process--
                                    ``(I) there shall be coordination, 
                                to the extent possible, across 
                                organizations developing such measures;
                                    ``(II) eligible professional 
                                organizations and other relevant 
                                stakeholders may submit best practices 
                                and clinical practice guidelines for 
                                the development of quality measures 
                                that address quality domains (as 
                                defined under clause (ii)) for 
                                potential inclusion in such core 
                                measure sets;
                                    ``(III) there is encouraged to be 
                                developed, as appropriate, meaningful 
                                outcome measures (or quality of life 
                                measures in cases for which outcomes 
                                may not be a valid measurement), 
                                functional status measures, and patient 
                                experience measures; and
                                    ``(IV) measures developed under 
                                this clause shall be developed, to the 
                                extent possible, in accordance with 
                                best practices and clinical practice 
                                guidelines.
                            ``(ii) Quality domains.--For purposes of 
                        this paragraph, the term `quality domains' 
                        means at least the following domains:
                                    ``(I) Clinical care.
                                    ``(II) Safety.
                                    ``(III) Care coordination.
                                    ``(IV) Patient and caregiver 
                                experience.
                                    ``(V) Population health and 
                                prevention.
                    ``(D) Process for establishing core measure sets.--
                            ``(i) In general.--Under the system under 
                        this subsection, for purposes of subparagraph 
                        (A), there shall be established a process to 
                        approve final core measure sets under this 
                        paragraph for peer cohorts. Each such final 
                        core measure set shall be composed of quality 
                        measures (and, as applicable, clinical practice 
                        improvement activities) with respect to which 
                        eligible professionals within such peer cohort 
                        shall report under this subsection and be 
                        assessed under subsection (q). Such process 
                        shall provide--
                                    ``(I) for the establishment of 
                                criteria, which shall be made publicly 
                                available before the request is made 
                                under clause (ii), for selecting such 
                                measures and activities for potential 
                                inclusion in such a final core measure 
                                set; and
                                    ``(II) that all peer cohorts, and 
                                to the extent practicable all quality 
                                domains, are addressed by measures and, 
                                as applicable, clinical practice 
                                improvement activities selected to be 
                                included in a core measure set under 
                                this paragraph, which may include 
                                through the use of such a measure or 
                                clinical practice improvement activity 
                                that addresses more than one such 
                                domain or cohort.
                            ``(ii) Solicitation of public input on 
                        quality measures and clinical practice 
                        improvement activities.--Under the process 
                        established under clause (i), relevant eligible 
                        professional organizations and other relevant 
                        stakeholders shall be requested to identify and 
                        submit quality measures and clinical practice 
                        improvement activities (as defined in paragraph 
                        (3)(C)) for selection under this paragraph. For 
                        purposes of the previous sentence, measures and 
                        activities 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).
                    ``(E) Core measure sets.--
                            ``(i) In general.--Under the process 
                        established under subparagraph (D)(i), the 
                        Secretary--
                                    ``(I) shall select, from quality 
                                measures described in clause (ii) 
                                applicable to a peer cohort, quality 
                                measures to be included in a core 
                                measure set for such cohort;
                                    ``(II) shall, to the extent there 
                                are insufficient quality measures 
                                applicable to a peer cohort to address 
                                one or more applicable quality domains, 
                                select to be included in a core measure 
                                set for such cohort such clinical 
                                practice improvement activities 
                                described in clause (ii)(IV) as are 
                                needed and available to sufficiently 
                                address such an applicable domain with 
                                respect to such peer cohort; and
                                    ``(III) may select, to the extent 
                                determined appropriate, any additional 
                                clinical practice improvement 
                                activities described in clause (ii)(IV) 
                                applicable to a peer cohort to be 
                                included in a core measure set for such 
                                cohort.
                        Activities selected under this paragraph shall 
                        be selected with consideration of best 
                        practices and clinical practice guidelines 
                        identified under subparagraph (C)(i)(II).
                            ``(ii) Sources of quality measures and 
                        clinical practice improvement activities.--A 
                        quality measure or clinical practice 
                        improvement activity selected for inclusion in 
                        a core measure set under the process under 
                        subparagraph (D)(i) shall be--
                                    ``(I) a measure endorsed by a 
                                consensus-based entity;
                                    ``(II) a measure developed under 
                                paragraph (2)(C) or a measure otherwise 
                                applied or developed for a similar 
                                purpose under this section;
                                    ``(III) a measure developed under 
                                subparagraph (C); or
                                    ``(IV) a measure or activity 
                                submitted under subparagraph (D)(ii).
                        A measure or activity may be selected under 
                        this subparagraph, regardless of whether such 
                        measure or activity was previously published in 
                        a proposed rule. A measure so selected shall be 
                        evidence-based but (other than a measure 
                        described in subclause (I)) shall not be 
                        required to be consensus-based.
                            ``(iii) Transparency.--Before publishing in 
                        a final regulation a core measure set under 
                        clause (i) as a final core measure set under 
                        subparagraph (F), the Secretary shall--
                                    ``(I) submit for publication in 
                                applicable specialty-appropriate peer-
                                reviewed journals such core measure set 
                                under clause (i) and the method for 
                                developing and selecting measures 
                                within such set, including clinical and 
                                other data supporting such measures, 
                                and, as applicable, the method for 
                                selecting clinical practice improvement 
                                activities included within such set; 
                                and
                                    ``(II) regardless of whether or not 
                                the core measure set or method is 
                                published in such a journal under 
                                subclause (I), provide for notice of 
                                the proposed regulation in the Federal 
                                Register, including with respect to the 
                                applicable methods and data described 
                                in subclause (I), and a period for 
                                public comment thereon.
                    ``(F) Final core measure sets.--Not later than 
                November 15 of the year prior to the first day of a 
                performance period, the Secretary shall publish a final 
                regulation in the Federal Register that includes a 
                final core measure set (and the applicable methods and 
                data described in subparagraph (E)(iii)(I)) for each 
                peer cohort to be applied for such performance period.
                    ``(G) Periodic review and updates.--
                            ``(i) In general.--In carrying out this 
                        paragraph, under the system under this 
                        subsection, there shall periodically be 
                        reviewed--
                                    ``(I) the quality measures and 
                                clinical practice improvement 
                                activities selected for inclusion in 
                                final core measure sets under this 
                                paragraph for each year such measures 
                                and activities are to be applied under 
                                this subsection or subsection (q) to 
                                ensure that such measures and 
                                activities continue to meet the 
                                conditions applicable to such measures 
                                and activities for such selection; and
                                    ``(II) the final core measure sets 
                                published under subparagraph (F) for 
                                each year such sets are to be applied 
                                to peer cohorts of eligible 
                                professionals to ensure that each 
                                applicable set continues to meet the 
                                conditions applicable to such sets 
                                before being so published.
                            ``(ii) Collaboration with stakeholders.--In 
                        carrying out clause (i), relevant eligible 
                        professional organizations and other relevant 
                        stakeholders may identify and submit updates to 
                        quality measures and clinical practice 
                        improvement activities selected under this 
                        paragraph for inclusion in final core measure 
                        sets as well as any additional quality measures 
                        and clinical practice improvement activities. 
                        Not later than November 15 of the year prior to 
                        the first day of a performance period, 
                        submissions under this clause shall be 
                        reviewed.
                            ``(iii) Additional, and updates to, 
                        measures and activities.--Based on the review 
                        conducted under this subparagraph for a period, 
                        as needed, there shall be--
                                    ``(I) selected additional, and 
                                updates to, quality measures and 
                                clinical practice improvement 
                                activities selected under this 
                                paragraph for potential inclusion in 
                                final core measure sets in the same 
                                manner such quality measures and 
                                clinical practice improvement 
                                activities are selected under this 
                                paragraph for such potential inclusion;
                                    ``(II) removed, from final core 
                                measure sets, quality measures and 
                                clinical practice improvement 
                                activities that are no longer 
                                meaningful; and
                                    ``(III) updated final core measure 
                                sets published under subparagraph (F) 
                                in the same manner as such sets are 
                                approved under such subparagraph.
                         For purposes of this subsection and subsection 
                        (q), a final core measure set, as updated under 
                        this subparagraph, shall be treated in the same 
                        manner as a final core measure set published 
                        under subparagraph (F).
                            ``(iv) Transparency.--
                                    ``(I) Notification required for 
                                certain updates.--In the case of an 
                                update under subclause (II) or (III) of 
                                clause (iii) that adds, materially 
                                changes, or removes a measure or 
                                activity from a measure set, such 
                                update shall not apply under this 
                                subsection or subsection (q) unless 
                                notification of such update is made 
                                available to applicable eligible 
                                professionals.
                                    ``(II) Public availability of 
                                updated final core measure sets.--
                                Subparagraph (E)(iii) shall apply with 
                                respect to measure sets updated under 
                                subclause (II) or (III) of clause (iii) 
                                in the same manner as such subparagraph 
                                applies to applicable core measure sets 
                                under subparagraph (E).
                    ``(H) Coordination with existing programs.--The 
                development and selection of quality measures and 
                clinical practice improvement activities under this 
                paragraph shall, as appropriate, be coordinated with 
                the development and selection of existing measures and 
                requirements, such as the development of the Physician 
                Compare Website under subsection (m)(5)(G) and the 
                application of resource use management under subsection 
                (n). To the extent feasible, such measures and 
                activities shall align with measures used by other 
                payers and with measures and activities in use under 
                other programs in order to streamline the process of 
                such development and selection under this paragraph. 
                The Secretary shall develop a plan to integrate 
                reporting on quality measures under this subsection 
                with reporting requirements under subsection (o) 
                relating to the meaningful use of certified EHR 
                technology.
                    ``(I) Consultation with relevant eligible 
                professional organizations and other relevant 
                stakeholders.--Relevant eligible professional 
                organizations (as defined in paragraph (3)(D)) and 
                other relevant stakeholders, including State and 
                national medical societies, shall be consulted in 
                carrying out this paragraph.
                    ``(J) Optional application.--The process under 
                section 1890A is not required to apply to the 
                development or selection of measures under this 
                paragraph.''; and
                    (F) in subsection (m)(3)(C)(i), by adding at the 
                end the following new sentence: ``Such process shall, 
                beginning for 2019, treat eligible professionals in 
                such a group practice as reporting on measures for 
                purposes of application of subsections (q) and 
                (a)(8)(A)(iii) if, in lieu of reporting measures under 
                subsection (k)(2)(D), the group practice reports 
                measures determined appropriate by the Secretary.''.
            (3) Establishment of quality update incentive program.--
                    (A) In general.--Section 1848 of the Social 
                Security Act (42 U.S.C. 1395w-4) is amended by adding 
                at the end the following new subsection:
    ``(q) Quality Update Incentive Program.--
            ``(1) Establishment.--
                    ``(A) In general.--The Secretary shall establish an 
                eligible professional quality update incentive program 
                (in this section referred to as the `quality update 
                incentive program') under which--
                            ``(i) there is developed and applied, in 
                        accordance with paragraph (2), appropriate 
                        methodologies for assessing the performance of 
                        eligible professionals with respect to quality 
                        measures and clinical practice improvement 
                        activities included within the final core 
                        measure sets published under subsection 
                        (k)(9)(F) applicable to the peer cohorts of 
                        such providers;
                            ``(ii) there is applied, consistent with 
                        the system under subsection (k), methods for 
                        collecting information needed for such 
                        assessments (which shall involve the minimum 
                        amount of administrative burden required to 
                        ensure reliable results); and
                            ``(iii) the applicable update adjustments 
                        under paragraph (3) are determined by such 
                        assessments.
                    ``(B) Definitions.--
                            ``(i) Eligible professional.--In this 
                        subsection, the term `eligible professional' 
                        has the meaning given such term in subsection 
                        (k)(3), except that such term shall not include 
                        a professional who has a payment arrangement 
                        described in section 1848A(a)(1) in effect.
                            ``(ii)  Peer cohorts; clinical practice 
                        improvement activities; eligible professional 
                        organizations.--In this subsection, the terms 
                        `peer cohort', `clinical practice improvement 
                        activity', and `eligible professional 
                        organization' have the meanings given such 
                        terms in subsection (k)(3).
                    ``(C) Consultation with eligible professional 
                organizations and other relevant stakeholders.--
                Eligible professional organizations and other relevant 
                stakeholders, including State and national medical 
                societies, shall be consulted in carrying out this 
                subsection.
                    ``(D) Application at group practice level.--The 
                Secretary shall establish a process, consistent with 
                subsection (m)(3)(C), under which the provisions of 
                this subsection are applied to eligible professionals 
                in a group practice if the group practice reports 
                measures determined appropriate by the Secretary under 
                such subsection.
                    ``(E) Coordination with existing programs.--The 
                application of measures and clinical practice 
                improvement activities and assessment of performance 
                under this subsection shall, as appropriate, be 
                coordinated with the application of measures and 
                assessment of performance under other provisions of 
                this section.
            ``(2) Assessing performance with respect to final core 
        measure sets for applicable peer cohorts.--
                    ``(A) Establishment of methods for assessment.--
                            ``(i) In general.--Under the quality update 
                        incentive program, the Secretary shall--
                                    ``(I) establish one or more 
                                methods, applicable with respect to a 
                                performance period, to assess (using a 
                                scoring scale of 0 to 100) the 
                                performance of an eligible professional 
                                with respect to, subject to paragraph 
                                (1)(D), quality measures and clinical 
                                practice improvement activities 
                                included within the final core measure 
                                set published under subsection 
                                (k)(9)(F) applicable for the period to 
                                the peer cohort in which the provider 
                                self-identified under subsection 
                                (k)(9)(B) for such period; and
                                    ``(II) subject to paragraph (1)(D), 
                                compute a composite score for such 
                                provider for such performance period 
                                with respect to the measures and 
                                activities included within such final 
                                core measure set.
                            ``(ii) Methods.--Such methods shall, with 
                        respect to an eligible professional, provide 
                        that the performance of such professional 
                        shall, subject to paragraph (1)(D), be assessed 
                        for a performance period with respect to the 
                        quality measures and clinical practice 
                        improvement activities within the final core 
                        measure set for such period for the peer cohort 
                        of such professional and on which information 
                        is collected from such professional.
                            ``(iii) Weighting of measures.--Such a 
                        method may provide for the assignment of 
                        different scoring weights or, as appropriate, 
                        other factors--
                                    ``(I) for quality measures and 
                                clinical practice improvement 
                                activities;
                                    ``(II) based on the type or 
                                category of measure or activity; and
                                    ``(III) based on the extent to 
                                which a quality measure or clinical 
                                practice improvement activity 
                                meaningfully assesses quality.
                            ``(iv) Risk adjustment.--Such a method 
                        shall provide for appropriate risk adjustments.
                            ``(v) Incorporation of other methods of 
                        measuring physician quality.--In establishing 
                        such methods, there shall be, as appropriate, 
                        incorporated comparable methods of measurement 
                        from physician quality incentive programs under 
                        this subsection.
                    ``(B) Performance period.--There shall be 
                established a period (in this subsection referred to as 
                a `performance period'), with respect to a year 
                (beginning with 2019) for which the quality adjustment 
                is applied under paragraph (3), to assess performance 
                on quality measures and clinical practice improvement 
                activities. Each such performance period shall be a 
                period of 12 consecutive months and shall end as close 
                as possible to the beginning of the year for which such 
                adjustment is applied.
            ``(3) Quality adjustment taking into account quality 
        assessments.--
                    ``(A) Quality adjustment.--For purposes of 
                subsection (d)(16), if the composite score computed 
                under paragraph (2)(A) for an eligible professional for 
                a year (beginning with 2019) is--
                            ``(i) a score of 67 or higher, the quality 
                        adjustment under this paragraph for the 
                        eligible professional and year is 1 percentage 
                        point;
                            ``(ii) a score of at least 34, but below 
                        67, the quality adjustment under this paragraph 
                        for the eligible professional and year is zero; 
                        or
                            ``(iii) a score below 34, the quality 
                        adjustment under this paragraph for the 
                        eligible professional and year is -1 percentage 
                        point.
                    ``(B) No effect on subsequent years' quality 
                adjustments.--Each such quality adjustment shall be 
                made each year without regard to the quality adjustment 
                for a previous year under this paragraph.
            ``(4) Transition for new eligible professionals.--In the 
        case of a physician, practitioner, or other supplier that 
        during a performance period, with respect to a year for which a 
        quality adjustment is applied under paragraph (3), first 
        becomes an eligible professional (and had not previously 
        submitted claims under this title as a person, as an entity, or 
        as part of a physician group or under a different billing 
        number or tax identifier), the quality adjustment under this 
        subsection applicable to such physician, practitioner, or 
        supplier--
                    ``(A) for such year, with respect to such first 
                performance period, shall be zero; and
                    ``(B) for a year, with respect to a subsequent 
                performance period, shall be the quality adjustment 
                that would otherwise be applied under this subsection.
            ``(5) Feedback.--
                    ``(A) Feedback.--
                            ``(i) Ongoing feedback.--Under the process 
                        under subsection (m)(5)(H), there shall be 
                        provided, as real time as possible, but at 
                        least quarterly, beginning not later than 6 
                        months after the first day of the first 
                        performance period, to each eligible 
                        professional feedback--
                                    ``(I) on the performance of such 
                                provider with respect to quality 
                                measures and clinical practice 
                                improvement activities within the final 
                                core measure set published under 
                                subsection (k)(9)(F) for the applicable 
                                performance period and the peer cohort 
                                of such professional; and
                                    ``(II) to assess the progress of 
                                such professional under the quality 
                                update incentive program with respect 
                                to a performance period for a year.
                            ``(ii) Use of registries and other 
                        mechanisms.--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 and based on performance received 
                        through the use of such registry, and to the 
                        extent that an eligible professional chooses 
                        not to participate in such a registry for such 
                        purposes, be provided through other similar 
                        mechanisms that allow for the provision of such 
                        feedback and receipt of such performance 
                        information.
                    ``(B) Data mechanism.--Under the quality update 
                incentive program, there shall be developed an 
                electronic interactive eligible professional mechanism 
                through which such a professional may receive 
                performance data, including data with respect to 
                performance on the measures and activities developed 
                and selected under this section. Such mechanism shall 
                be developed in consultation with private payers and 
                health insurance issuers (as defined in section 
                2791(b)(2) of the Public Health Service Act) as 
                appropriate.
                    ``(C) Transfer of funds.--The Secretary shall 
                provide for the transfer of $100,000,000 from the 
                Federal Supplementary Medical Insurance Trust Fund 
                established in section 1841 to the Center for Medicare 
                & Medicaid Services Program Management Account to 
                support such efforts to develop the infrastructure as 
                necessary to carry out subsection (k)(9) and this 
                subsection and for purposes of section 1889(h). Such 
                funds shall be so transferred on the date of the 
                enactment of this subsection and shall remain available 
                until expended.''.
                    (B) Incentive to report under quality update 
                incentive program.--Section 1848(a)(8)(A) of the Social 
                Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
                            (i) in clause (i), by striking ``With 
                        respect to'' and inserting ``Subject to clause 
                        (iii), with respect to''; and
                            (ii) by adding at the end the following new 
                        clause:
                            ``(iii) Application to eligible 
                        professionals not reporting.--With respect to 
                        covered professional services (as defined in 
                        subsection (k)(3)) furnished by an eligible 
                        professional during 2019 or any subsequent 
                        year, if the eligible professional does not 
                        submit data for the performance period (as 
                        defined in subsection (q)(2)(B)) with respect 
                        to such year on, subject to subsection 
                        (q)(1)(D), the quality measures and, as 
                        applicable, clinical practice improvement 
                        activities within the final core measure set 
                        under subsection (k)(9)(F) applicable to the 
                        peer cohort of such provider, the fee schedule 
                        amount for such services furnished by such 
                        professional during the year (including the fee 
                        schedule amount for purposes of determining a 
                        payment based on such amount) shall be equal to 
                        95 percent (in lieu of the applicable percent) 
                        of the fee schedule amount that would otherwise 
                        apply to such services under this subsection 
                        (determined after application of paragraphs 
                        (3), (5), and (7), but without regard to this 
                        paragraph). The Secretary shall develop a 
                        minimum per year caseload threshold, with 
                        respect to eligible professionals, and the 
                        previous sentence shall not apply to eligible 
                        professionals with a caseload for a year below 
                        such threshold for such year.''.
                    (C) Education on quality update incentive 
                program.--Section 1889 of the Social Security Act (42 
                U.S.C. 1395zz) is amended by adding at the end the 
                following new subsection:
    ``(h) Quality Update Incentive Program.--Under this section, 
information shall be disseminated to educate and assist eligible 
professionals (as defined in section 1848(k)(3)) about the quality 
update incentive program under section 1848(q) and quality measures 
under section 1848(k)(9) through multiple approaches, including a 
national dissemination strategy and outreach by medicare 
contractors.''.
            (4) Conforming amendments.--
                    (A) Treatment of satisfactorily reporting pqrs 
                measures through participation in a qualified clinical 
                data registry.--Section 1848(m)(3)(D) of the Social 
                Security Act (42 U.S.C. 1395w-4(m)(3)(D)) is amended by 
                striking ``For 2014 and subsequent years'' and 
                inserting ``For each of 2014 through 2018''.
                    (B) Coordinating enhanced pqrs reporting with 
                ehr.--Section 1848(o)(2)(B)(iii) of the Social Security 
                Act (42 U.S.C. 1395w-4(o)(2)(B)(iii)) is amended by 
                striking ``subsection (k)(2)(C)'' and inserting 
                ``subparagraph (C) or (D) of subsection (k)(2)''.
                    (C) Coordinating pqrs reporting period with quality 
                update incentive program performance period.--Section 
                1848(m)(6)(C) of the Social Security Act (42 U.S.C. 
                1395w-4(m)(6)(C)) is amended--
                            (i) in clause (i), by striking ``and 
                        (iii)'' and inserting ``, (iii), and (iv)''; 
                        and
                            (ii) by adding at the end the following new 
                        clause:
                            ``(iv) Coordination with quality update 
                        incentive program.--For 2019 and each 
                        subsequent year the reporting period shall be 
                        coordinated with the performance period under 
                        subsection (q)(2)(B).''.
                    (D) Coordinating ehr reporting with quality update 
                incentive program performance period.--Section 
                1848(o)(5)(B) of the Social Security Act (42 U.S.C. 
                1395w-4(o)(5)(B)) is amended by adding at the end the 
                following: ``Beginning for 2019, the EHR reporting 
                period shall be coordinated with the performance period 
                under subsection (q)(2)(B).''.
    (c) Advancing Alternative Payment Models.--
            (1) In general.--Part B of title XVIII of the Social 
        Security Act (42 U.S.C. 1395w-4 et seq.) is amended by adding 
        at the end the following new section:

``SEC. 1848A. ADVANCING ALTERNATIVE PAYMENT MODELS.

    ``(a) Payment Model Choice Program.--Payment for covered 
professional services (as defined in section 1848(k)) that are 
furnished by an eligible professional (as defined in such section) 
under an Alternative Payment Model specified on the list under 
subsection (h) (in this section referred to as an `eligible APM') shall 
be made under this title in accordance with the payment arrangement 
under such model. In applying the previous sentence, such a 
professional with such a payment arrangement in effect, shall be deemed 
for purposes of section 1848(a)(8) to be satisfactorily submitting data 
on quality measures for such covered professional services.
    ``(b) Process for Implementing Eligible APMs.--
            ``(1) In general.--For purposes of subsection (a) and in 
        accordance with this section, the Secretary shall establish a 
        process under which--
                    ``(A) a contract is entered into, in accordance 
                with paragraph (2);
                    ``(B) proposals for potential Alternative Payment 
                Models are submitted in accordance with subsection (c);
                    ``(C) Alternative Payment Models so proposed are 
                recommended, in accordance with subsection (d), for 
                testing and evaluation, including through the 
                demonstration program under subsection (e), and 
                approval under subsection (f);
                    ``(D) applicable Alternative Payment Models are 
                tested and evaluated under such demonstration program;
                    ``(E) models are implemented as eligible APMs in 
                accordance with subsection (f); and
                    ``(F) a comprehensive list of all eligible APMs is 
                made publicly available, in accordance with subsection 
                (h), for application under subsection (a).
            ``(2) Contract with apm contracting entity.--
                    ``(A) In general.--For purposes of paragraph 
                (1)(A), the Secretary shall identify and have in effect 
                a contract with an independent entity that has 
                appropriate expertise to carry out the functions 
                applicable to such entity under this section. Such 
                entity shall be referred to in this section as the `APM 
                contracting entity'.
                    ``(B) Timing for first contract.--The Secretary 
                shall enter into the first contract under subparagraph 
                (A) to be in effect January 1, 2019.
                    ``(C) Competitive procedures.--Competitive 
                procedures (as defined in section 4(5) of the Office of 
                Federal Procurement Policy Act (41 U.S.C. 403(5)) shall 
                be used to enter into a contract under subparagraph 
                (A).
    ``(c) Submission of Proposed Alternative Payment Models.--Beginning 
not later than 90 days after the date the Secretary enters into a 
contract under subsection (b)(2) with the APM contracting entity, 
physicians, eligible professional organizations, health care provider 
organizations, and other entities may submit to the APM contracting 
entity proposals for Alternative Payment Models for application under 
this section. Such a proposal of a model shall include suggestions for 
measures to be used under subsection (e)(1)(B) for purposes of 
evaluating such model. In reviewing submissions under this subsection 
for purposes of making recommendations under subsection (d)(1), the 
contracting entity shall focus on submissions for such models that are 
intended to improve care coordination and quality for patients through 
modifying the manner in which physicians and other providers are paid 
under this title.
    ``(d) Recommendation by APM Contracting Entity of Proposed 
Models.--
            ``(1) Recommendation.--
                    ``(A) Recommendations to secretary.--
                            ``(i) In general.--Under the process under 
                        subsection (b), the APM contracting entity 
                        shall at least quarterly recommend, in 
                        accordance with clause (ii), to the Secretary--
                                    ``(I) Alternative Payment Models 
                                submitted under subsection (c) to be 
                                tested and evaluated through a 
                                demonstration program under subsection 
                                (e); and
                                    ``(II) Alternative Payment Models 
                                submitted under subsection (c) to be 
                                implemented under subsection (f) 
                                without testing and evaluation through 
                                such a demonstration program.
                        Such a recommendation under subclause (I) may 
                        be made with respect to a model for which a 
                        waiver would be required under paragraph (2). 
                        Any reference in this subsection to an 
                        Alternative Payment Model under this clause is 
                        a reference to such model as may be modified 
                        under clause (iii).
                            ``(ii) Requirements.--In recommending an 
                        Alternative Payment Model under clause (i), 
                        each of the following shall apply:
                                    ``(I) The APM contracting entity 
                                may recommend an Alternative Payment 
                                Model under clause (i)(I) only if the 
                                entity determines that the model 
                                satisfies the criteria described in 
                                subparagraph (B), including the 
                                criteria described in subparagraph 
                                (B)(iv).
                                    ``(II) The APM contracting entity 
                                may recommend an Alternative Payment 
                                Model under clause (i)(II) only if the 
                                entity determines that the model 
                                satisfies the criteria described in 
                                subparagraph (C), including the 
                                criteria described in subparagraph 
                                (C)(iii).
                                    ``(III) The APM contracting entity 
                                shall include with the recommended 
                                Alternative Payment Model 
                                recommendations for rules of 
                                coordination described in clause (v).
                            ``(iii) Modifications by apm contracting 
                        entity.--For purposes of this subparagraph, to 
                        the extent necessary to meet the applicable 
                        requirements of clause (ii), the APM 
                        contracting entity may modify an Alternative 
                        Payment Model submitted under subsection (c) to 
                        ensure that the model would--
                                    ``(I) reduce spending under this 
                                title without reducing the quality of 
                                care; or
                                    ``(II) improve the quality of care 
                                without increasing spending under this 
                                title.
                            ``(iv) Forms of modifications.--Such a 
                        modification under clause (iii) may include one 
                        or more of the following:
                                    ``(I) A change to the payment 
                                arrangement under which eligible 
                                professionals participating in such 
                                model would be paid for covered 
                                professional services furnished under 
                                such model.
                                    ``(II) A change to the criteria for 
                                eligible professionals to be eligible 
                                to participate under such model in 
                                order to ensure that the requirement 
                                described in subclause (I) or (II) is 
                                satisfied.
                                    ``(III) A change to the rules of 
                                coordination described in clause (v).
                                    ``(IV) The application of a 
                                withhold mechanism under the payment 
                                arrangement under which the 
                                distribution of withheld amounts is 
                                based on the success of the model in 
                                meeting spending reduction 
                                requirements.
                                    ``(V) Such other change as the 
                                contracting entity may specify.
                            ``(v) Rules of coordination for application 
                        of payment arrangements under models.--
                                    ``(I) In general.--Rules of 
                                coordination described in this clause 
                                for an Alternative Payment Model shall 
                                be designed to determine, for purposes 
                                of applying subsection (a) and section 
                                1848(d)(16), under what circumstances 
                                an eligible professional is treated as 
                                having a payment arrangement under a 
                                particular model.
                                    ``(II) Nonduplication of payment.--
                                Such rules of coordination shall ensure 
                                coordination and nonduplication of 
                                payment of services that might be 
                                covered under more than one payment 
                                arrangement or under section 
                                1848(d)(16).
                                    ``(III) Application to non-apm 
                                payment.--In applying such rules of 
                                coordination for purposes of section 
                                1848(d)(16), an eligible professional 
                                shall not be treated as having a 
                                payment arrangement in effect under 
                                such a model for any covered 
                                professional services not treated as 
                                furnished under the model.
                    ``(B) Criteria for recommending models for 
                demonstration.--For purposes of subparagraph 
                (A)(ii)(I), the criteria described in this 
                subparagraph, with respect to an Alternative Payment 
                Model, are each of the following:
                            ``(i) The model has been supported by 
                        meaningful clinical and non-clinical data, with 
                        respect to a sufficient population sample, that 
                        indicates the model would be successful at 
                        addressing each of the abilities described in 
                        clause (iv).
                            ``(ii)(I) In the case of a model that has 
                        already been evaluated and supported by data 
                        with respect to a population of individuals 
                        enrolled under this part, if the model were 
                        evaluated under the demonstration under 
                        subsection (e) such a population would 
                        represent a sufficient number of individuals 
                        enrolled under this part to ensure a meaningful 
                        evaluation of the likely effect of expanding 
                        the demonstration.
                            ``(II) In the case of a model that has not 
                        been so evaluated and supported by data with 
                        respect to such a population, the population 
                        that would be furnished services under such 
                        model if the model were evaluated under the 
                        demonstration under subsection (e) would 
                        represent a sufficient number of individuals 
                        enrolled under this part to ensure a meaningful 
                        evaluation of the likely effect of expanding 
                        the demonstration.
                            ``(iii) Such model, including if tested and 
                        evaluated under the demonstration under 
                        subsection (e), would not deny or limit the 
                        coverage or provision of benefits under this 
                        title for applicable individuals.
                            ``(iv) The proposal for such model 
                        demonstrates--
                                    ``(I) the significant likelihood to 
                                successfully manage the cost of 
                                furnishing items and services under 
                                this title so as to not result in 
                                expenditures under this title being 
                                greater than expenditures under this 
                                title if the APM were not implemented; 
                                and
                                    ``(II) the ability to maintain or 
                                improve the overall quality of patient 
                                care provided to individuals enrolled 
                                under this part.
                            ``(v) The model provides for a payment 
                        arrangement--
                                    ``(I) that specifies the items and 
                                services covered under the arrangement 
                                and specifies rules of coordination 
                                described in subparagraph (A)(v) 
                                between the items and services covered 
                                under the arrangement and other items 
                                and services not covered under the 
                                arrangement;
                                    ``(II) in the case such payment 
                                arrangement does not provide for 
                                payment under the fee schedule under 
                                section 1848 for such items and 
                                services furnished by such eligible 
                                professionals, that provides for a 
                                payment adjustment based on meaningful 
                                EHR use comparable to such adjustment 
                                that would otherwise apply under 
                                section 1848; and
                                    ``(III) that provides for a payment 
                                adjustment based on quality measures 
                                comparable to such adjustment that 
                                would otherwise apply under section 
                                1848.
                    ``(C) Criteria for recommending models for approval 
                without evaluation under demonstration.--For purposes 
                of subparagraph (A)(ii)(II), the criteria described in 
                this subparagraph, with respect to an Alternative 
                Payment Model, is that the model has already been 
                tested and evaluated for a sufficient enough period and 
                through such testing and evaluation the model was 
                shown--
                            ``(i) to have satisfied the criteria 
                        described in each of clauses (i), (ii), (iii), 
                        and (v) of subparagraph (B); and
                            ``(ii)(I) to have reduced spending under 
                        this title without reducing the quality of 
                        care; or
                            ``(II) to have improved the quality of 
                        patient care without increasing such spending.
                    ``(D) Transparency and disclosures.--
                            ``(i) Disclosures.--Not later than 90 days 
                        after receipt of a submission of a model under 
                        subsection (c) by the APM contracting entity, 
                        the APM contracting entity shall submit to the 
                        Secretary and the model submitter and make 
                        publicly available a notification on whether or 
                        not, and if so how, the model meets criteria 
                        for recommending such model under subparagraph 
                        (A), including whether or not such model 
                        requires a waiver under paragraph (2). In the 
                        case that the APM contracting entity determines 
                        not to recommend such model under this 
                        paragraph, such notification shall include an 
                        explanation of the reasons for not making such 
                        a recommendation. Any information made publicly 
                        available pursuant to the previous sentence 
                        shall not include proprietary data.
                            ``(ii) Submission of recommended models.--
                        The APM contracting entity shall at least 
                        quarterly submit to the Secretary, the Medicare 
                        Payment Advisory Commission, and the Chief 
                        Actuary of the Centers for Medicare & Medicaid 
                        Services the following:
                                    ``(I) The models recommended under 
                                subparagraph (A)(i)(I), including any 
                                such models that require a waiver under 
                                paragraph (2), and the data and 
                                analyses on such recommended models 
                                that support the criteria described in 
                                subparagraph (B).
                                    ``(II) The models recommended under 
                                subparagraph (A)(i)(II) and the data 
                                and analyses on such recommended models 
                                that support the criteria described in 
                                subparagraph (C).
                            ``(iii) Explanation for no 
                        recommendations.--For any year beginning with 
                        2015 that the APM contracting entity does not 
                        recommend any models under subparagraph (A)(i), 
                        the entity shall instead satisfy this clause by 
                        submitting to the Secretary and making publicly 
                        available an explanation for not having any 
                        such recommendations.
                            ``(iv) Justifications for 
                        recommendations.--In submitting data and 
                        analyses under subclause (I) or (II) of clause 
                        (ii) with respect to a model, the APM 
                        contracting entity shall include a specific 
                        explanation of how the model would (and 
                        recommendations for ensuring that the model 
                        will) meet the criteria described in 
                        subparagraph (B) or (C), respectively.
                            ``(v) Confirmation of spending estimates by 
                        cms chief actuary.--For each Alternative 
                        Payment Model described in subclause (I) or 
                        (II) of clause (ii), the Chief Actuary of the 
                        Centers for Medicare & Medicaid Services shall 
                        submit to the Secretary a determination of 
                        whether or not the Chief Actuary confirms that 
                        the model satisfies the criterion described in 
                        subparagraph (B)(iv)(I) or (C)(ii), 
                        respectively.
            ``(2) Models requiring waiver approval.--
                    ``(A) In general.--In the case that an Alternative 
                Payment Model recommended under paragraph (1)(A)(i) 
                would require a waiver from any requirement under this 
                title, in determining approval of such model, the 
                Secretary may make such a waiver solely in order for 
                such model to be tested and evaluated under the 
                demonstration program.
                    ``(B) Approval.--Not later than 180 days after the 
                date of the receipt of such submission for a model, the 
                Secretary shall notify the APM contracting entity and 
                the entity submitting such model under subsection (c) 
                whether or not such a waiver for such model is approved 
                and the reason for any denial of such a waiver.
    ``(e) Demonstration.--
            ``(1) In general.--Subject to paragraphs (5), (6), and (7), 
        the Secretary may conduct a demonstration program, with respect 
        to an Alternative Payment Model approved under paragraph (2), 
        under which participating APM providers shall be paid under 
        this title in accordance with the payment arrangement under 
        such model and such model shall be evaluated by the independent 
        evaluation entity under paragraph (4). The duration of a 
        demonstration program under this subsection, with respect to 
        such a model, shall be 3 years.
            ``(2) Approval by secretary of models for demonstration.--
                    ``(A) In general.--Not later than 180 days after 
                the date of receipt of a submission under subsection 
                (d)(1)(D)(ii), with respect to an Alternative Payment 
                Model recommended under subsection (d)(1)(A)(i)(I), the 
                Secretary shall--
                            ``(i) review the basis for such 
                        recommendation in order to assess, taking into 
                        account the determination of the Chief Actuary 
                        under subsection (d)(1)(D)(v) with respect to 
                        such model, if the model is significantly 
                        likely to--
                                    ``(I) reduce spending under this 
                                title without reducing the quality of 
                                care; or
                                    ``(II) improve the quality of care 
                                without increasing spending under this 
                                title;
                            ``(ii) assess whether the model is 
                        significantly likely to result in participation 
                        under such model of a sufficient number of 
                        those eligible professionals for whom the model 
                        was designed consistent with clause (i) to be 
                        able to evaluate the likely effect of expanding 
                        the demonstration; and
                            ``(iii) approve such model for a 
                        demonstration program under this subsection, 
                        including as modified under subparagraph (B), 
                        only if the Secretary determines--
                                    ``(I) the model is significantly 
                                likely to satisfy the criterion 
                                described in subclause (I) or (II) of 
                                clause (i);
                                    ``(II) the model is significantly 
                                likely to result in the participation 
                                of a sufficient number of eligible 
                                professionals described in clause (ii);
                                    ``(III) the model applies rules of 
                                coordination described in subparagraph 
                                (C) applicable to such model; and
                                    ``(IV) the model satisfies the 
                                criteria described in subsection 
                                (d)(1)(B).
                The Secretary shall periodically make available a list 
                of such models approved under clause (iii).
                    ``(B) Modifications by secretary.--
                            ``(i) Before approval.--For purposes of 
                        subparagraph (A), the Secretary may modify an 
                        Alternative Payment Model recommended under 
                        subsection (d)(1)(A)(i)(I) to ensure that the 
                        model meets the requirements described in 
                        subparagraph (A)(iii). Such a modification may 
                        include one or more of the following:
                                    ``(I) A change to the payment 
                                arrangement under which eligible 
                                professionals participating in such 
                                model would be paid for covered 
                                professional services furnished under 
                                such model.
                                    ``(II) A change to the criteria for 
                                eligible professionals to be eligible 
                                to participate under such model in 
                                order to ensure that such requirements 
                                are satisfied.
                                    ``(III) A change to the rules of 
                                coordination described in subparagraph 
                                (C).
                                    ``(IV) The application of a 
                                withhold mechanism under the payment 
                                arrangement under which the 
                                distribution of withheld amounts is 
                                based on the success of the model in 
                                meeting spending reduction 
                                requirements.
                                    ``(V) Such other change as the 
                                Secretary may specify.
                            ``(ii) Termination or modification during 
                        demonstration.--The Secretary shall terminate 
                        or modify the design and implementation of an 
                        Alternative Payment Model approved under 
                        subparagraph (A)(iii) for a demonstration 
                        program, after testing has begun, unless the 
                        Secretary determines (and the Chief Actuary of 
                        the Centers for Medicare & Medicaid Services, 
                        with respect to program spending under this 
                        title, certifies) that the model is expected to 
                        continue to satisfy the requirements described 
                        in such paragraph relating to quality of care 
                        and reduced spending. Such termination may 
                        occur at any time after such testing has begun 
                        and before completion of the testing.
                    ``(C) Rules of coordination for application of 
                payment arrangements under models.--
                            ``(i) In general.--Rules of coordination 
                        described in this subparagraph for an 
                        Alternative Payment Model shall be designed to 
                        determine, for purposes of applying subsection 
                        (a) and section 1848(d)(16), under what 
                        circumstances an eligible professional is 
                        treated as having a payment arrangement under a 
                        particular model.
                            ``(ii) Nonduplication of payment.--Such 
                        rules of coordination shall ensure coordination 
                        and nonduplication of payment of services that 
                        might be covered under more than one payment 
                        arrangement or under section 1848(d)(16).
                            ``(iii) Application to non-apm payment.--In 
                        applying such rules for purposes of section 
                        1848(d)(16), an eligible professional shall not 
                        be treated as having a payment arrangement in 
                        effect under such a model for any covered 
                        professional services not treated as furnished 
                        under the model.
            ``(3) Participating apm providers.--
                    ``(A) In general.--To participate under a 
                demonstration program under this subsection, with 
                respect to an Alternative Payment Model, an eligible 
                professional shall enter into a contract with the 
                Administrator of the Centers for Medicare & Medicaid 
                Services under this subsection. For purposes of this 
                section, such an eligible professional who so 
                participates under such an Alternative Payment Model in 
                this section is referred to as a `participating APM 
                provider'.
                    ``(B) Requirements.--The Secretary shall establish 
                criteria for eligible professionals to enter into 
                contracts under this paragraph for purposes of 
                participation under a demonstration program with 
                respect to an Alternative Payment Model. Such criteria 
                shall ensure participation under such model of a 
                sufficient number of eligible professionals for whom 
                the model was designed in order to satisfy the 
                criterion described in paragraph (2)(A)(iii)(II).
            ``(4) Reporting and evaluation.--
                    ``(A) Independent evaluation entity.--Under this 
                subsection, the Secretary shall enter into a contract 
                with an independent entity to evaluate Alternative 
                Payment Models under demonstration programs under this 
                subsection based on appropriate measures specified 
                under subparagraph (B). In this section, such entity 
                shall be referred to as the `independent evaluation 
                entity'. Such contract shall be entered into in a 
                timely manner so as to ensure evaluation of an 
                Alternative Payment Model under a demonstration program 
                under this subsection may begin as soon as possible 
                after the model is approved under paragraph (2).
                    ``(B) Performance measures.--For purposes of this 
                subsection, the Secretary shall specify--
                            ``(i) measures to evaluate Alternative 
                        Payment Models under demonstration programs 
                        under this subsection, which may include 
                        measures suggested under subsection (c) and 
                        shall be sufficient to allow for a 
                        comprehensive assessment of such a model; and
                            ``(ii) quality measures on which 
                        participating APM providers shall report, which 
                        shall be similar to measures applicable under 
                        section 1848(k).
                    ``(C) Reporting requirements.--A contract entered 
                into with a participating APM provider under paragraph 
                (3) shall require such provider to report on 
                appropriate measures specified under subparagraph (B).
                    ``(D) Periodic review.--The independent evaluation 
                entity shall periodically review and analyze and submit 
                such analysis to the Secretary and the participating 
                APM providers involved data reported under subparagraph 
                (C) and such other data as deemed necessary to evaluate 
                the model.
                    ``(E) Final evaluation.--Not later than 6 months 
                after the date of completion of a demonstration 
                program, the independent evaluation entity shall submit 
                to the Secretary, the Medicare Payment Advisory 
                Commission, and the Chief Actuary of the Centers for 
                Medicare & Medicaid Services (and make publicly 
                available) a report on each model evaluated under such 
                program. Such report shall include--
                            ``(i) outcomes on the clinical and claims 
                        data received through such program with respect 
                        to such model;
                            ``(ii) recommendations on--
                                    ``(I) whether or not such model 
                                should be implemented as an eligible 
                                APM under this section; or
                                    ``(II) whether or not the 
                                evaluation of such model under the 
                                demonstration program should be 
                                extended or expanded;
                            ``(iii) the justification for each such 
                        recommendation described in clause (ii); and
                            ``(iv) in the case of a recommendation to 
                        implement such model as an eligible APM, 
                        recommendations on standardized rules for 
                        purposes of such implementation.
            ``(5) Approval of extending evaluation under 
        demonstration.--Not later than 90 days after the date of 
        receipt of a submission under paragraph (4)(E), the Secretary 
        shall, including based on a recommendation submitted under such 
        paragraph, determine whether an Alternative Payment Model may 
        be extended or expanded under the demonstration program.
            ``(6) Termination.--The Secretary shall terminate a 
        demonstration program for a model under this subsection unless 
        the Secretary determines (and the Chief Actuary of the Centers 
        for Medicare & Medicaid Services, with respect to spending 
        under this title, certifies), after testing has begun, that the 
        model is expected to--
                    ``(A) improve the quality of care (as determined by 
                the Administrator of the Centers for Medicare & 
                Medicaid Services) without increasing spending under 
                this title;
                    ``(B) reduce spending under this title without 
                reducing the quality of care; or
                    ``(C) improve the quality of care and reduce 
                spending.
        Such termination may occur at any time after such testing has 
        begun and before completion of the testing.
            ``(7) Funding.--
                    ``(A) In general.--There are appropriated, from 
                amounts in the Federal Supplementary Medical Insurance 
                Trust Fund under section 1841 not otherwise 
                appropriated and as of the date of the enactment of 
                this section, $2,000,000,000 for the purposes described 
                in subparagraph (B), of which no more than 2.5 percent 
                may be used for the purpose described in clause (iii) 
                of such subparagraph. Amounts appropriated under this 
                subparagraph shall be available until expended.
                    ``(B) Purposes.--Amounts appropriated under 
                subparagraph (A) shall be used for--
                            ``(i) payments for items and services 
                        furnished by participating APM providers under 
                        an Alternative Payment Model under a 
                        demonstration program under this subsection 
                        that--
                                    ``(I) would not otherwise be 
                                eligible for payment under this title; 
                                or
                                    ``(II) exceed the amount of payment 
                                that would otherwise be made for such 
                                items and services under this title if 
                                such items and services were not 
                                furnished under such demonstration 
                                program;
                            ``(ii) the evaluations provided for under 
                        this section of models under such a 
                        demonstration program;
                            ``(iii) payment to the APM contracting 
                        entity for carrying out its duties under this 
                        section; and
                            ``(iv) for otherwise carrying out this 
                        subsection.
                    ``(C) Limitation.--The amounts appropriated under 
                subparagraph (A) are the only amounts authorized or 
                appropriated to carry out the purposes described in 
                subparagraph (B).
    ``(f) Implementation of Recommended Models as Eligible APMs.--
            ``(1) Assessment.--With respect to each Alternative Payment 
        Model recommended under subsection (d)(1)(A)(i)(II) or 
        (e)(4)(E)(ii)(I), the Secretary shall review the basis for such 
        recommendation and assess and determine, in consultation with 
        the Chief Actuary of the Centers for Medicare & Medicaid 
        Services, whether the model is significantly likely to continue 
        to result in meeting the criterion described in subsection 
        (e)(2)(A)(iii)(I), with or without a modification described in 
        paragraph (5).
            ``(2) Implementation through rulemaking.--
                    ``(A) Publication of nprm.--If the Secretary 
                determines that such a model is significantly likely to 
                meet such criterion, the Secretary shall publish as 
                part of the applicable physician fee schedule 
                rulemaking process (specified in paragraph (3)) a 
                notice of proposed rulemaking to implement such model, 
                including as modified under paragraph (5).
                    ``(B) Comments by medpac.--Not later than 90 days 
                after the date of issuance of such notice with respect 
                to a model, the Medicare Payment Advisory Commission 
                shall submit comments on the proposed rule for such 
                model to Congress and to the Secretary. Such comments 
                shall include an evaluation of the reports from the 
                contracting entity and independent evaluation entity on 
                such model regarding the model's impact on expenditures 
                and quality of care under this title.
                    ``(C) Final rule and conditions.--The Secretary 
                shall publish as part of the applicable physician fee 
                schedule rulemaking process (specified in paragraph 
                (3)) a final notice implementing such proposed rule, 
                including as modified under paragraph (5), as an 
                eligible APM only if--
                            ``(i) the Secretary determines that such 
                        model is expected to--
                                    ``(I) reduce spending under this 
                                title without reducing the quality of 
                                care; or
                                    ``(II) improve the quality of 
                                patient care without increasing 
                                spending;
                            ``(ii) the Chief Actuary of the Centers for 
                        Medicare & Medicaid Services certifies that 
                        such model would reduce (or would not result in 
                        any increase in) spending under this title;
                            ``(iii) the Secretary determines that such 
                        model would not deny or limit the coverage or 
                        provision of benefits under this title for 
                        applicable individuals;
                            ``(iv) the Secretary determines that the 
                        model is significantly likely to result in the 
                        participation of a sufficient number of 
                        appropriate eligible professionals for whom the 
                        model was designed in order to satisfy the 
                        criterion described in subsection 
                        (d)(2)(A)(iii)(II);
                            ``(v) the Secretary determines that the 
                        model applies rules of coordination described 
                        in paragraph (6); and
                            ``(vi) the Secretary determines that model 
                        meets such other criteria as the Secretary may 
                        determine.
            ``(3) Applicable physician fee schedule rulemaking 
        process.--For purposes of paragraph (2), in the case of an 
        Alternative Payment Model recommended under subsection 
        (d)(1)(A)(ii) or (e)(4)(E)(ii)(I)--
                    ``(A) on or before April 1 of a year, the 
                applicable physician fee schedule rulemaking process is 
                the process for publication by November 1 of that year 
                of the fee schedule amounts under this section for the 
                succeeding year; or
                    ``(B) after April 1 of a year, the applicable 
                physician fee schedule rulemaking process is the 
                process for publication by November 1 of the following 
                year of the fee schedule amounts under this section for 
                the second succeeding year.
            ``(4) Justification for disapprovals.--In the case that an 
        Alternative Payment Model recommended under subsection 
        (d)(1)(A)(ii) or (e)(4)(E)(ii)(I) is not implemented as an 
        eligible APM under this subsection, the Secretary shall make 
        publicly available the rational, in detail, for such decision.
            ``(5) Modifications by secretary.--For purposes of this 
        subsection, the Secretary may modify an Alternative Payment 
        Model recommended under subsection (d)(1)(A)(i)(II) or 
        (e)(4)(E)(ii)(I) to ensure that the model meets the 
        requirements under paragraph (1)(B). Such a modification may 
        include one or more of the following:
                    ``(A) A change to the payment arrangement under 
                which eligible professionals participating in such 
                model would be paid for covered professional services 
                furnished under such model.
                    ``(B) A change to the criteria for eligible 
                professionals to be eligible to participate under such 
                model in order to ensure that such requirements are 
                satisfied.
                    ``(C) A change to the rules of coordination 
                described in paragraph (6).
                    ``(D) The application of a withhold mechanism under 
                the payment arrangement under which the distribution of 
                withheld amounts is based on the success of the model 
                in meeting spending reduction requirements.
                    ``(E) Such other change as the Secretary may 
                specify.
            ``(6) Rules of coordination for application of payment 
        arrangements under models.--
                    ``(A) In general.--Rules of coordination described 
                in this paragraph for an Alternative Payment Model 
                shall be designed to determine, for purposes of 
                applying subsection (a) and section 1848(d)(16), under 
                what circumstances an eligible professional is treated 
                as having a payment arrangement under a particular 
                model.
                    ``(B) Nonduplication of payment.--Such rules of 
                coordination shall ensure coordination and 
                nonduplication of payment of services that might be 
                covered under more than one payment arrangement or 
                under section 1848(d)(16).
                    ``(C) Application to non-apm payment.--In applying 
                such rules for purposes of section 1848(d)(16), an 
                eligible professional shall not be treated as having a 
                payment arrangement in effect under such a model for 
                any covered professional services not treated as 
                furnished under the model.
    ``(g) Periodic Review and Termination.--
            ``(1) Periodic review.--In the case of an Alternative 
        Payment Model that has been implemented, the Secretary and the 
        Chief Actuary of the Centers for Medicare & Medicaid Services 
        shall review such model every 3 years to determine (and 
        certify, in the case of the Chief Actuary and spending under 
        this title), for the previous 3 years, whether the model has--
                    ``(A) reduced the quality of care, or
                    ``(B) increased spending under this title,
        compared to the quality of care or spending that would have 
        resulted if the model had not been implemented.
            ``(2) Termination.--
                    ``(A) Quality of care reduction termination.--If 
                based upon such review the Secretary determines under 
                paragraph (1)(A) that the model has reduced the quality 
                of care, the Secretary may terminate such model.
                    ``(B) Spending increase termination.--Unless such 
                Chief Actuary certifies under paragraph (1)(B) that the 
                expenditures under this title under the model do not 
                exceed the expenditures that would otherwise have been 
                made if the model had not been implemented for the 
                period involved, the Secretary shall terminate such 
                model.
    ``(h) Dissemination of Eligible APMs.--Under this section there 
shall be established a process for specifying, and making publicly 
available a list of, all eligible APMs, which shall include at least 
those implemented under subsection (f) and demonstrations carried out 
with respect to payments under section 1848 through authority in 
existence as of the day before the date of the enactment of this 
section. Under such process such list shall be periodically updated 
and, beginning with January 1, 2015, and annually thereafter, such list 
shall be published in the Federal Register.''.
            (2) Conforming amendment.--Section 1848(a)(1) of the Social 
        Security Act (42 U.S.C. 1395w-4(a)(1)) is amended by striking 
        ``shall instead'' and inserting ``shall, subject to section 
        1848A, instead''.
    (d) Adjustment to Medicare Payment Localities.--
            (1) In general.--Section 1848(e) of the Social Security Act 
        (42 U.S.C. 1395w-4(e)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Use of msas as fee schedule areas in california.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this paragraph and notwithstanding the 
                previous provisions of this subsection, for services 
                furnished on or after January 1, 2017, the fee schedule 
                areas used for payment under this section applicable to 
                California shall be the following:
                            ``(i) Each Metropolitan Statistical Area 
                        (each in this paragraph referred to as an 
                        `MSA'), as defined by the Director of the 
                        Office of Management and Budget as of December 
                        31 of the previous year, shall be a fee 
                        schedule area.
                            ``(ii) All areas not included in an MSA 
                        shall be treated as a single rest-of-State fee 
                        schedule area.
                    ``(B) Transition for msas previously in rest-of-
                state payment locality or in locality 3.--
                            ``(i) In general.--For services furnished 
                        in California during a year beginning with 2017 
                        and ending with 2021 in an MSA in a transition 
                        area (as defined in subparagraph (D)), subject 
                        to subparagraph (C), the geographic index 
                        values to be applied under this subsection for 
                        such year shall be equal to the sum of the 
                        following:
                                    ``(I) Current law component.--The 
                                old weighting factor (described in 
                                clause (ii)) for such year multiplied 
                                by the geographic index values under 
                                this subsection for the fee schedule 
                                area that included such MSA that would 
                                have applied in such area (as estimated 
                                by the Secretary) if this paragraph did 
                                not apply.
                                    ``(II) MSA-based component.--The 
                                MSA-based weighting factor (described 
                                in clause (iii)) for such year 
                                multiplied by the geographic index 
                                values computed for the fee schedule 
                                area under subparagraph (A) for the 
                                year (determined without regard to this 
                                subparagraph).
                            ``(ii) Old weighting factor.--The old 
                        weighting factor described in this clause--
                                    ``(I) for 2017, is \5/6\; and
                                    ``(II) for each succeeding year, is 
                                the old weighting factor described in 
                                this clause for the previous year minus 
                                \1/6\.
                            ``(iii) MSA-based weighting factor.--The 
                        MSA-based weighting factor described in this 
                        clause for a year is 1 minus the old weighting 
                        factor under clause (ii) for that year.
                    ``(C) Hold harmless.--For services furnished in a 
                transition area in California during a year beginning 
                with 2017, the geographic index values to be applied 
                under this subsection for such year shall not be less 
                than the corresponding geographic index values that 
                would have applied in such transition area (as 
                estimated by the Secretary) if this paragraph did not 
                apply.
                    ``(D) Transition area defined.--In this paragraph, 
                the term `transition area' means each of the following 
                fee schedule areas for 2013:
                            ``(i) The rest-of-State payment locality.
                            ``(ii) Payment locality 3.
                    ``(E) References to fee schedule areas.--Effective 
                for services furnished on or after January 1, 2017, for 
                California, any reference in this section to a fee 
                schedule area shall be deemed a reference to a fee 
                schedule area established in accordance with this 
                paragraph.''.
            (2) Conforming amendment to definition of fee schedule 
        area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C. 
        1395w-4(j)(2)) is amended by striking ``The term'' and 
        inserting ``Except as provided in subsection (e)(6)(D), the 
        term''.
    (e) Relative Values Under the Medicare Physician Fee Schedule.--
            (1) Eligible physicians reporting system to improve 
        accuracy of relative values.--Section 1848(c) of the Social 
        Security Act (42 U.S.C. 1395w-4(c)) is amended by adding at the 
        end the following new paragraph:
            ``(7) Physician reporting system to improve accuracy of 
        relative values.--
                    ``(A) In general.--The Secretary shall implement a 
                system for the periodic reporting by physicians of data 
                on the accuracy of relative values under this 
                subsection, such as data relating to service volume and 
                time. Such data shall be submitted in a form and manner 
                specified by the Secretary and shall, as appropriate, 
                incorporate data from existing sources of data, patient 
                scheduling systems, cost accounting systems, and other 
                similar systems.
                    ``(B) Identification of reporting cohort.--Not 
                later than January 1, 2015, the Secretary shall 
                establish a mechanism for physicians to participate 
                under the reporting system under this paragraph, all of 
                whom shall collectively be referred to under this 
                paragraph as the `reporting group'. The reporting group 
                shall include physicians across settings that 
                collectively represent a range of specialties and 
                practitioner types, furnish a range of physicians' 
                services, and serve a range of patient populations.
                    ``(C) Incentive to report.--Under the system under 
                this paragraph, the Secretary may provide for such 
                payments under this part to physicians included in the 
                reporting group as the Secretary determines appropriate 
                to compensate such physicians for reporting data under 
                the system. Such payments shall be provided in such 
                form and manner as specified by the Secretary. In 
                carrying out this subparagraph, reporting by such a 
                physician under this paragraph shall not be treated as 
                the furnishing of physicians' services for purposes of 
                applying this section.
                    ``(D) Funding.--To carry out this paragraph (other 
                than with respect to payments made under subparagraph 
                (C)), in addition to funds otherwise appropriated, the 
                Secretary shall provide for the transfer from the 
                Federal Supplementary Medical Insurance Trust Fund 
                under section 1841 of $1,000,000 to the Centers for 
                Medicare & Medicaid Services Program Management Account 
                for each fiscal year beginning with fiscal year 2014. 
                Amounts transferred under this subparagraph for a 
                fiscal year shall be available until expended.''.
            (2) Relative value adjustments for misvalued physicians' 
        services.--
                    (A) In general.--Section 1848(c)(2) of the Social 
                Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by 
                adding at the end the following new subparagraph:
                    ``(M) Adjustments for misvalued physicians' 
                services.--
                            ``(i) In general.--Only with respect to fee 
                        schedules established for 2016, 2017, and 2018 
                        (and not for subsequent years), the Secretary 
                        shall--
                                    ``(I) identify, based on the data 
                                reported under paragraph (8) and other 
                                relevant data, misvalued services for 
                                which adjustments to the relative 
                                values established under this paragraph 
                                would result in a reduction in 
                                expenditures under the fee schedule 
                                under this section, with respect to 
                                such year, of not more than 1 percent 
                                of the projected amount of expenditures 
                                under such fee schedule for such year; 
                                and
                                    ``(II) make such adjustments for 
                                each such year so as only to result in 
                                such a reduction for such year.
                            ``(ii) No effect on subsequent years.--A 
                        reduction under this subparagraph for a year 
                        shall not affect any reduction for any 
                        subsequent year.
                            ``(iii) Rule of construction relating to 
                        undervalued codes.--Nothing in this 
                        subparagraph shall be construed as preventing 
                        the Secretary from increasing the relative 
                        values for codes that are undervalued.''.
                    (B) Budget neutrality.--Section 1848(c)(2)(B)(v) of 
                the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) 
                is amended by adding at the end the following new 
                subclause:
                                    ``(VIII) Reductions for misvalued 
                                physicians' services.--Reduced 
                                expenditures attributable to 
                                subparagraph (M) for fiscal years 2016, 
                                2017, and 2018.''.
            (3) Disclosure of data used to establish multiple procedure 
        payment reduction policy.--The Secretary of Health and Human 
        Services shall make publicly available the data used to 
        establish the multiple procedure payment reduction policy to 
        the professional component of imaging services in the final 
        rule published in the Federal Register, v. 77, n. 222, November 
        16, 2012, pages 68891-69380 under the physician fee schedule 
        under section 1848 of the Social Security Act (42 U.S.C. 1395w-
        4).

SEC. 3. EXPANDING AVAILABILITY OF MEDICARE DATA.

    (a) Expanding Uses of Medicare Data by Qualified Entities.--
            (1) In general.--To the extent consistent with applicable 
        information, privacy, security, and disclosure laws, beginning 
        with 2014, notwithstanding paragraph (4)(B) of section 1874(e) 
        of the Social Security Act (42 U.S.C. 1395kk(e)) and the second 
        sentence of paragraph (4)(D) of such section, a qualified 
        entity may use data received by such entity under such section, 
        and information derived from the evaluation described in such 
        paragraph (4)(D), for additional non-public analyses (as 
        determined appropriate by the Secretary of Health and Human 
        Services) or provide or sell such data to registered or 
        authorized users and subscribers, including to providers of 
        services and suppliers, for non-public use (including for the 
        purposes of assisting providers of services and suppliers to 
        develop and participate in quality and patient care improvement 
        activities, including developing new models of care).
            (2) Definitions.--In this section:
                    (A) The term ``qualified entity'' has the meaning 
                given such term in section 1874(e)(2) of the Social 
                Security Act (42 U.S.C. 1395kk(e)).
                    (B) The terms ``supplier'' and ``provider of 
                services'' have the meanings given such terms in 
                subsections (d) and (u), respectively, of section 1861 
                of the Social Security Act (42 U.S.C. 1395x).
    (b) Access to Medicare Data to Providers of Services and Suppliers 
to Facilitate Development of Alternative Payment Models and to 
Qualified Clinical Data Registries to Facilitate Quality Improvement.--
Consistent with applicable laws and regulations with respect to privacy 
and other relevant matters, the Secretary shall provide Medicare claims 
data (in a form and manner determined to be appropriate) to--
            (1) qualified entities, that may share with providers of 
        services and suppliers that are registered or authorized users 
        or subscribers, for non-public use including to facilitate the 
        development of new models of care (including development of 
        Alternate Payment Models under section 1848A of the Social 
        Security Act, models for small group specialty practices, and 
        care coordination models); and
            (2) qualified clinical data registries under section 
        1848(m)(3)(E)) of the Social Security Act (42 U.S.C. 1395w-
        4(m)(3)(E)) for purposes of linking such data with clinical 
        outcomes data and performing and disseminating risk-adjusted, 
        scientifically valid analysis and research to support quality 
        improvement or patient safety, provided that any public 
        reporting of identifiable provider data shall only be conducted 
        with prior consent of such provider.

SEC. 4. ENCOURAGING CARE COORDINATION AND MEDICAL HOMES.

     Section 1848(b) of the Social Security Act (42 U.S.C. 1395w-4(b)) 
is amended by adding at the end the following new paragraph:
            ``(8) Encouraging care coordination and medical homes.--
                    ``(A) In general.--In order to promote the 
                coordination of care by an applicable provider (as 
                defined in subparagraph (B)) for individuals with 
                complex chronic care needs who are furnished items and 
                services by multiple physicians and other suppliers and 
                providers of services, the Secretary shall--
                            ``(i) develop one or more HCPCS codes for 
                        complex chronic care management services for 
                        individuals with complex chronic care needs; 
                        and
                            ``(ii) for such services furnished on or 
                        after January 1, 2015, by an applicable 
                        provider, make payment (as the Secretary 
                        determines to be appropriate) under the fee 
                        schedule under this section using such HCPCS 
                        codes.
                    ``(B) Applicable provider defined.--For purposes of 
                this paragraph, the term `applicable provider' means a 
                physician (as defined in section 1861(r)(1)) or a 
                physician assistant or nurse practitioner (as defined 
                in section 1861(aa)(5)(A)) who--
                            ``(i) is certified as a medical home (by 
                        achieving an accreditation status of level 3 by 
                        the National Committee for Quality Assurance);
                            ``(ii) is recognized as a patient-centered 
                        specialty practice by the National Committee 
                        for Quality Assurance;
                            ``(iii) has received equivalent 
                        certification (as determined by the Secretary); 
                        or
                            ``(iv) meets such other comparable 
                        qualifications as the Secretary determines to 
                        be appropriate.
                    ``(C) Budget neutrality.--The budget neutrality 
                provision under subsection (c)(2)(B)(ii)(II) shall 
                apply in establishing the payment under subparagraph 
                (A)(ii).
                    ``(D) Single applicable provider payment.--In 
                carrying out this paragraph, the Secretary shall only 
                make payment to a single applicable provider for 
                complex chronic care management services furnished to 
                an individual.''.

SEC. 5. MISCELLANEOUS.

    (a) Solicitations, Recommendations, and Reports.--
            (1) Solicitation for recommendations on episodes of care 
        definition.--The Administrator of the Centers for Medicare & 
        Medicaid Services shall request eligible professional 
        organizations (as defined in section 1848(k)(3) of the Social 
        Security Act (42 U.S.C. 1395w-4(k)(3))) and other relevant 
        stakeholders to submit recommendations for defining non-acute 
        related episodes of care for purposes of applying such 
        definition under subsections (k) and (q) of section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4) and section 1848A of 
        such Act, as added by subsections (b) and (c) of section 2.
            (2) Solicitation for recommendations on provider fee 
        schedule payment bundles.--
                    (A) In general.--The Administrator of the Centers 
                for Medicare & Medicaid Services shall solicit from 
                eligible professional organizations (as defined in 
                section 1848(k)(3) of the Social Security Act (42 
                U.S.C. 1395w-4(k)(3))) recommendations for payment 
                bundles for chronic conditions and expensive, high 
                volume services for which payment is made under title 
                XVIII of such Act.
                    (B) Report to congress.--Not later than 24 months 
                after the date of the enactment of this Act, the 
                Administrator shall submit to Congress a report on 
                proposals for such payment bundles.
            (3) Reports on modified pfs system and payment system 
        alternatives.--
                    (A) Biannual progress reports.--Not later than 
                January 15, 2016, and annually thereafter, the 
                Secretary of Health and Human Services shall submit to 
                Congress and post on the public Internet website of the 
                Centers for Medicare & Medicaid Services a biannual 
                progress report--
                            (i) on the implementation of paragraph (9) 
                        of section 1848(k) of the Social Security Act 
                        (42 U.S.C. 1395w-4(k)), as added by section 
                        2(b)(2), and the quality update incentive 
                        program under subsection (q) of section 1848 of 
                        the Social Security Act (42 U.S.C. 1395w-4), as 
                        added by section 2(b)(3);
                            (ii) that includes an evaluation of such 
                        paragraph and such quality update incentive 
                        program and recommendations with respect to 
                        such program and appropriate update mechanisms; 
                        and
                            (iii) on the actions taken to promote and 
                        fulfill the identification of eligible APMs 
                        under section 1848A of the Social Security Act, 
                        as added by section 2(c), for application under 
                        such section 1848A.
                    (B) GAO and medpac reports.--
                            (i) GAO report on initial stages of 
                        program.--The Comptroller General of the United 
                        States shall submit to Congress a report for 
                        2019 and each subsequent year analyzing the 
                        extent to which the system under section 
                        1848(k)(9) of the Social Security Act (42 
                        U.S.C. 1395w-4(k)(9)) and such quality update 
                        incentive program under section 1848(q) of the 
                        Social Security Act, as added by section 2(b) 
                        is successfully satisfying performance 
                        objectives, including with respect to--
                                    (I) the process for developing and 
                                selecting measures and activities under 
                                subsection (k)(9) of section 1848 of 
                                such Act (42 U.S.C. 1395w-4);
                                    (II) the process for assessing 
                                performance against such measures and 
                                activities under subsection (q) of such 
                                section; and
                                    (III) the adequacy of the measures 
                                and activities so selected.
                            (ii) Evaluation by gao and medpac on 
                        implementation of quality update incentive 
                        program.--
                                    (I) GAO.--The Comptroller General 
                                of the United States shall evaluate the 
                                initial phase of the quality update 
                                incentive program under subsection (q) 
                                of section 1848 of the Social Security 
                                Act (42 U.S.C. 1395w-4) and shall 
                                submit to Congress, not later than 
                                2019, a report with recommendations for 
                                improving such quality update incentive 
                                program.
                                    (II) MedPAC.--In the course of its 
                                March Report to Congress on Medicare 
                                payment policy, MedPAC shall analyze 
                                the initial phase of such quality 
                                update incentive program and make 
                                recommendations, as appropriate, for 
                                improving such quality update incentive 
                                program.
                            (iii) MedPAC report on payment system 
                        alternatives.--
                                    (I) In general.--Not later than 
                                June 15, 2016, the Medicare Payment 
                                Advisory Commission shall submit to 
                                Congress a report that analyzes 
                                multiple options for alternative 
                                payment models in lieu of section 1848 
                                of the Social Security Act (42 U.S.C. 
                                1395w-4). In analyzing such models, the 
                                Medicare Payment Advisory Commission 
                                shall examine at least the following 
                                models:
                                            (aa) Accountable care 
                                        organization payment models.
                                            (bb) Primary care medical 
                                        home payment models.
                                            (cc) Bundled or episodic 
                                        payments for certain conditions 
                                        and services.
                                            (dd) Gainsharing 
                                        arrangements
                                    (II) Items to be included.--Such 
                                report shall include information on how 
                                each recommended new payment model will 
                                achieve maximum flexibility to reward 
                                high quality, efficient care.
                    (C) Tracking expenditure growth and access.--
                Beginning in 2015, the Chief Actuary of the Centers for 
                Medicare & Medicaid Services shall track expenditure 
                growth and beneficiary access to physicians' services 
                under section 1848 of the Social Security Act (42 
                U.S.C. 1395w-4) and shall post on the public Internet 
                website of the Centers for Medicare & Medicaid Services 
                annual reports on such topics.
            (4) Report on clinical decision support mechanisms.--Not 
        later than one year after the date of the enactment of this 
        Act, the Secretary of Health and Human Services shall submit to 
        Congress a report on the extent to which clinical decision 
        support mechanisms and other provider support tools could be 
        used to further program objectives under section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4)) and recommendation for 
        how such mechanisms and tools should be so used.
    (b) Rule of Construction Regarding Health Care Provider Standards 
of Care.--
            (1) In general.--The development, recognition, or 
        implementation of any guideline or other standard under any 
        Federal health care provision shall not be construed to 
        establish the standard of care or duty of care owed by a health 
        care provider to a patient in any medical malpractice or 
        medical product liability action or claim.
            (2) Definitions.--For purposes of this subsection:
                    (A) The term ``Federal health care provision'' 
                means any provision of the Patient Protection and 
                Affordable Care Act (Public Law 111-148), title I and 
                subtitle B of title III of the Health Care and 
                Education Reconciliation Act of 2010 (Public Law 111-
                152), and titles XVIII and XIX of the Social Security 
                Act.
                    (B) The term ``health care provider'' means any 
                individual or entity--
                            (i) licensed, registered, or certified 
                        under Federal or State laws or regulations to 
                        provide health care services; or
                            (ii) required to be so licensed, 
                        registered, or certified but that is exempted 
                        by other statute or regulation.
                    (C) The term ``medical malpractice or medical 
                liability action or claim'' means a medical malpractice 
                action or claim (as defined in section 431(7) of the 
                Health Care Quality Improvement Act of 1986 (42 U.S.C. 
                11151(7))) and includes a liability action or claim 
                relating to a health care provider's prescription or 
                provision of a drug, device, or biological product (as 
                such terms are defined in section 201 of the Federal 
                Food, Drug, and Cosmetic Act or section 351 of the 
                Public Health Service Act).
                    (D) The term ``State'' includes the District of 
                Columbia, Puerto Rico, and any other commonwealth, 
                possession, or territory of the United States.
            (3) No preemption.--No provision of the Patient Protection 
        and Affordable Care Act (Public Law 111-148), title I or 
        subtitle B of title III of the Health Care and Education 
        Reconciliation Act of 2010 (Public Law 111-152), or title XVIII 
        or XIX of the Social Security Act shall be construed to preempt 
        any State or common law governing medical professional or 
        medical product liability actions or claims.

SEC. 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``SGR Repeal and 
Medicare Beneficiary Access Act of 2013''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Repealing the sustainable growth rate (SGR) and improving 
                            medicare payment for physicians' services.
Sec. 3. Priorities and funding for quality measure development.
Sec. 4. Encouraging care management for individuals with chronic care 
                            needs.
Sec. 5. Ensuring accurate valuation of services under the physician fee 
                            schedule.
Sec. 6. Promoting evidence-based care.
Sec. 7. Empowering beneficiary choices through access to information on 
                            physicians' services.
Sec. 8. Expanding claims data availability to improve care.
Sec. 9. Reducing administrative burden and other provisions.

SEC. 2. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING 
              MEDICARE PAYMENT FOR PHYSICIANS' SERVICES.

    (a) Stabilizing Fee Updates.--
            (1) Repeal of sgr payment methodology.--Section 1848 of the 
        Social Security Act (42 U.S.C. 1395w-4) is amended--
                    (A) in subsection (d)--
                            (i) in paragraph (1)(A), by inserting ``or 
                        a subsequent paragraph'' after ``paragraph 
                        (4)''; and
                            (ii) in paragraph (4)--
                                    (I) in the heading, by inserting 
                                ``and ending with 2013'' after ``years 
                                beginning with 2001''; and
                                    (II) in subparagraph (A), by 
                                inserting ``and ending with 2013'' 
                                after ``a year beginning with 2001''; 
                                and
                    (B) in subsection (f)--
                            (i) in paragraph (1)(B), by inserting 
                        ``through 2013'' after ``of each succeeding 
                        year''; and
                            (ii) in paragraph (2), by inserting ``and 
                        ending with 2013'' after ``beginning with 
                        2000''.
            (2) Update of rates for 2014 and subsequent years.--
        Subsection (d) of section 1848 of the Social Security Act (42 
        U.S.C. 1395w-4) is amended by adding at the end the following 
        new paragraphs:
            ``(15) Update for 2014 through 2016.--The update to the 
        single conversion factor established in paragraph (1)(C) for 
        each of 2014 through 2016 shall be 0.5 percent.
            ``(16) Update for 2017 through 2023.--The update to the 
        single conversion factor established in paragraph (1)(C) for 
        each of 2017 through 2023 shall be zero percent.
            ``(17) Update for 2024 and subsequent years.--The update to 
        the single conversion factor established in paragraph (1)(C) 
        for 2024 and each subsequent year shall be--
                    ``(A) for items and services furnished by a 
                qualifying APM participant (as defined in section 
                1833(z)(2)) for such year, 2 percent; and
                    ``(B) for other items and services, 1 percent.''.
            (3) MedPAC reports.--
                    (A) Initial report.--Not later than July 1, 2016, 
                the Medicare Payment Advisory Commission shall submit 
                to Congress a report on the relationship between--
                            (i) physician and other health professional 
                        utilization and expenditures (and the rate of 
                        increase of such utilization and expenditures) 
                        of items and services for which payment is made 
                        under section 1848 of the Social Security Act 
                        (42 U.S.C. 1395w-4); and
                            (ii) total utilization and expenditures 
                        (and the rate of increase of such utilization 
                        and expenditures) under parts A, B, and D of 
                        title XVIII of such Act.
                Such report shall include a methodology to describe 
                such relationship and the impact of changes in such 
                physician and other health professional practice and 
                service ordering patterns on total utilization and 
                expenditures under parts A, B, and D of such title.
                    (B) Final report.--Not later than July 1, 2020, the 
                Medicare Payment Advisory Commission shall submit to 
                Congress a report on the relationship described in 
                subparagraph (A), including the results determined from 
                applying the methodology included in the report 
                submitted under such subparagraph.
    (b) Consolidation of Certain Current Law Performance Programs With 
New Value-based Performance Incentive Program.--
            (1) EHR meaningful use incentive program.--
                    (A) Sunsetting separate meaningful use payment 
                adjustments.--Section 1848(a)(7)(A) of the Social 
                Security Act (42 U.S.C. 1395w-4(a)(7)(A)) is amended--
                            (i) in clause (i), by striking ``or any 
                        subsequent payment year'' and inserting ``or 
                        2016'';
                            (ii) in clause (ii)--
                                    (I) in the matter preceding 
                                subclause (I), by striking ``Subject to 
                                clause (iii), for'' and inserting 
                                ``For'';
                                    (II) in subclause (I), by adding at 
                                the end ``and'';
                                    (III) in subclause (II), by 
                                striking ``; and'' and inserting a 
                                period; and
                                    (IV) by striking subclause (III); 
                                and
                            (iii) by striking clause (iii).
                    (B) Continuation of meaningful use determinations 
                for vbp program.--Section 1848(o)(2) of the Social 
                Security Act (42 U.S.C. 1395w-4(o)(2)) is amended--
                            (i) in subparagraph (A), in the matter 
                        preceding clause (i)--
                                    (I) by striking ``For purposes of 
                                paragraph (1), an'' and inserting 
                                ``An''; and
                                    (II) by inserting ``, or pursuant 
                                to subparagraph (D) for purposes of 
                                subsection (q), for a performance 
                                period under such subsection for a 
                                year'' after ``under such subsection 
                                for a year''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(D) Continued application for purposes of vbp 
                program.--With respect to 2017 and each subsequent 
                payment year, the Secretary shall, for purposes of 
                subsection (q) and in accordance with paragraph (1)(F) 
                of such subsection, determine whether an eligible 
                professional who is a VBP eligible professional (as 
                defined in subsection (q)(1)(C)) for such year is a 
                meaningful EHR user under this paragraph for the 
                performance period under subsection (q) for such 
                year.''.
            (2) Quality reporting.--
                    (A) Sunsetting separate quality reporting 
                incentives.--Section 1848(a)(8)(A) of the Social 
                Security Act (42 U.S.C. 1395w-4(a)(8)(A)) is amended--
                            (i) in clause (i), by striking ``or any 
                        subsequent year'' and inserting ``or 2016''; 
                        and
                            (ii) in clause (ii)(II), by striking ``and 
                        each subsequent year''.
                    (B) Continuation of quality measures and processes 
                for vbp program.--Section 1848 of the Social Security 
                Act (42 U.S.C. 1395w-4) is amended--
                            (i) in subsection (k), by adding at the end 
                        the following new paragraph:
            ``(9) Continued application for purposes of vbp program.--
        The Secretary shall, in accordance with subsection (q)(1)(F), 
        carry out the provisions of this subsection for purposes of 
        subsection (q).''; and
                            (ii) in subsection (m)--
                                    (I) by redesignating the paragraph 
                                (7) added by section 10327(a) of Public 
                                Law 111-148 as paragraph (8); and
                                    (II) by adding at the end the 
                                following new paragraph:
            ``(9) Continued application for purposes of vbp program.--
        The Secretary shall, in accordance with subsection (q)(1)(F), 
        carry out the processes under this subsection for purposes of 
        subsection (q).''.
            (3) Value-based payments.--
                    (A) Sunsetting separate value-based payments.--
                Clause (iii) of section 1848(p)(4)(B) of the Social 
                Security Act (42 U.S.C. 1395w-4(p)(4)(B)) is amended to 
                read as follows:
                            ``(iii) Application.--The Secretary shall 
                        apply the payment modifier established under 
                        this subsection for items and services 
                        furnished on or after January 1, 2015, but 
                        before January 1, 2017, with respect to 
                        specific physicians and groups of physicians 
                        the Secretary determines appropriate. Such 
                        payment modifier shall not be applied for items 
                        and services furnished on or after January 1, 
                        2017.''.
                    (B) Continuation of value-based payment modifier 
                measures for vbp program.--Section 1848(p) of the 
                Social Security Act (42 U.S.C. 1395w-4(p)) is amended--
                            (i) in paragraph (2), by adding at the end 
                        the following new subparagraph:
                    ``(C) Continued application for purposes of vbp 
                program.--The Secretary shall, in accordance with 
                subsection (q)(1)(F), carry out subparagraph (B) for 
                purposes of subsection (q).'' ; and
                            (ii) in paragraph (3), by adding at the end 
                        the following: ``With respect to 2017 and each 
                        subsequent year, the Secretary shall, in 
                        accordance with subsection (q)(1)(F), carry out 
                        this paragraph for purposes of subsection 
                        (q).''.
    (c) Value-based Performance Incentive Program.--
            (1) In general.--Section 1848 of the Social Security Act 
        (42 U.S.C. 1395w-4) is amended by adding at the end the 
        following new subsection:
    ``(q) Value-based Performance Incentive Program.--
            ``(1) Establishment.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this subsection, the Secretary shall 
                establish an eligible professional value-based 
                performance incentive program (in this subsection 
                referred to as the `VBP program') under which the 
                Secretary shall--
                            ``(i) develop a methodology for assessing 
                        the total performance of each VBP eligible 
                        professional according to performance standards 
                        under paragraph (3) for a performance period 
                        (as established under paragraph (4)) for a 
                        year;
                            ``(ii) using such methodology, provide for 
                        a composite performance score in accordance 
                        with paragraph (5) for each such professional 
                        for each performance period; and
                            ``(iii) use such composite performance 
                        score of the VBP eligible professional for a 
                        performance period for a year to make VBP 
                        program incentive payments under paragraph (7) 
                        to the professional for the year.
                    ``(B) Program implementation.--The VBP program 
                shall apply to payments for items and services 
                furnished on or after January 1, 2017.
                    ``(C) VBP eligible professional defined.--
                            ``(i) In general.--For purposes of this 
                        subsection, subject to clauses (ii) and (iv), 
                        the term `VBP eligible professional' means--
                                    ``(I) for the first and second 
                                years for which the VBP program applies 
                                to payments (and for the performance 
                                period for such first and second year), 
                                a physician (as defined in section 
                                1861(r)(1)), a physician assistant, 
                                nurse practitioner, and clinical nurse 
                                specialist (as such terms are defined 
                                in section 1861(aa)(5)), and a 
                                certified registered nurse anesthetist 
                                (as defined in section 1861(bb)(2)); 
                                and
                                    ``(II) for the third year for which 
                                the VBP program applies to payments 
                                (and for the performance period for 
                                such third year) and for each 
                                succeeding year (and for the 
                                performance period for each such year), 
                                the professionals described in 
                                subclause (I) and such other eligible 
                                professionals (as defined in subsection 
                                (k)(3)(B)) as specified by the 
                                Secretary.
                            ``(ii) Exclusions.--For purposes of clause 
                        (i), the term `VBP eligible professional' does 
                        not include, with respect to a year, an 
                        eligible professional (as defined in subsection 
                        (k)(3)(B))--
                                    ``(I) who is a qualifying APM 
                                participant (as defined in section 
                                1833(z)(2));
                                    ``(II) who, subject to clause 
                                (vii), is a partial qualifying APM 
                                participant (as defined in clause 
                                (iii)) for the most recent period for 
                                which data are available and who, for 
                                the performance period with respect to 
                                such year, does not report on 
                                applicable measures and activities 
                                described in paragraph (2)(B) that are 
                                required to be reported by such a 
                                professional under the VBP program; or
                                    ``(III) who, for the performance 
                                period with respect to such year, does 
                                not exceed the low-volume threshold 
                                measurement selected under clause (iv).
                            ``(iii) Partial qualifying apm 
                        participant.--For purposes of this 
                        subparagraph, the term `partial qualifying APM 
                        participant' means, with respect to a year, an 
                        eligible professional for whom the Secretary 
                        determines the minimum payment percentage (or 
                        percentages), as applicable, described in 
                        paragraph (2) of section 1833(z) for such year 
                        have not been satisfied, but who would be 
                        considered a qualifying APM participant (as 
                        defined in such paragraph) for such year if--
                                    ``(I) with respect to 2017 and 
                                2018, the reference in subparagraph (A) 
                                of such paragraph to 25 percent was 
                                instead a reference to 20 percent;
                                    ``(II) with respect to 2019 and 
                                2020--
                                            ``(aa) the reference in 
                                        subparagraph (B)(i) of such 
                                        paragraph to 50 percent was 
                                        instead a reference to 40 
                                        percent; and
                                            ``(bb) the references in 
                                        subparagraph (B)(ii) of such 
                                        paragraph to 50 percent and 25 
                                        percent of such paragraph were 
                                        instead references to 40 
                                        percent and 20 percent, 
                                        respectively; and
                                    ``(III) with respect to 2021 and 
                                subsequent years--
                                            ``(aa) the reference in 
                                        subparagraph (C)(i) of such 
                                        paragraph to 75 percent was 
                                        instead a reference to 50 
                                        percent; and
                                            ``(bb) the references in 
                                        subparagraph (C)(ii) of such 
                                        paragraph to 75 percent and 25 
                                        percent of such paragraph were 
                                        instead references to 50 
                                        percent and 20 percent, 
                                        respectively.
                            ``(iv) Selection of low-volume threshold 
                        measurement.--The Secretary shall select one of 
                        the following low-volume threshold measurements 
                        to apply for purposes of clause (ii)(III):
                                    ``(I) The minimum number (as 
                                determined by the Secretary) of 
                                individuals enrolled under this part 
                                who are treated by the VBP eligible 
                                professional for the performance period 
                                involved.
                                    ``(II) The minimum number (as 
                                determined by the Secretary) of items 
                                and services furnished to individuals 
                                enrolled under this part by such 
                                professional for such performance 
                                period.
                                    ``(III) The minimum amount (as 
                                determined by the Secretary) of allowed 
                                charges billed by such professional 
                                under this part for such performance 
                                period.
                            ``(v) Treatment of new medicare enrolled 
                        eligible professionals.--In the case of a 
                        professional who first becomes a Medicare 
                        enrolled eligible professional during the 
                        performance period for a year (and had not 
                        previously submitted claims under this title 
                        such as a person, an entity, or a part of a 
                        physician group or under a different billing 
                        number or tax identifier), such professional 
                        shall not be treated under this subsection as a 
                        VBP eligible professional until the subsequent 
                        year and performance period for such subsequent 
                        year.
                            ``(vi) Clarification.--In the case of items 
                        and services furnished during a year by an 
                        individual who is not a VBP eligible 
                        professional (including pursuant to clauses 
                        (ii) and (v)) with respect to a year, in no 
                        case shall a reduction under paragraph (6) or a 
                        VBP program incentive payment under paragraph 
                        (7) apply to such individual for such year.
                            ``(vii) Partial qualifying apm participant 
                        clarification.--In the case of an eligible 
                        professional who is a partial qualifying APM 
                        participant, with respect to a year, and who 
                        for the performance period for such year 
                        reports on applicable measures and activities 
                        described in paragraph (2)(B) that are required 
                        to be reported by such a professional under the 
                        VBP program, such eligible professional is 
                        considered to be a VBP eligible professional 
                        with respect to such year.
                    ``(D) Application to group practices.--
                            ``(i) In general.--Under the VBP program:
                                    ``(I) Quality performance 
                                category.--The Secretary shall 
                                establish and apply a process that 
                                includes features of the provisions of 
                                subsection (m)(3)(C) for VBP eligible 
                                professionals in a group practice with 
                                respect to assessing performance of 
                                such group with respect to the 
                                performance category described in 
                                clause (i) of paragraph (2)(A).
                                    ``(II) Other performance 
                                categories.--The Secretary may 
                                establish and apply a process that 
                                includes features of the provisions of 
                                subsection (m)(3)(C) for VBP eligible 
                                professionals in a group practice with 
                                respect to assessing the performance of 
                                such group with respect to the 
                                performance categories described in 
                                clauses (ii) through (iv) of such 
                                paragraph.
                            ``(ii) Ensuring comprehensiveness of group 
                        practice assessment.--The process established 
                        under clause (i) shall to the extent 
                        practicable reflect the full range of items and 
                        services furnished by the VBP eligible 
                        professionals in the group practice involved.
                            ``(iii) Clarification.--VBP eligible 
                        professionals electing to be a virtual group 
                        under paragraph (5)(J) shall not be considered 
                        VBP eligible professionals in a group practice 
                        for purposes of applying this subparagraph.
                    ``(E) Use of registries.--Under the VBP program, 
                the Secretary shall encourage the use of qualified 
                clinical data registries pursuant to subsection 
                (m)(3)(E) in carrying out this subsection.
                    ``(F) Application of certain provisions.--In 
                applying a provision of subsection (k), (m), (o), or 
                (p) for purposes of this subsection, the Secretary 
                shall--
                            ``(i) adjust the application of such 
                        provision to ensure the provision is consistent 
                        with the provisions of this subsection; and
                            ``(ii) not apply such provision to the 
                        extent that the provision is duplicative with a 
                        provision of this subsection.
            ``(2) Measures and activities under performance 
        categories.--
                    ``(A) Performance categories.--Under the VBP 
                program, the Secretary shall use the following 
                performance categories (each of which is referred to in 
                this subsection as a performance category) in 
                determining the composite performance score under 
                paragraph (5):
                            ``(i) Quality.
                            ``(ii) Resource use.
                            ``(iii) Clinical practice improvement 
                        activities.
                            ``(iv) Meaningful use of certified EHR 
                        technology.
                    ``(B) Measures and activities specified for each 
                category.--For purposes of paragraph (3)(A) and subject 
                to subparagraph (C), measures and activities specified 
                for a performance period (as established under 
                paragraph (4)) for a year are as follows:
                            ``(i) Quality.--For the performance 
                        category described in subparagraph (A)(i), the 
                        quality measures established for such period 
                        under subsections (k) and (m), including under 
                        subsection (m)(3)(E), and the measures of 
                        quality of care established for such period 
                        under subsection (p)(2).
                            ``(ii) Resource use.--For the performance 
                        category described in subparagraph (A)(ii), the 
                        measurement of resource use for such period 
                        under subsection (p)(3), using the methodology 
                        under subsection (r), as appropriate, and, as 
                        feasible and applicable, accounting for the 
                        cost of covered part D drugs.
                            ``(iii) Clinical practice improvement 
                        activities.--For the performance category 
                        described in subparagraph (A)(iii), clinical 
                        practice improvement activities under 
                        subcategories specified by the Secretary for 
                        such period, which shall include at least the 
                        following:
                                    ``(I) The subcategory of expanded 
                                practice access, which shall include 
                                activities such as same day 
                                appointments for urgent needs and after 
                                hours access to clinician advice.
                                    ``(II) The subcategory of 
                                population management, which shall 
                                include activities such as monitoring 
                                health conditions of individuals to 
                                provide timely health care 
                                interventions or participation in a 
                                qualified clinical data registry.
                                    ``(III) The subcategory of care 
                                coordination, which shall include 
                                activities such as timely communication 
                                of test results, timely exchange of 
                                clinical information to patients and 
                                other providers, and use of remote 
                                monitoring or telehealth.
                                    ``(IV) The subcategory of 
                                beneficiary engagement, which shall 
                                include activities such as the 
                                establishment of care plans for 
                                individuals with complex care needs, 
                                beneficiary self-management training, 
                                and using shared decision-making 
                                mechanisms.
                                    ``(V) The subcategory of patient 
                                safety and practice assessment, such as 
                                through use of clinical or surgical 
                                checklists and practice assessments 
                                related to maintaining certification.
                                    ``(VI) The subcategory of 
                                participation in an alternative payment 
                                model (as defined in section 
                                1833(z)(3)(C)).
                        In establishing activities under this clause, 
                        the Secretary shall give consideration to the 
                        circumstances of small practices (consisting of 
                        fewer than 20 professionals) and practices 
                        located in rural areas and in health 
                        professional shortage areas (as designated 
                        under section 332(a)(1)(A) of the Public Health 
                        Service Act).
                            ``(iv) Meaningful ehr use.--For the 
                        performance category described in subparagraph 
                        (A)(iv), the requirements established for such 
                        period under subsection (o)(2) for determining 
                        whether an eligible professional is a 
                        meaningful EHR user.
                    ``(C) Additional provisions.--
                            ``(i) Emphasizing outcome measures under 
                        quality performance category.--In applying 
                        subparagraph (B)(i), the Secretary shall, as 
                        feasible, emphasize the application of outcome 
                        measures.
                            ``(ii) Application of additional system 
                        measures.--The Secretary may use measures used 
                        for a payment system other than for physicians 
                        for purposes of the performance category 
                        described in subparagraph (A)(i).
                            ``(iii) Global and population-based 
                        measures.--The Secretary may use global 
                        measures, such as global outcome measures, and 
                        population-based measures for purposes of the 
                        performance category described in subparagraph 
                        (A)(i).
                            ``(iv) Request for information for clinical 
                        practice improvement activities.--In initially 
                        applying subparagraph (B)(iii), the Secretary 
                        shall use a request for information to solicit 
                        recommendations from stakeholders for 
                        identifying activities described in such 
                        subparagraph and specifying criteria for such 
                        activities.
                            ``(v) Contract authority for clinical 
                        practice improvement activities performance 
                        category.--In applying subparagraph (B)(iii), 
                        the Secretary may contract with entities to 
                        assist the Secretary in--
                                    ``(I) identifying activities 
                                described in subparagraph (B)(iii);
                                    ``(II) specifying criteria for such 
                                activities; and
                                    ``(III) determining whether a VBP 
                                eligible professional meets such 
                                criteria.
                            ``(vi) Application of measures and 
                        activities to non-patient-facing providers.--In 
                        carrying out this paragraph, with respect to 
                        measures and activities specified in 
                        subparagraph (B) for performance categories 
                        described in subparagraph (A), the Secretary--
                                    ``(I) shall give consideration to 
                                the circumstances of professional types 
                                (or subcategories of those types 
                                determined by practice characteristics) 
                                who typically provide services that do 
                                not involve face-to-face interaction 
                                with a patient; and
                                    ``(II) may, to the extent feasible 
                                and appropriate, take into account such 
                                circumstances and apply under this 
                                subsection with respect to VBP eligible 
                                professionals of such professional 
                                types or subcategories, in lieu of such 
                                a measure or activity, a comparable 
                                measure or activity that fulfills the 
                                goals of the applicable performance 
                                category.
                        In carrying out the previous sentence, the 
                        Secretary shall consult with professionals of 
                        such professional types or subcategories.
            ``(3) Performance standards.--
                    ``(A) Establishment.--Under the VBP program, the 
                Secretary shall establish performance standards with 
                respect to measures and activities specified under 
                paragraph (2)(B) for a performance period (as 
                established under paragraph (4)) for a year.
                    ``(B) Considerations in establishing standards.--In 
                establishing such performance standards with respect to 
                measures and activities specified under paragraph 
                (2)(B), the Secretary shall take into account the 
                following:
                            ``(i) Historical performance standards.
                            ``(ii) Improvement rates.
                            ``(iii) The opportunity for continued 
                        improvement.
            ``(4) Performance period.--The Secretary shall establish a 
        performance period (or periods) for a year (beginning with the 
        year described in paragraph (1)(B)). Such performance period 
        (or periods) shall begin and end prior to the beginning of such 
        year and be as close as possible to such year. In this 
        subsection, such performance period (or periods) for a year 
        shall be referred to as the performance period for the year.
            ``(5) Composite performance score.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this paragraph and consistent with 
                section 2(g)(2) of the SGR Repeal and Medicare 
                Beneficiary Access Act of 2013, the Secretary shall 
                develop a methodology for assessing the total 
                performance of each VBP eligible professional according 
                to performance standards under paragraph (3) with 
                respect to applicable measures and activities specified 
                in paragraph (2)(B) with respect to each performance 
                category applicable to such professional for a 
                performance period (as established under paragraph (4)) 
                for a year. Using such methodology, the Secretary shall 
                provide for a composite assessment (in this subsection 
                referred to as the `composite performance score') for 
                each such professional for each performance period.
                    ``(B) Weighting performance categories, measures, 
                and activities.--Under the methodology under 
                subparagraph (A), the Secretary--
                            ``(i) may assign different scoring weights 
                        (including a weight of 0) for--
                                    ``(I) each performance category 
                                based on the extent to which the 
                                category is applicable to the type of 
                                eligible professional involved; and
                                    ``(II) each measure and activity 
                                specified under paragraph (2)(B) with 
                                respect to each such category based on 
                                the extent to which the measure or 
                                activity is applicable to the type of 
                                eligible professional involved; and
                            ``(ii) with respect to the performance 
                        category described in paragraph (2)(A)(i)--
                                    ``(I) shall assign a higher scoring 
                                weight to outcomes measures than to 
                                other measures and increase the scoring 
                                weight for outcome measures over time; 
                                and
                                    ``(II) may assign a higher scoring 
                                weight to patient experience measures.
                    ``(C) Incentive to report; encouraging use of 
                certified ehr technology for reporting quality 
                measures.--
                            ``(i) Incentive to report.--Under the 
                        methodology established under subparagraph (A), 
                        the Secretary shall provide that in the case of 
                        a VBP eligible professional who fails to report 
                        on an applicable measure or activity that is 
                        required to be reported by the professional, 
                        the professional shall be treated as achieving 
                        the lowest potential score applicable to such 
                        measure or activity.
                            ``(ii) Encouraging use of certified ehr 
                        technology for reporting quality measures.--
                        Under the methodology established under 
                        subparagraph (A), the Secretary shall--
                                    ``(I) encourage VBP eligible 
                                professionals to report on applicable 
                                measures with respect to the 
                                performance category described in 
                                paragraph (2)(A)(i) through the use of 
                                certified EHR technology; and
                                    ``(II) with respect to a 
                                performance period, with respect to a 
                                year, for which a VBP eligible 
                                professional reports such measures 
                                through the use of such EHR technology, 
                                treat such professional as satisfying 
                                the clinical quality measures reporting 
                                requirement described in subsection 
                                (o)(2)(A)(iii) for such year.
                    ``(D) Clinical practice improvement activities 
                performance score.--
                            ``(i) Rule for accreditation.--A VBP 
                        eligible professional who is in a practice that 
                        is certified as a patient-centered medical home 
                        or comparable specialty practice pursuant to 
                        subsection (b)(8)(B)(i) with respect to a 
                        performance period shall be given the highest 
                        potential score for the performance category 
                        described in paragraph (2)(A)(iii) for such 
                        period.
                            ``(ii) APM participation.--Participation by 
                        a VBP eligible professional in an alternative 
                        payment model (as defined in section 
                        1833(z)(3)(C)) with respect to a performance 
                        period shall earn such eligible professional 
                        one-half of the highest potential score for the 
                        performance category described in paragraph 
                        (2)(A)(iii) for such performance period. 
                        Nothing in the previous sentence shall prevent 
                        such professional from earning more than one-
                        half of such highest potential score for such 
                        performance period by performing additional 
                        activities with respect to such performance 
                        category.
                            ``(iii) Subcategories.--A VBP eligible 
                        professional shall not be required to perform 
                        activities in each subcategory under paragraph 
                        (2)(B)(iii) to achieve the highest potential 
                        score for the performance category described in 
                        paragraph (2)(A)(iii).
                    ``(E) Distribution.--The Secretary shall ensure 
                that the application of the methodology developed under 
                subparagraph (A) results in a continuous distribution 
                of performance scores, which shall result in 
                differential payments under paragraph (7).
                    ``(F) Achievement and improvement.--
                            ``(i) Taking into account improvement.--
                        Beginning with the second year to which the VBP 
                        program applies, in addition to the achievement 
                        score of a VBP eligible professional, the 
                        methodology developed under subparagraph (A)--
                                    ``(I) in the case of the 
                                performance score for the performance 
                                category described in clauses (i) and 
                                (ii) of paragraph (2)(A), shall take 
                                into account the improvement of the 
                                professional; and
                                    ``(II) in the case of performance 
                                scores for other performance 
                                categories, may take into account the 
                                improvement of the professional.
                            ``(ii) Assigning higher weight for 
                        achievement.--Beginning with the fourth year to 
                        which the VBP program applies, under the 
                        methodology developed under subparagraph (A), 
                        the Secretary may assign a higher scoring 
                        weight under subparagraph (B) with respect to 
                        the achievement score of a VBP eligible 
                        professional with respect to a measure or 
                        activity specified under paragraph (2)(B) (or 
                        with respect to such a measure or activity and 
                        with respect to categories described in 
                        paragraph (2)(A)) than to any improvement score 
                        applied under clause (i) with respect to such 
                        measure or activity (or such measure or 
                        activity and categories).
                    ``(G) Weights for the performance categories.--
                            ``(i) In general.--Under the methodology 
                        developed under subparagraph (A), subject to 
                        clauses (ii) and (iii), the composite 
                        performance score shall be determined as 
                        follows:
                                    ``(I) Quality.--
                                            ``(aa) In general.--Subject 
                                        to item (bb), 30 percent of 
                                        such score shall be based on 
                                        performance with respect to the 
                                        category described in clause 
                                        (i) of paragraph (2)(A).
                                            ``(bb) First 2 years and 
                                        test year.--For the first and 
                                        second years for which the VBP 
                                        program applies to payments, 60 
                                        percent of such score shall be 
                                        based on performance with 
                                        respect to the category 
                                        described in clause (i) of 
                                        paragraph (2)(A). With respect 
                                        to the subsequent year, the 
                                        percent described in item (aa) 
                                        of such score shall be based on 
                                        performance with respect to 
                                        such category only for purposes 
                                        of feedback and 60 percent of 
                                        such score shall be based on 
                                        performance with respect to 
                                        such category for any other 
                                        purpose under this subsection.
                                    ``(II) Resource use.--
                                            ``(aa) In general.--Subject 
                                        to item (bb), 30 percent of 
                                        such score shall be based on 
                                        performance with respect to the 
                                        category described in clause 
                                        (ii) of paragraph (2)(A).
                                            ``(bb) First 2 years and 
                                        test year.--For the first and 
                                        second years for which the VBP 
                                        program applies to payments, 
                                        zero percent of such score 
                                        shall be based on performance 
                                        with respect to the category 
                                        described in clause (ii) of 
                                        paragraph (2)(A). With respect 
                                        to the subsequent year, the 
                                        percent described in item (aa) 
                                        of such score shall be based on 
                                        performance with respect to 
                                        such category only for purposes 
                                        of feedback and zero percent of 
                                        such score shall be based on 
                                        performance with respect to 
                                        such category for any other 
                                        purpose under this subsection.
                                    ``(III) Clinical practice 
                                improvement activities.--Fifteen 
                                percent of such score shall be based on 
                                performance with respect to the 
                                category described in clause (iii) of 
                                paragraph (2)(A).
                                    ``(IV) Meaningful use of certified 
                                ehr technology.--Twenty-five percent of 
                                such score shall be based on 
                                performance with respect to the 
                                category described in clause (iv) of 
                                paragraph (2)(A).
                            ``(ii) Authority to adjust percentages in 
                        case of high ehr meaningful use adoption.--In 
                        any year in which the Secretary estimates that 
                        the proportion of eligible professionals (as 
                        defined in subsection (o)(5)) who are 
                        meaningful EHR users (as determined under 
                        subsection (o)(2)) is 75 percent or greater, 
                        the Secretary may reduce the percent applicable 
                        under clause (i)(IV), but not below 15 percent. 
                        If the Secretary makes such reduction for a 
                        year, the percentages applicable under one or 
                        more of subclauses (I), (II), and (III) of 
                        clause (i) for such year (or, in the case of a 
                        year described in clause (i)(II)(bb), 
                        applicable under one or more of subclauses (I) 
                        and (III)) shall be increased in a manner such 
                        that the total percentage points of the 
                        increase under this clause for such year equals 
                        the total number of percentage points reduced 
                        under the preceding sentence for such year.
                            ``(iii) Authority to adjust percentages for 
                        quality and resource use.--Other than for a 
                        year described in clause (i)(II)(bb), the 
                        percentages described in subclauses (I) and 
                        (II) of clause (i), including after application 
                        of clause (ii), shall be equal.
                    ``(H) Resource use.--Analysis of the performance 
                category described in paragraph (2)(A)(ii) shall 
                include results from the methodology described in 
                subsection (r)(5), as appropriate.
                    ``(I) Inclusion of quality measure data from 
                multiple payers.--In applying subsections (k), (m), and 
                (p) with respect to measures described in paragraph 
                (2)(B)(i), analysis of the performance category 
                described in paragraph (2)(A)(i) may include data 
                submitted by VBP eligible professionals with respect to 
                multiple payers.
                    ``(J) Use of voluntary virtual groups for certain 
                assessment purposes.--
                            ``(i) In general.--In the case of VBP 
                        eligible professionals electing to be a virtual 
                        group under clause (ii) with respect to a 
                        performance period for a year, for purposes of 
                        applying the methodology under subparagraph 
                        (A)--
                                    ``(I) the assessment of performance 
                                provided under such methodology with 
                                respect to the performance categories 
                                described in clauses (i) and (ii) of 
                                paragraph (2)(A) that is to be applied 
                                to each such professional in such group 
                                for such performance period shall be 
                                with respect to the combined 
                                performance of all such professionals 
                                in such group for such period; and
                                    ``(II) the composite score provided 
                                under this paragraph for such 
                                performance period with respect to each 
                                such performance category for each such 
                                VBP eligible professional in such 
                                virtual group shall be based on the 
                                assessment of the combined performance 
                                under subclause (I) for the performance 
                                category and performance period.
                            ``(ii) Election of practices to be a 
                        virtual group.--The Secretary shall, in 
                        accordance with clause (iii), establish and 
                        have in place a process to allow an individual 
                        VBP eligible professional or a group practice 
                        consisting of not more than 10 VBP eligible 
                        professionals to elect, with respect to a 
                        performance period for a year, for such 
                        individual VBP eligible professional or all 
                        such VBP eligible professionals in such group 
                        practice, respectively, to be a virtual group 
                        under this subparagraph with at least one other 
                        such individual VBP eligible professional or 
                        group practice making such an election.
                            ``(iii) Requirements.--The process under 
                        clause (ii) shall provide that--
                                    ``(I) an election under such 
                                clause, with respect to a performance 
                                period, shall be made before the 
                                beginning of such performance period 
                                and may not be changed during such 
                                performance period; and
                                    ``(II) a practice described in such 
                                clause, and each VBP eligible 
                                professional in such practice, may 
                                elect to be in no more than one virtual 
                                group for a performance period.
            ``(6) Funding for vbp program incentive payments.--
                    ``(A) Total amount for incentive payments.--The 
                total amount for VBP program incentive payments under 
                paragraph (7) for all VBP eligible professionals for a 
                year shall be equal to the total amount of the 
                performance funding pool for all VBP eligible 
                professionals under subparagraph (B) for such year, as 
                estimated by the Secretary.
                    ``(B) Performance funding pool.--
                            ``(i) In general.--In the case of items and 
                        services furnished by a VBP eligible 
                        professional during a year (beginning with 
                        2017), the otherwise applicable fee schedule 
                        amount (as defined in clause (iii)) with 
                        respect to such items and services and eligible 
                        professional for such year shall be reduced by 
                        the applicable percent under clause (ii). The 
                        total amount of such reductions for a year 
                        shall be referred to in this subsection as the 
                        `performance funding pool' for such year.
                            ``(ii) Applicable percent defined.--For 
                        purposes of clause (i), the term `applicable 
                        percent' means--
                                    ``(I) for 2017, 4 percent;
                                    ``(II) for 2018, 6 percent;
                                    ``(III) for 2019, 8 percent;
                                    ``(IV) for 2020, 10 percent; and
                                    ``(V) for 2021 and subsequent 
                                years, a percent specified by the 
                                Secretary (but in no case less than 10 
                                percent or more than 12 percent).
                            ``(iii) Otherwise applicable fee schedule 
                        amount.--For purposes of this subparagraph and 
                        paragraph (7), the term `otherwise applicable 
                        fee schedule amount' means, with respect to 
                        items and services furnished by a VBP eligible 
                        professional during a year, the fee schedule 
                        amount for such items and services and year 
                        that would otherwise apply (without application 
                        of this subparagraph or paragraph (7)) with 
                        respect to such eligible professional under 
                        subsection (b), after application of subsection 
                        (a)(3), or under another fee schedule under 
                        this part.
            ``(7) VBP program incentive payments.--
                    ``(A) VBP program incentive payment adjustment 
                factor.--Consistent with section 2(g)(2) of the SGR 
                Repeal and Medicare Beneficiary Access Act of 2013, the 
                Secretary shall specify a VBP program incentive payment 
                adjustment factor for each VBP eligible professional 
                for a year. Such VBP program incentive payment 
                adjustment factor for a VBP eligible professional for a 
                year shall be determined--
                            ``(i) by the composite performance score of 
                        the eligible professional for such year;
                            ``(ii) in a manner such that the adjustment 
                        factors specified under this subparagraph for a 
                        year results in differential payments under 
                        this paragraph reflecting the full range of the 
                        distribution of composite performance scores of 
                        VBP eligible professionals determined under 
                        paragraph (5)(E) for such year, with such 
                        professionals having higher composite 
                        performance scores receiving higher payment; 
                        and
                            ``(iii) in a manner such that the 
                        adjustment factors specified under this 
                        subparagraph for a year--
                                    ``(I) does not result in a payment 
                                reduction for such year by an amount 
                                that exceeds the applicable percent 
                                described in paragraph (6)(B)(ii) for 
                                such year; and
                                    ``(II) does not result in a payment 
                                increase for such year by an amount 
                                that exceeds the applicable percent 
                                described in paragraph (6)(B)(ii) for 
                                such year.
                    ``(B) Calculation of vbp program incentive payment 
                amounts.--The VBP program incentive payment amount with 
                respect to items and services furnished by a VBP 
                eligible professional during a year shall be equal to 
                the difference between--
                            ``(i) the product of--
                                    ``(I) the VBP program incentive 
                                payment adjustment factor determined 
                                under subparagraph (A) for such VBP 
                                eligible professional for such year; 
                                and
                                    ``(II) the otherwise applicable fee 
                                schedule amount (as defined in 
                                paragraph (6)(B)(iii)) with respect to 
                                such items and services and eligible 
                                professional for such year; and
                            ``(ii) the otherwise applicable fee 
                        schedule amount, as reduced under paragraph 
                        (6)(B), with respect to such items and 
                        services, eligible professional, and year.
                The application of the preceding sentence may result in 
                the VBP program incentive payment amount being 0.0 with 
                respect to an item or service furnished by a VBP 
                eligible professional.
                    ``(C) Application of vbp program incentive payment 
                amount.--In the case of items and services furnished by 
                a VBP eligible professional during a year (beginning 
                with 2017), the otherwise applicable fee schedule 
                amount, as reduced under paragraph (6)(B), with respect 
                to such items and services and eligible professional 
                for such year shall be increased, if applicable, by the 
                VBP program incentive payment amount determined under 
                subparagraph (B) with respect to such items and 
                services, professional, and year.
                    ``(D) Budget neutrality.--In specifying the VBP 
                program incentive payment adjustment factor for each 
                VBP eligible professional for a year under subparagraph 
                (A), the Secretary shall ensure that the total amount 
                of VBP program incentive payment amounts under this 
                paragraph for all VBP eligible professionals in a year 
                shall be equal to the performance funding pool for such 
                year under paragraph (6), as estimated by the 
                Secretary.
            ``(8) Announcement of result of adjustments.--Under the VBP 
        program, the Secretary shall, not later than 60 days prior to 
        the year involved, make available to each VBP eligible 
        professional the VBP program incentive payment adjustment 
        factor under paragraph (7) and the payment reduction under 
        paragraph (6) applicable to the eligible professional for items 
        and services furnished by the professional in such year. The 
        Secretary may include such information in the confidential 
        feedback under paragraph (13).
            ``(9) No effect in subsequent years.--The VBP program 
        incentive payment under paragraph (7) and the payment reduction 
        under paragraph (6) shall each apply only with respect to the 
        year involved, and the Secretary shall not take into account 
        such VBP program incentive payment or payment reduction in 
        making payments to a VBP eligible professional under this part 
        in a subsequent year.
            ``(10) Public reporting.--
                    ``(A) In general.--The Secretary shall, in an 
                easily understandable format, make available on the 
                Physician Compare Internet website under subsection (t) 
                the following:
                            ``(i) Information regarding the performance 
                        of VBP eligible professionals under the VBP 
                        program, which--
                                    ``(I) shall include the composite 
                                score for each such VBP eligible 
                                professional and the performance of 
                                each such VBP eligible professional 
                                with respect to each performance 
                                category; and
                                    ``(II) may include the performance 
                                of each such VBP eligible professional 
                                with respect to each measure or 
                                activity specified in paragraph (2)(B).
                            ``(ii) The names of eligible professionals 
                        in eligible alternative payment models (as 
                        defined in section 1833(z)(3)(D)) and, to the 
                        extent feasible, the names of such eligible 
                        alternative payment models and performance of 
                        such models.
                    ``(B) Disclosure.--The information made available 
                under this paragraph shall indicate, where appropriate, 
                that publicized information may not be representative 
                of the eligible professional's entire patient 
                population, the variety of services furnished by the 
                eligible professional, or the health conditions of 
                individuals treated.
                    ``(C) Opportunity to review and submit 
                corrections.--The Secretary shall provide for an 
                opportunity for a professional described in 
                subparagraph (A) to review, and submit corrections for, 
                the information to be made public with respect to the 
                professional under such subparagraph prior to such 
                information being made public.
                    ``(D) Aggregate information.--The Secretary shall 
                periodically post on the Physician Compare Internet 
                website aggregate information on the VBP program, 
                including the range of composite scores for all VBP 
                eligible professionals and the range of the performance 
                of all VBP eligible professionals with respect to each 
                performance category.
            ``(11) Consultation.--The Secretary shall consult with 
        stakeholders in carrying out the VBP program, including for the 
        identification of measures and activities under paragraph 
        (2)(B) and the methodologies developed under paragraphs (5)(A) 
        and (7). Such consultation shall include the use of a request 
        for information or other mechanisms determined appropriate.
            ``(12) Technical assistance to small practices and 
        practices in health professional shortage areas.--
                    ``(A) In general.--The Secretary shall enter into 
                contracts or agreements with appropriate entities (such 
                as quality improvement organizations, regional 
                extension centers (as described in section 3012(c) of 
                the Public Health Service Act), or regional health 
                collaboratives) to offer guidance and assistance to VBP 
                eligible professionals in practices of fewer than 20 
                professionals (with priority given to such practices 
                located in rural areas, health professional shortage 
                areas (as designated under in section 332(a)(1)(A) of 
                the Public Health Service Act), or practices with low 
                composite scores) with respect to--
                            ``(i) the performance categories described 
                        in clauses (i) through (iv) of paragraph 
                        (2)(A); or
                            ``(ii) how to transition to the 
                        implementation of and participation in an 
                        alternative payment model as described in 
                        section 1833(z)(3)(C).
                    ``(B) Funding for implementation.--For purposes of 
                implementing subparagraph (A), the Secretary shall 
                provide for the transfer from the Federal Supplementary 
                Medical Insurance Trust Fund established under section 
                1841 to the Centers for Medicare & Medicaid Services 
                Program Management Account of $50,000,000 for each of 
                fiscal years 2014 through 2018. Amounts transferred 
                under this subparagraph for a fiscal year shall be 
                available until expended.
            ``(13) Feedback and information to improve performance.--
                    ``(A) Performance feedback.--
                            ``(i) In general.--Beginning July 1, 2015, 
                        the Secretary--
                                    ``(I) shall make available timely 
                                (such as quarterly) confidential 
                                feedback to each VBP eligible 
                                professional on the performance of such 
                                professional with respect to the 
                                performance categories under clauses 
                                (i) and (ii) of paragraph (2)(A); and
                                    ``(II) may make available 
                                confidential feedback to each such 
                                professional on the performance of such 
                                professional with respect to the 
                                performance categories under clauses 
                                (iii) and (iv) of such paragraph.
                            ``(ii) Mechanisms.--The Secretary may use 
                        one or more mechanisms to make feedback 
                        available under clause (i), which may include 
                        use of a web-based portal or other mechanisms 
                        determined appropriate by the Secretary. The 
                        Secretary shall encourage provision of feedback 
                        through qualified clinical data registries as 
                        described in subsection (m)(3)(E)).
                            ``(iii) Use of data.--For purposes of 
                        clause (i), the Secretary may use data, with 
                        respect to a VBP eligible professional, from 
                        periods prior to the current performance period 
                        and may use rolling periods in order to make 
                        illustrative calculations about the performance 
                        of such professional.
                            ``(iv) Disclosure exemption.--Feedback made 
                        available under this subparagraph shall be 
                        exempt from disclosure under section 552 of 
                        title 5, United States Code.
                            ``(v) Receipt of information.--The 
                        Secretary may use the mechanisms established 
                        under clause (ii) to receive information from 
                        professionals, such as information with respect 
                        to this subsection.
                    ``(B) Additional information.--
                            ``(i) In general.--Beginning July 1, 2016, 
                        the Secretary shall make available to each VBP 
                        eligible professional information, with respect 
                        to individuals who are patients of such VBP 
                        eligible professional, about items and services 
                        for which payment is made under this title that 
                        are furnished to such individuals by other 
                        suppliers and providers of services, which may 
                        include information described in clause (ii). 
                        Such information shall be made available under 
                        the previous sentence to such VBP eligible 
                        professionals by mechanisms determined 
                        appropriate by the Secretary, which may include 
                        use of a web-based portal. Such information 
                        shall be made available in accordance with the 
                        same or similar terms as data are made 
                        available to accountable care organizations 
                        under section 1899, including a beneficiary 
                        opt-out.
                            ``(ii) Type of information.--For purposes 
                        of clause (i), the information described in 
                        this clause, is the following:
                                    ``(I) With respect to selected 
                                items and services (as determined 
                                appropriate by the Secretary) for which 
                                payment is made under this title and 
                                that are furnished to individuals, who 
                                are patients of a VBP eligible 
                                professional, by another supplier or 
                                provider of services during the most 
                                recent period for which data are 
                                available (such as the most recent 
                                three-month period), the name of such 
                                providers furnishing such items and 
                                services to such patients during such 
                                period, the types of such items and 
                                services so furnished, and the dates 
                                such items and services were so 
                                furnished.
                                    ``(II) Historical averages (and 
                                other measures of the distribution if 
                                appropriate) of the total, and 
                                components of, allowed charges (and 
                                other figures as determined appropriate 
                                by the Secretary) for care episodes for 
                                such period.
            ``(14) Review.--
                    ``(A) Targeted review.--The Secretary shall 
                establish a process under which a VBP eligible 
                professional may seek an informal review of the 
                calculation of the VBP program incentive payment 
                adjustment factor applicable to such eligible 
                professional under this subsection for a year. The 
                results of a review conducted pursuant to the previous 
                sentence shall not be taken into account for purposes 
                of paragraph (7) with respect to a year (other than 
                with respect to the calculation of such eligible 
                professional's VBP program incentive payment adjustment 
                factor for such year) after the factors determined in 
                subparagraph (A) of such paragraph have been determined 
                for such year.
                    ``(B) Limitation.--Except as provided for in 
                subparagraph (A), there shall be no administrative or 
                judicial review under section 1869, section 1878, or 
                otherwise of the following:
                            ``(i) The methodology used to determine the 
                        amount of the VBP program incentive payment 
                        adjustment factor under paragraph (7) and the 
                        determination of such amount.
                            ``(ii) The determination of the amount of 
                        funding available for such VBP program 
                        incentive payments under paragraph (6)(A) and 
                        the payment reduction under paragraph 
                        (6)(B)(i).
                            ``(iii) The establishment of the 
                        performance standards under paragraph (3) and 
                        the performance period under paragraph (4).
                            ``(iv) The identification of measures and 
                        activities specified under paragraph (2)(B) and 
                        information made public or posted on the 
                        Physician Compare Internet website of the 
                        Centers for Medicare & Medicaid Services under 
                        paragraph (10).
                            ``(v) The methodology developed under 
                        paragraph (5) that is used to calculate 
                        performance scores and the calculation of such 
                        scores, including the weighting of measures and 
                        activities under such methodology.''.
            (2) GAO reports.--
                    (A) Evaluation of eligible professional vbp 
                program.--Not later than October 1, 2018, and October 
                1, 2021, the Comptroller General of the United States 
                shall submit to Congress a report evaluating the 
                eligible professional value-based performance incentive 
                program under subsection (q) of section 1848 of the 
                Social Security Act (42 U.S.C. 1395w-4), as added by 
                paragraph (1). Such report shall--
                            (i) examine the distribution of the 
                        performance and incentive payments for VBP 
                        eligible professionals (as defined in 
                        subsection (q)(1)(C) of such section) under 
                        such program, and patterns relating to such 
                        performance and incentive payments, including 
                        based on type of provider, practice size, 
                        geographic location, and patient mix; and
                            (ii) provide recommendations for improving 
                        such program.
                    (B) Study to examine alignment of quality measures 
                used in public and private programs.--Not later than 18 
                months after the date of the enactment of this Act, the 
                Comptroller General of the United States shall submit 
                to Congress a report that--
                            (i) compares the similarities and 
                        differences in the use of quality measures 
                        under the original medicare fee-for-service 
                        program under parts A and B of title XVIII of 
                        the Social Security Act, the Medicare Advantage 
                        program under part C of such title, and private 
                        payer arrangements; and
                            (ii) makes recommendations on how to reduce 
                        the administrative burden involved in applying 
                        such quality measures.
            (3) Funding for implementation.--For purposes of 
        implementing the provisions of and the amendments made by this 
        section, the Secretary of Health and Human Services shall 
        provide for the transfer of $50,000,000 from the Supplementary 
        Medical Insurance Trust Fund established under section 1841 of 
        the Social Security Act (42 U.S.C. 1395t) to the Centers for 
        Medicare & Medicaid Program Management Account for each of the 
        fiscal years 2014 through 2017. Amounts transferred under this 
        paragraph shall be available until expended.
    (d) Improving Quality Reporting for Composite Scores.--
            (1) Changes for group reporting option.--
                    (A) In general.--Section 1848(m)(3)(C)(ii)) of the 
                Social Security Act (42 U.S.C. 1395w-4(m)(3)(C)(ii)) is 
                amended by inserting ``and, for 2014 and subsequent 
                years, may provide'' after ``shall provide''.
                    (B) Clarification of qualified clinical data 
                registry reporting to group practices.--Section 
                1848(m)(3)(D) of the Social Security Act (42 U.S.C. 
                1395w-4(m)(3)(D)) is amended by inserting ``and, for 
                2015 and subsequent years, subparagraph (A) or (C)'' 
                after ``subparagraph (A)''.
            (2) Changes for multiple reporting periods and alternative 
        criteria for satisfactory reporting.--Section 1848(m)(5)(F)) of 
        the Social Security Act (42 U.S.C. 1395w-4(m)(5)(F)) is 
        amended--
                    (A) by striking ``and subsequent years'' and 
                inserting ``through reporting periods occurring in 
                2013''; and
                    (B) by inserting ``and, for reporting periods 
                occurring in 2014 and subsequent years, the Secretary 
                may establish'' following ``shall establish''.
            (3) Physician feedback program reports succeeded by reports 
        under vbp program.--Section 1848(n) of the Social Security Act 
        (42 U.S.C. 1395w-4(n)) is amended by adding at the end the 
        following new paragraph:
            ``(11) Reports ending with 2016.--Reports under the Program 
        shall not be provided after December 31, 2016. See subsection 
        (q)(13) for reports beginning with 2017.''.
            (4) Coordination with satisfying meaningful ehr use 
        clinical quality measure reporting requirement.--Section 
        1848(o)(2)(A)(iii) of the Social Security Act (42 U.S.C. 1395w-
        4(o)(2)(A)(iii)) is amended by inserting ``and subsection 
        (q)(5)(C)(ii)(II)'' after ``Subject to subparagraph (B)(ii)''.
    (e) Promoting Alternative Payment Models.--
            (1) Incentive payments for participation in eligible 
        alternative payment models.--Section 1833 of the Social 
        Security Act (42 U.S.C. 1395l) is amended by adding at the end 
        the following new subsection:
    ``(z) Incentive Payments for Participation in Eligible Alternative 
Payment Models.--
            ``(1) Payment incentive.--
                    ``(A) In general.--In the case of covered 
                professional services furnished by an eligible 
                professional during a year that is in the period 
                beginning with 2017 and ending with 2022 and for which 
                the professional is a qualifying APM participant, in 
                addition to the amount of payment that would otherwise 
                be made for such covered professional services under 
                this part for such year, there also shall be paid to 
                such professional an amount equal to 5 percent of the 
                payment amount for the covered professional services 
                under this part for the preceding year. For purposes of 
                the previous sentence, the payment amount for the 
                preceding year may be an estimation for the full 
                preceding year based on a period of such preceding year 
                that is less than the full year. The Secretary shall 
                establish policies to implement this subparagraph in 
                cases where payment for covered professional services 
                furnished by a qualifying APM participant in an 
                alternative payment model is made to an entity 
                participating in the alternative payment model rather 
                than directly to the qualifying APM participant.
                    ``(B) Form of payment.--Payments under this 
                subsection shall be made in a lump sum, on an annual 
                basis, as soon as practicable.
                    ``(C) Treatment of payment incentive.--Payments 
                under this subsection shall not be taken into account 
                for purposes of determining actual expenditures under 
                an alternative payment model and for purposes of 
                determining or rebasing any benchmarks used under the 
                alternative payment model.
                    ``(D) Coordination.--The amount of the additional 
                payment for an item or service under this subsection or 
                subsection (m) shall be determined without regard to 
                any additional payment for the item or service under 
                subsection (m) and this subsection, respectively. The 
                amount of the additional payment for an item or service 
                under this subsection or subsection (x) shall be 
                determined without regard to any additional payment for 
                the item or service under subsection (x) and this 
                subsection, respectively. The amount of the additional 
                payment for an item or service under this subsection or 
                subsection (y) shall be determined without regard to 
                any additional payment for the item or service under 
                subsection (y) and this subsection, respectively.
            ``(2) Qualifying apm participant.--For purposes of this 
        subsection, the term `qualifying APM participant' means the 
        following:
                    ``(A) 2017 and 2018.--With respect to 2017 and 
                2018, an eligible professional for whom the Secretary 
                determines that at least 25 percent of payments under 
                this part for covered professional services furnished 
                by such professional during the most recent period for 
                which data are available (which may be less than a 
                year) were attributable to such services furnished 
                under this part through an entity that participates in 
                an eligible alternative payment model with respect to 
                such services.
                    ``(B) 2019 and 2020.--With respect to 2019 and 
                2020, an eligible professional described in either of 
                the following clauses:
                            ``(i) Medicare revenue threshold option.--
                        An eligible professional for whom the Secretary 
                        determines that at least 50 percent of payments 
                        under this part for covered professional 
                        services furnished by such professional during 
                        the most recent period for which data are 
                        available (which may be less than a year) were 
                        attributable to such services furnished under 
                        this part through an entity that participates 
                        in an eligible alternative payment model with 
                        respect to such services.
                            ``(ii) Combination all-payer and medicare 
                        revenue threshold option.--An eligible 
                        professional--
                                    ``(I) for whom the Secretary 
                                determines, with respect to items and 
                                services furnished by such professional 
                                during the most recent period for which 
                                data are available (which may be less 
                                than a year), that at least 50 percent 
                                of the sum of--
                                            ``(aa) payments described 
                                        in clause (i); and
                                            ``(bb) all other payments, 
                                        regardless of payer (other than 
                                        payments made by the Secretary 
                                        of Defense or the Secretary of 
                                        Veterans Affairs under chapter 
                                        55 of title 10, United States 
                                        Code, or title 38, United 
                                        States Code, or any other 
                                        provision of law),
                                 meet the requirement described in 
                                clause (iii)(I) with respect to 
                                payments described in item (aa) and 
                                meet the requirement described in 
                                clause (iii)(II) with respect to 
                                payments described in item (bb);
                                    ``(II) for whom the Secretary 
                                determines at least 25 percent of 
                                payments under this part for covered 
                                professional services furnished by such 
                                professional during the most recent 
                                period for which data are available 
                                (which may be less than a year) were 
                                attributable to such services furnished 
                                under this part through an entity that 
                                participates in an eligible alternative 
                                payment model with respect to such 
                                services; and
                                    ``(III) who provides to the 
                                Secretary such information as is 
                                necessary for the Secretary to make a 
                                determination under subclause (I), with 
                                respect to such professional.
                            ``(iii) Requirement.--For purposes of 
                        clause (ii)(I)--
                                    ``(I) the requirement described in 
                                this subclause, with respect to 
                                payments described in item (aa) of such 
                                clause, is that such payments are made 
                                under an eligible alternative payment 
                                model; and
                                    ``(II) the requirement described in 
                                this subclause, with respect to 
                                payments described in item (bb) of such 
                                clause, is that such payments are made 
                                under an arrangement in which--
                                            ``(aa) quality measures 
                                        comparable to measures under 
                                        the performance category 
                                        described in section 
                                        1848(q)(2)(B)(i) apply;
                                            ``(bb) certified EHR 
                                        technology is used; and
                                            ``(cc) the eligible 
                                        professional bears more than 
                                        nominal financial risk if 
                                        actual aggregate expenditures 
                                        exceeds expected aggregate 
                                        expenditures.
                    ``(C) Beginning in 2021.--With respect to 2021 and 
                each subsequent year, an eligible professional 
                described in either of the following clauses:
                            ``(i) Medicare revenue threshold option.--
                        An eligible professional for whom the Secretary 
                        determines that at least 75 percent of payments 
                        under this part for covered professional 
                        services furnished by such professional during 
                        the most recent period for which data are 
                        available (which may be less than a year) were 
                        attributable to such services furnished under 
                        this part through an entity that participates 
                        in an eligible alternative payment model with 
                        respect to such services.
                            ``(ii) Combination all-payer and medicare 
                        revenue threshold option.--An eligible 
                        professional--
                                    ``(I) for whom the Secretary 
                                determines, with respect to items and 
                                services furnished by such professional 
                                during the most recent period for which 
                                data are available (which may be less 
                                than a year), that at least 75 percent 
                                of the sum of--
                                            ``(aa) payments described 
                                        in clause (i); and
                                            ``(bb) all other payments, 
                                        regardless of payer (other than 
                                        payments made by the Secretary 
                                        of Defense or the Secretary of 
                                        Veterans Affairs under chapter 
                                        55 of title 10, United States 
                                        Code, or title 38, United 
                                        States Code, or any other 
                                        provision of law),
                                 meet the requirement described in 
                                clause (iii)(I) with respect to 
                                payments described in item (aa) and 
                                meet the requirement described in 
                                clause (iii)(II) with respect to 
                                payments described in item (bb);
                                    ``(II) for whom the Secretary 
                                determines at least 25 percent of 
                                payments under this part for covered 
                                professional services furnished by such 
                                professional during the most recent 
                                period for which data are available 
                                (which may be less than a year) were 
                                attributable to such services furnished 
                                under this part through an entity that 
                                participates in an eligible alternative 
                                payment model with respect to such 
                                services; and
                                    ``(III) who provides to the 
                                Secretary such information as is 
                                necessary for the Secretary to make a 
                                determination under subclause (I), with 
                                respect to such professional.
                            ``(iii) Requirement.--For purposes of 
                        clause (ii)(I)--
                                    ``(I) the requirement described in 
                                this subclause, with respect to 
                                payments described in item (aa) of such 
                                clause, is that such payments are made 
                                under an eligible alternative payment 
                                model; and
                                    ``(II) the requirement described in 
                                this subclause, with respect to 
                                payments described in item (bb) of such 
                                clause, is that such payments are made 
                                under an arrangement in which--
                                            ``(aa) quality measures 
                                        comparable to measures under 
                                        the performance category 
                                        described in section 
                                        1848(q)(2)(B)(i) apply;
                                            ``(bb) certified EHR 
                                        technology is used; and
                                            ``(cc) the eligible 
                                        professional bears more than 
                                        nominal financial risk if 
                                        actual aggregate expenditures 
                                        exceeds expected aggregate 
                                        expenditures.
            ``(2) Additional definitions.--In this subsection:
                    ``(A) Covered professional services.--The term 
                `covered professional services' has the meaning given 
                that term in section 1848(k)(3)(A).
                    ``(B) Eligible professional.--The term `eligible 
                professional' has the meaning given that term in 
                section 1848(k)(3)(B).
                    ``(C) Alternative payment model (apm).--The term 
                `alternative payment model' means any of the following:
                            ``(i) A model under section 1115A (other 
                        than a health care innovation award).
                            ``(ii) An accountable care organization 
                        under section 1899.
                            ``(iii) A demonstration under section 
                        1866C.
                            ``(iv) A demonstration required by Federal 
                        law.
                    ``(D) Eligible alternative payment model (apm).--
                            ``(i) In general.--The term `eligible 
                        alternative payment model' means, with respect 
                        to a year, an alternative payment model--
                                    ``(I) that requires use of 
                                certified EHR technology (as defined in 
                                subsection (o)(4));
                                    ``(II) that provides for payment 
                                for covered professional services based 
                                on quality measures comparable to 
                                measures under the performance category 
                                described in section 1848(q)(2)(B)(i); 
                                and
                                    ``(III) that satisfies the 
                                requirement described in clause (ii).
                            ``(ii) Additional requirement.--For 
                        purposes of clause (i)(III), the requirement 
                        described in this clause, with respect to a 
                        year and an alternative payment model, is that 
                        the alternative payment model--
                                    ``(I) is one in which one or more 
                                entities bear financial risk for 
                                monetary losses under such model that 
                                are in excess of a nominal amount; or
                                    ``(II) is a medical home expanded 
                                under section 1115A(c).
            ``(3) Limitation.--There shall be no administrative or 
        judicial review under section 1869, 1878, or otherwise, of the 
        following:
                    ``(A) The determination that an eligible 
                professional is a qualifying APM participant under 
                paragraph (2) and the determination that an alternative 
                payment model is an eligible alternative payment model 
                under paragraph (3)(D).
                    ``(B) The determination of the amount of the 5 
                percent payment incentive under paragraph (1)(A), 
                including any estimation as part of such 
                determination.''.
            (2) Coordination conforming amendments.--Section 1833 of 
        the Social Security Act (42 U.S.C. 1395l) is further amended--
                    (A) in subsection (x)(3), by adding at the end the 
                following new sentence: ``The amount of the additional 
                payment for a service under this subsection and 
                subsection (z) shall be determined without regard to 
                any additional payment for the service under subsection 
                (z) and this subsection, respectively.''; and
                    (B) in subsection (y)(3), by adding at the end the 
                following new sentence: ``The amount of the additional 
                payment for a service under this subsection and 
                subsection (z) shall be determined without regard to 
                any additional payment for the service under subsection 
                (z) and this subsection, respectively.''.
            (3) Encouraging development and testing of certain 
        models.--Section 1115A(b)(2) of the Social Security Act (42 
        U.S.C. 1315a(b)(2)) is amended--
                    (A) in subparagraph (B), by adding at the end the 
                following new clauses:
                            ``(xxi) Focusing primarily on physicians' 
                        services (as defined in section 1848(j)(3)) 
                        furnished by physicians who are not primary 
                        care practitioners.
                            ``(xxii) Focusing on practices of fewer 
                        than 20 professionals.''; and
                    (B) in subparagraph (C)(viii), by striking ``other 
                public sector or private sector payers'' and inserting 
                ``other public sector payers, private sector payers, or 
                Statewide payment models''.
    (f) Study and Report on Fraud Related to Alternative Payment Models 
Under the Medicare Program.--
            (1) Study.--The Secretary of Health and Human Services, in 
        consultation with the Inspector General of the Department of 
        Health and Human Services, shall conduct a study that--
                    (A) examines the applicability of the Federal fraud 
                prevention laws to items and services furnished under 
                title XVIII of the Social Security Act for which 
                payment is made under an alternative payment model (as 
                defined in section 1833(z)(3)(C) of such Act (42 U.S.C. 
                1395l(z)(3)(C)));
                    (B) identifies aspects of such alternative payment 
                models that are vulnerable to fraudulent activity; and
                    (C) examines the implications of waivers to such 
                laws granted in support of such alternative payment 
                models, including under any potential expansion of such 
                models.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Secretary shall submit to Congress a 
        report containing the results of the study conducted under 
        paragraph (1). Such report shall include recommendations for 
        actions to be taken to reduce the vulnerability of such 
        alternative payment models to fraudulent activity. Such report 
        also shall include, as appropriate, recommendations of the 
        Inspector General for changes in Federal fraud prevention laws 
        to reduce such vulnerability.
    (g) Improving Payment Accuracy.--
            (1) Studies and reports of effect of certain information on 
        quality and resource use .--
                    (A) Study using existing medicare data.--
                            (i) Study.--The Secretary of Health and 
                        Human Services (in this subsection referred to 
                        as the ``Secretary'') shall conduct a study 
                        that examines the effect of individuals' 
                        socioeconomic status on quality and resource 
                        use outcome measures for individuals under the 
                        Medicare program (such as to recognize that 
                        less healthy individuals may require more 
                        intensive interventions). The study shall use 
                        information collected on such individuals in 
                        carrying out such program, such as urban and 
                        rural location, eligibility for Medicaid 
                        (recognizing and accounting for varying 
                        Medicaid eligibility across States), and 
                        eligibility for benefits under the supplemental 
                        security income (SSI) program. The Secretary 
                        shall carry out this paragraph acting through 
                        the Assistant Secretary for Planning and 
                        Evaluation.
                            (ii) Report.--Not later than 2 years after 
                        the date of the enactment of this Act, the 
                        Secretary shall submit to Congress a report on 
                        the study conducted under clause (i).
                    (B) Study using other data.--
                            (i) Study.--The Secretary shall conduct a 
                        study that examines the impact of risk factors, 
                        such as those described in section 1848(p)(3) 
                        of the Social Security Act (42 U.S.C. 1395w-
                        4(p)(3)), race, health literacy, limited 
                        English proficiency (LEP), and patient 
                        activation, on quality and resource use outcome 
                        measures under the Medicare program (such as to 
                        recognize that less healthy individuals may 
                        require more intensive interventions). In 
                        conducting such study the Secretary may use 
                        existing Federal data and collect such 
                        additional data as may be necessary to complete 
                        the study.
                            (ii) Report.--Not later than 5 years after 
                        the date of the enactment of this Act, the 
                        Secretary shall submit to Congress a report on 
                        the study conducted under clause (i).
                    (C) Examination of data in conducting studies.--In 
                conducting the studies under subparagraphs (A) and (B), 
                the Secretary shall examine what non-Medicare data 
                sets, such as data from the American Community Survey 
                (ACS), can be useful in conducting the types of studies 
                under such paragraphs and how such data sets that are 
                identified as useful can be coordinated with Medicare 
                administrative data in order to improve the overall 
                data set available to do such studies and for the 
                administration of the Medicare program.
                    (D) Recommendations to account for information in 
                payment adjustment mechanisms.--If the studies 
                conducted under subparagraphs (A) and (B) find a 
                relationship between the factors examined in the 
                studies and quality and resource use outcome measures, 
                then the Secretary shall also provide recommendations 
                for how the Centers for Medicare & Medicaid Services 
                should--
                            (i) obtain access to the necessary data (if 
                        such data is not already being collected) on 
                        such factors, including recommendations on how 
                        to address barriers to the Centers in accessing 
                        such data; and
                            (ii) account for such factors in 
                        determining payment adjustments based on 
                        quality and resource use outcome measures under 
                        the eligible professional value-based 
                        performance incentive program under section 
                        1848(q) of the Social Security Act (42 U.S.C. 
                        1395w-4(q)) and, as the Secretary determines 
                        appropriate, other similar provisions of title 
                        XVIII of such Act.
                    (E) Funding.--There are hereby appropriated from 
                the Federal Supplemental Medical Insurance Trust Fund 
                to the Secretary to carry out this paragraph 
                $6,000,000, to remain available until expended.
            (2) CMS activities.--
                    (A) Hierarchal condition category (hcc) 
                improvement.--Taking into account the relevant studies 
                conducted and recommendations made in reports under 
                paragraph (1), the Secretary, on an ongoing basis, 
                shall estimate how an individual's health status and 
                other risk factors affect quality and resource use 
                outcome measures and, as feasible, shall incorporate 
                information from quality and resource use outcome 
                measurement (including care episode and patient 
                condition groups) into the eligible professional value-
                based performance incentive program under section 
                1848(q) of the Social Security Act and, as the 
                Secretary determines appropriate, other similar 
                provisions of title XVIII of such Act.
                    (B) Accounting for other factors in payment 
                adjustment mechanisms.--
                            (i) In general.--Taking into account the 
                        studies conducted and recommendations made in 
                        reports under paragraph (1), the Secretary 
                        shall account for identified factors (other 
                        than those applied under subparagraph (A)) with 
                        an effect on quality and resource use outcome 
                        measures when determining payment adjustments 
                        under the eligible professional value-based 
                        performance incentive program under section 
                        1848(q) of the Social Security Act and, as the 
                        Secretary determines appropriate, other similar 
                        provisions of title XVIII of such Act.
                            (ii) Accessing data.--The Secretary shall 
                        collect or otherwise obtain access to the data 
                        necessary to carry out this paragraph through 
                        existing and new data sources.
                            (iii) Periodic analyses.--The Secretary 
                        shall carry out periodic analyses, at least 
                        every 3 years, based on the factors referred to 
                        in clause (i) so as to monitor changes in 
                        possible relationships.
                    (C) Funding.--There are hereby appropriated from 
                the Federal Supplemental Medical Insurance Trust Fund 
                to the Secretary to carry out this paragraph 
                $10,000,000, to remain available until expended.
            (3) Strategic plan for accessing race and ethnicity data.--
        Not later than 18 months after the date of the enactment of 
        this Act, the Secretary shall develop and report to Congress on 
        a strategic plan for collecting or otherwise accessing data on 
        race and ethnicity for purposes of carrying out the eligible 
        professional value-based performance incentive program under 
        section 1848(q) of the Social Security Act and, as the 
        Secretary determines appropriate, other similar provisions of 
        title XVIII of such Act.
    (h) Collaborating With the Physician, Practitioner, and Other 
Stakeholder Communities to Improve Resource Use Measurement.--Section 
1848 of the Social Security Act (42 U.S.C. 1395w-4), as amended by 
subsection (c), is further amended by adding at the end the following 
new subsection:
    ``(r) Collaborating With the Physician, Practitioner, and Other 
Stakeholder Communities To Improve Resource Use Measurement.--
            ``(1) In general.--In order to involve the physician, 
        practitioner, and other stakeholder communities in enhancing 
        the infrastructure for resource use measurement, including for 
        purposes of the value-based performance incentive program under 
        subsection (q) and alternative payment models under section 
        1833(z), the Secretary shall undertake the steps described in 
        the succeeding provisions of this subsection.
            ``(2) Development of care episode and patient condition 
        groups and classification codes.--
                    ``(A) In general.--In order to classify similar 
                patients into distinct care episode groups and distinct 
                patient condition groups, the Secretary shall undertake 
                the steps described in the succeeding provisions of 
                this paragraph.
                    ``(B) Public availability of existing efforts to 
                design an episode grouper.--Not later than 60 days 
                after the date of the enactment of this subsection, the 
                Secretary shall post on the Internet website of the 
                Centers for Medicare & Medicaid Services a list of the 
                episode groups developed pursuant to subsection 
                (n)(9)(A) and related descriptive information.
                    ``(C) Stakeholder input.--The Secretary shall 
                accept, through the date that is 60 days after the day 
                the Secretary posts the list pursuant to subparagraph 
                (B), suggestions from physician specialty societies, 
                applicable practitioner organizations, and other 
                stakeholders for episode groups in addition to those 
                posted pursuant to such subparagraph, and specific 
                clinical criteria and patient characteristics to 
                classify patients into--
                            ``(i) distinct care episode groups; and
                            ``(ii) distinct patient condition groups.
                    ``(D) Development of proposed classification 
                codes.--
                            ``(i) In general.--Taking into account the 
                        information described in subparagraph (B) and 
                        the information received under subparagraph 
                        (C), the Secretary shall--
                                    ``(I) establish distinct care 
                                episode groups and distinct patient 
                                condition groups, which account for at 
                                least an estimated two-thirds of 
                                expenditures under parts A and B; and
                                    ``(II) assign codes to such groups.
                            ``(ii) Care episode groups.--In 
                        establishing the care episode groups under 
                        clause (i), the Secretary shall take into 
                        account--
                                    ``(I) the patient's clinical 
                                problems at the time items and services 
                                are furnished during an episode of 
                                care, such as the clinical conditions 
                                or diagnoses, whether or not inpatient 
                                hospitalization is anticipated or 
                                occurs, and the principal procedures or 
                                services planned or furnished; and
                                    ``(II) other factors determined 
                                appropriate by the Secretary.
                            ``(iii) Patient condition groups.--In 
                        establishing the patient condition groups under 
                        clause (i), the Secretary shall take into 
                        account--
                                    ``(I) the patient's clinical 
                                history at the time of each medical 
                                visit, such as the patient's 
                                combination of chronic conditions, 
                                current health status, and recent 
                                significant history (such as 
                                hospitalization and major surgery 
                                during a previous period, such as 3 
                                months); and
                                    ``(II) other factors determined 
                                appropriate by the Secretary, such as 
                                eligibility status under this title 
                                (including eligibility under section 
                                226(a), 226(b), or 226A, and dual 
                                eligibility under this title and title 
                                XIX).
                    ``(E) Draft care episode and patient condition 
                groups and classification codes.--Not later than 120 
                days after the end of the comment period described in 
                subparagraph (C), the Secretary shall post on the 
                Internet website of the Centers for Medicare & Medicaid 
                Services a draft list of the care episode and patient 
                condition codes established under subparagraph (D) (and 
                the criteria and characteristics assigned to such 
                code).
                    ``(F) Solicitation of input.--The Secretary shall 
                seek, through the date that is 60 days after the 
                Secretary posts the list pursuant to subparagraph (E), 
                comments from physician specialty societies, applicable 
                practitioner organizations, and other stakeholders, 
                including representatives of individuals entitled to 
                benefits under part A or enrolled under this part, 
                regarding the care episode and patient condition groups 
                (and codes) posted under subparagraph (E). In seeking 
                such comments, the Secretary shall use one or more 
                mechanisms (other than notice and comment rulemaking) 
                that may include use of open door forums, town hall 
                meetings, or other appropriate mechanisms.
                    ``(G) Operational list of care episode and patient 
                condition groups and codes.--Not later than 120 days 
                after the end of the comment period described in 
                subparagraph (F), taking into account the comments 
                received under such subparagraph, the Secretary shall 
                post on the Internet website of the Centers for 
                Medicare & Medicaid Services an operational list of 
                care episode and patient condition codes (and the 
                criteria and characteristics assigned to such code).
                    ``(H) Subsequent revisions.--Not later than 
                November 1 of each year (beginning with 2016), the 
                Secretary shall, through rulemaking, make revisions to 
                the operational lists of care episode and patient 
                condition codes as the Secretary determines may be 
                appropriate. Such revisions may be based on experience, 
                new information developed pursuant to subsection 
                (n)(9)(A), and input from the physician specialty 
                societies, applicable practitioner organizations, and 
                other stakeholders, including representatives of 
                individuals entitled to benefits under part A or 
                enrolled under this part.
            ``(3) Attribution of patients to physicians or 
        practitioners.--
                    ``(A) In general.--In order to facilitate the 
                attribution of patients and episodes (in whole or in 
                part) to one or more physicians or applicable 
                practitioners furnishing items and services, the 
                Secretary shall undertake the steps described in the 
                succeeding provisions of this paragraph.
                    ``(B) Development of patient relationship 
                categories and codes.--The Secretary shall develop 
                patient relationship categories and codes that define 
                and distinguish the relationship and responsibility of 
                a physician or applicable practitioner with a patient 
                at the time of furnishing an item or service. Such 
                patient relationship categories shall include different 
                relationships of the physician or applicable 
                practitioner to the patient (and the codes may reflect 
                combinations of such categories), such as a physician 
                or applicable practitioner who--
                            ``(i) considers themself to have the 
                        primary responsibility for the general and 
                        ongoing care for the patient over extended 
                        periods of time;
                            ``(ii) considers themself to be the lead 
                        physician or practitioner and who furnishes 
                        items and services and coordinates care 
                        furnished by other physicians or practitioners 
                        for the patient during an acute episode;
                            ``(iii) furnishes items and services to the 
                        patient on a continuing basis during an acute 
                        episode of care, but in a supportive rather 
                        than a lead role;
                            ``(iv) furnishes items and services to the 
                        patient on an occasional basis, usually at the 
                        request of another physician or practitioner; 
                        or
                            ``(v) furnishes items and services only as 
                        ordered by another physician or practitioner.
                    ``(C) Draft list of patient relationship categories 
                and codes.--Not later than 180 days after the date of 
                the enactment of this subsection, the Secretary shall 
                post on the Internet website of the Centers for 
                Medicare & Medicaid Services a draft list of the 
                patient relationship categories and codes developed 
                under subparagraph (B).
                    ``(D) Stakeholder input.--The Secretary shall seek, 
                through the date that is 60 days after the Secretary 
                posts the list pursuant to subparagraph (C), comments 
                from physician specialty societies, applicable 
                practitioner organizations, and other stakeholders, 
                including representatives of individuals entitled to 
                benefits under part A or enrolled under this part, 
                regarding the patient relationship categories and codes 
                posted under subparagraph (C). In seeking such 
                comments, the Secretary shall use one or more 
                mechanisms (other than notice and comment rulemaking) 
                that may include open door forums, town hall meetings, 
                or other appropriate mechanisms.
                    ``(E) Operational list of patient relationship 
                categories and codes.--Not later than 120 days after 
                the end of the comment period described in subparagraph 
                (D), taking into account the comments received under 
                such subparagraph, the Secretary shall post on the 
                Internet website of the Centers for Medicare & Medicaid 
                Services an operational list of patient relationship 
                categories and codes.
                    ``(F) Subsequent revisions.--Not later than 
                November 1 of each year (beginning with 2016), the 
                Secretary shall, through rulemaking, make revisions to 
                the operational list of patient relationship categories 
                and codes as the Secretary determines appropriate. Such 
                revisions may be based on experience, new information 
                developed pursuant to subsection (n)(9)(A), and input 
                from the physician specialty societies, applicable 
                practitioner organizations, and other stakeholders, 
                including representatives of individuals entitled to 
                benefits under part A or enrolled under this part.
            ``(4) Reporting of information for resource use 
        measurement.--Claims submitted for items and services furnished 
        by a physician or applicable practitioner on or after January 
        1, 2016, shall, as determined appropriate by the Secretary, 
        include--
                    ``(A) applicable codes established under paragraphs 
                (2) and (3); and
                    ``(B) the national provider identifier of the 
                ordering physician or applicable practitioner (if 
                different from the billing physician or applicable 
                practitioner).
            ``(5) Methodology for resource use analysis.--
                    ``(A) In general.--In order to evaluate the 
                resources used to treat patients (with respect to care 
                episode and patient condition groups), the Secretary 
                shall--
                            ``(i) use the patient relationship codes 
                        reported on claims pursuant to paragraph (4) to 
                        attribute patients (in whole or in part) to one 
                        or more physicians and applicable 
                        practitioners;
                            ``(ii) use the care episode and patient 
                        condition codes reported on claims pursuant to 
                        paragraph (4) as a basis to compare similar 
                        patients and care episodes and patient 
                        condition groups; and
                            ``(iii) conduct an analysis of resource use 
                        (with respect to care episodes and patient 
                        condition groups of such patients), as the 
                        Secretary determines appropriate.
                    ``(B) Analysis of patients of physicians and 
                practitioners.--In conducting the analysis described in 
                subparagraph (A)(iii) with respect to patients 
                attributed to physicians and applicable practitioners, 
                the Secretary shall, as feasible--
                            ``(i) use the claims data experience of 
                        such patients by patient condition codes during 
                        a common period, such as 12 months; and
                            ``(ii) use the claims data experience of 
                        such patients by care episode codes--
                                    ``(I) in the case of episodes 
                                without a hospitalization, during 
                                periods of time (such as the number of 
                                days) determined appropriate by the 
                                Secretary; and
                                    ``(II) in the case of episodes with 
                                a hospitalization, during periods of 
                                time (such as the number of days) 
                                before, during, and after the 
                                hospitalization.
                    ``(C) Measurement of resource use.--In measuring 
                such resource use, the Secretary--
                            ``(i) shall use per patient total allowed 
                        amounts for all services under part A and this 
                        part (and, if the Secretary determines 
                        appropriate, part D) for the analysis of 
                        patient resource use, by care episode codes and 
                        by patient condition codes; and
                            ``(ii) may, as determined appropriate, use 
                        other measures of allowed amounts (such as 
                        subtotals for categories of items and services) 
                        and measures of utilization of items and 
                        services (such as frequency of specific items 
                        and services and the ratio of specific items 
                        and services among attributed patients or 
                        episodes).
                    ``(D) Stakeholder input.--The Secretary shall seek 
                comments from the physician specialty societies, 
                applicable practitioner organizations, and other 
                stakeholders, including representatives of individuals 
                entitled to benefits under part A or enrolled under 
                this part, regarding the resource use methodology 
                established pursuant to this paragraph. In seeking 
                comments the Secretary shall use one or more mechanisms 
                (other than notice and comment rulemaking) that may 
                include open door forums, town hall meetings, or other 
                appropriate mechanisms.
            ``(6) Limitation.--There shall be no administrative or 
        judicial review under section 1869, section 1878, or otherwise 
        of--
                    ``(A) care episode and patient condition groups and 
                codes established under paragraph (2);
                    ``(B) patient relationship categories and codes 
                established under paragraph (3); and
                    ``(C) measurement of, and analyses of resource use 
                with respect to, care episode and patient condition 
                codes and patient relationship codes pursuant to 
                paragraph (5).
            ``(7) Administration.--Chapter 35 of title 44, United 
        States Code, shall not apply to this section.
            ``(8) Definitions.--In this section:
                    ``(A) Physician.--The term `physician' has the 
                meaning given such term in section 1861(r)(1).
                    ``(B) Applicable practitioner.--The term 
                `applicable practitioner' means--
                            ``(i) a physician assistant, nurse 
                        practitioner, and clinical nurse specialist (as 
                        such terms are defined in section 1861(aa)(5)); 
                        and
                            ``(ii) beginning January 1, 2017, such 
                        other eligible professionals (as defined in 
                        subsection (k)(3)(B)) as specified by the 
                        Secretary.
            ``(9) Clarification.--The provisions of sections 1890(b)(7) 
        and 1890A shall not apply to this subsection.''.

SEC. 3. PRIORITIES AND FUNDING FOR QUALITY MEASURE DEVELOPMENT.

    Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as 
amended by subsections (c) and (h) of section 2, is further amended by 
inserting at the end the following new subsection:
    ``(s) Priorities and Funding for Quality Measure Development.--
            ``(1) Plan identifying measure development priorities and 
        timelines.--
                    ``(A) Draft measure development plan.--
                            ``(i) Draft plan.--
                                    ``(I) In general.--Not later than 
                                October 1, 2014, the Secretary shall 
                                develop, and post on the Internet 
                                website of the Centers for Medicare & 
                                Medicaid Services, a draft plan for the 
                                development of quality measures for 
                                application under the applicable 
                                provisions.
                                    ``(II) Requirement.--Such plan 
                                shall address how measures used by 
                                private payers and integrated delivery 
                                systems could be incorporated under 
                                such subsection.
                            ``(ii) Consideration.--In developing the 
                        draft plan under subparagraph (A), the 
                        Secretary shall consider--
                                    ``(I) gap analyses conducted by the 
                                entity with a contract under section 
                                1890(a) or other contractors or 
                                entities; and
                                    ``(II) whether measures are 
                                applicable across health care settings.
                            ``(iii) Priorities.--In developing the 
                        draft plan under subparagraph (A), the 
                        Secretary shall give priority to the following 
                        types of measures:
                                    ``(I) Outcome measures including 
                                patient reported outcome and functional 
                                status measures.
                                    ``(II) Patient experience measures.
                                    ``(III) Care coordination measures.
                                    ``(IV) Measures of appropriate use 
                                of services, including measures of over 
                                use.
                            ``(iv) Definition of applicable 
                        provisions.--In this subsection, the term 
                        `applicable provisions' means the following 
                        provisions:
                                    ``(I) Subsection (q)(2)(B)(i).
                                    ``(II) Section 1833(z)(2)(C).
                    ``(B) Stakeholder input.--The Secretary shall 
                accept through December 1, 2014, comments on the draft 
                plan posted under paragraph (1)(A) from the public, 
                including health care providers, payers, consumers, and 
                other stakeholders.
                    ``(C) Operational measure development plan.--Not 
                later than February 1, 2015, taking into account the 
                comments received under subparagraph (B), the Secretary 
                shall post on the Internet website of the Centers for 
                Medicare & Medicaid Services an operational plan for 
                the development of quality measures for use under 
                subsection (q)(2)(A)(i).
            ``(2) Contracts and other arrangements for quality measure 
        development.--
                    ``(A) In general.--The Secretary shall enter into 
                contracts or other arrangements with entities for the 
                purpose of developing, improving, updating, or 
                expanding quality measures for application under the 
                applicable provisions. Such entities may include 
                physician specialty societies and other practitioner 
                organizations.
                    ``(B) Prioritization.--
                            ``(i) In general.--In entering into 
                        contracts or other arrangements under 
                        subparagraph (A), the Secretary shall give 
                        priority to the development of the types of 
                        measures described in paragraph (1)(A)(iii).
                            ``(ii) Consideration.--In selecting 
                        measures for development under this subsection, 
                        the Secretary shall consider whether such 
                        measures would be electronically specified.
            ``(3) Annual report by the secretary.--
                    ``(A) In general.--Not later than February 1, 2016, 
                and annually thereafter, the Secretary shall post on 
                the Internet website of the Centers for Medicare & 
                Medicaid Services a report on the progress made in 
                developing quality measures for application under the 
                applicable provisions.
                    ``(B) Requirements.--Each report submitted pursuant 
                to paragraph (1) shall include the following:
                            ``(i) A description of the Secretary's 
                        efforts to implement this subsection.
                            ``(ii) With respect to the measures 
                        developed during the previous year--
                                    ``(I) a description of the total 
                                number of quality measures developed 
                                and the types of such measures, such as 
                                an outcome or patient experience 
                                measure;
                                    ``(II) the name of each measure 
                                developed;
                                    ``(III) the name of the developer 
                                and steward of each measure;
                                    ``(IV) with respect to each type of 
                                measure, an estimate of the total 
                                amount expended under this title to 
                                develop all measures of such type; and
                                    ``(V) whether the measure would be 
                                electronically specified.
                            ``(iii) With respect to measures in 
                        development at the time of the report--
                                    ``(I) the information described in 
                                clause (ii), if available; and
                                    ``(II) a timeline for completion of 
                                the development of such measures.
                            ``(iv) An update on the progress in 
                        developing the types of measures described in 
                        paragraph (1)(A)(iii), including a description 
                        of issues affecting such progress.
                            ``(v) A list of quality topics and concepts 
                        that are being considered for development of 
                        measures and the rationale for the selection of 
                        topics and concepts including their 
                        relationship to gap analyses.
                            ``(vi) A description of any updates to the 
                        plan under paragraph (1) (including newly 
                        identified gaps and the status of previously 
                        identified gaps) and the inventory of measures 
                        applicable under the applicable provisions.
                            ``(vii) Other information the Secretary 
                        determines to be appropriate.
            ``(4) Stakeholder input.--With respect to measures 
        applicable under the applicable provisions, the Secretary shall 
        seek stakeholder input with respect to--
                    ``(A) the identification of gaps where no quality 
                measures exist, particularly with respect to the types 
                of measures described in paragraph (1)(A)(iii);
                    ``(B) prioritizing quality measure development to 
                address such gaps; and
                    ``(C) other areas related to quality measure 
                development determined appropriate by the Secretary.
            ``(5) Funding.--For purposes of carrying out this 
        subsection, the Secretary shall provide for the transfer, from 
        the Federal Supplementary Medical Insurance Trust Fund under 
        section 1841, of $15,000,000 to the Centers for Medicare & 
        Medicaid Services Program Management Account for each of fiscal 
        years 2014 through 2018. Amounts transferred under this 
        paragraph shall remain available through the end of fiscal year 
        2021.''.

SEC. 4. ENCOURAGING CARE MANAGEMENT FOR INDIVIDUALS WITH CHRONIC CARE 
              NEEDS.

    Section 1848(b) of the Social Security Act (42 U.S.C. 1395w-4(b)) 
is amended by adding at the end the following new paragraph:
            ``(8) Encouraging care management for individuals with 
        chronic care needs.--
                    ``(A) In general.--In order to encourage the 
                management of care by an applicable provider (as 
                defined in subparagraph (B)) for individuals with 
                chronic care needs the Secretary shall--
                            ``(i) establish one or more HCPCS codes for 
                        chronic care management services for such 
                        individuals; and
                            ``(ii) subject to subparagraph (D), make 
                        payment (as the Secretary determines to be 
                        appropriate) under this section for such 
                        management services furnished on or after 
                        January 1, 2015, by an applicable provider.
                    ``(B) Applicable provider defined.--For purposes of 
                this paragraph, the term `applicable provider' means a 
                physician (as defined in section 1861(r)(1)), physician 
                assistant or nurse practitioner (as defined in section 
                1861(aa)(5)(A)), or clinical nurse specialist (as 
                defined in section 1861(aa)(5)(B)) who furnishes 
                services as part of a patient-centered medical home or 
                a comparable specialty practice that--
                            ``(i) is recognized as such a medical home 
                        or comparable specialty practice by an 
                        organization that is recognized by the 
                        Secretary for purposes of such recognition as 
                        such a medical home or practice; or
                            ``(ii) meets such other comparable 
                        qualifications as the Secretary determines to 
                        be appropriate.
                    ``(C) Budget neutrality.--The budget neutrality 
                provision under subsection (c)(2)(B)(ii)(II) shall 
                apply in establishing the payment under subparagraph 
                (A)(ii).
                    ``(D) Policies relating to payment.--In carrying 
                out this paragraph, with respect to chronic care 
                management services, the Secretary shall--
                            ``(i) make payment to only one applicable 
                        provider for such services furnished to an 
                        individual during a period;
                            ``(ii) not make payment under subparagraph 
                        (A) if such payment would be duplicative of 
                        payment that is otherwise made under this title 
                        for such services (such as in the case of 
                        hospice care or home health services); and
                            ``(iii) not require that an annual wellness 
                        visit (as defined in section 1861(hhh)) or an 
                        initial preventive physical examination (as 
                        defined in section 1861(ww)) be furnished as a 
                        condition of payment for such management 
                        services.''.

SEC. 5. ENSURING ACCURATE VALUATION OF SERVICES UNDER THE PHYSICIAN FEE 
              SCHEDULE.

    (a) Authority To Collect and Use Information on Physicians' 
Services in the Determination of Relative Values.--
            (1) In general.--Section 1848(c)(2) of the Social Security 
        Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end 
        the following new subparagraph:
                    ``(M) Authority to collect and use information on 
                physicians' services in the determination of relative 
                values.--
                            ``(i) Collection of information.--
                        Notwithstanding any other provision of law, the 
                        Secretary may collect or obtain information on 
                        the resources directly or indirectly related to 
                        furnishing services for which payment is made 
                        under the fee schedule established under 
                        subsection (b). Such information may be 
                        collected or obtained from any eligible 
                        professional or any other source.
                            ``(ii) Use of information.--Notwithstanding 
                        any other provision of law, subject to clause 
                        (v), the Secretary may (as the Secretary 
                        determines appropriate) use information 
                        collected or obtained pursuant to clause (i) in 
                        the determination of relative values for 
                        services under this section.
                            ``(iii) Types of information.--The types of 
                        information described in clauses (i) and (ii) 
                        may, at the Secretary's discretion, include any 
                        or all of the following:
                                    ``(I) Time involved in furnishing 
                                services.
                                    ``(II) Amounts and types of 
                                practice expense inputs involved with 
                                furnishing services.
                                    ``(III) Prices (net of any 
                                discounts) for practice expense inputs, 
                                which may include paid invoice prices 
                                or other documentation or records.
                                    ``(IV) Overhead and accounting 
                                information for practices of physicians 
                                and other suppliers.
                                    ``(V) Any other element that would 
                                improve the valuation of services under 
                                this section.
                            ``(iv) Information collection mechanisms.--
                        Information may be collected or obtained 
                        pursuant to this subparagraph from any or all 
                        of the following:
                                    ``(I) Surveys of physicians, other 
                                suppliers, providers of services, 
                                manufacturers, and vendors.
                                    ``(II) Surgical logs, billing 
                                systems, or other practice or facility 
                                records.
                                    ``(III) Electronic health records.
                                    ``(IV) Any other mechanism 
                                determined appropriate by the 
                                Secretary.
                            ``(v) Transparency of use of information.--
                                    ``(I) In general.--Subject to 
                                subclauses (II) and (III), if the 
                                Secretary uses information collected or 
                                obtained under this subparagraph in the 
                                determination of relative values under 
                                this subsection, the Secretary shall 
                                disclose the information source and 
                                discuss the use of such information in 
                                such determination of relative values 
                                through notice and comment rulemaking.
                                    ``(II) Thresholds for use.--The 
                                Secretary may establish thresholds in 
                                order to use such information, 
                                including the exclusion of information 
                                collected or obtained from eligible 
                                professionals who use very high 
                                resources (as determined by the 
                                Secretary) in furnishing a service.
                                    ``(III) Disclosure of 
                                information.--The Secretary shall make 
                                aggregate information available under 
                                this subparagraph but shall not 
                                disclose information in a form or 
                                manner that identifies an eligible 
                                professional or a group practice, or 
                                information collected or obtained 
                                pursuant to a nondisclosure agreement.
                            ``(vi) Incentive to participate.--The 
                        Secretary may provide for such payments under 
                        this part to an eligible professional that 
                        submits such solicited information under this 
                        subparagraph as the Secretary determines 
                        appropriate in order to compensate such 
                        eligible professional for such submission. Such 
                        payments shall be provided in a form and manner 
                        specified by the Secretary.
                            ``(vii) Administration.--Chapter 35 of 
                        title 44, United States Code, shall not apply 
                        to information collected or obtained under this 
                        subparagraph.
                            ``(viii) Definition of eligible 
                        professional.--In this subparagraph, the term 
                        `eligible professional' has the meaning given 
                        such term in subsection (k)(3)(B).
                            ``(ix) Funding.--For purposes of carrying 
                        out this subparagraph, in addition to funds 
                        otherwise appropriated, the Secretary shall 
                        provide for the transfer, from the Federal 
                        Supplementary Medical Insurance Trust Fund 
                        under section 1841, of $2,000,000 to the 
                        Centers for Medicare & Medicaid Services 
                        Program Management Account for each fiscal year 
                        beginning with fiscal year 2014. Amounts 
                        transferred under the preceding sentence for a 
                        fiscal year shall be available until 
                        expended.''.
            (2) Limitation on review.--Section 1848(i)(1) of the Social 
        Security Act (42 U.S.C. 1395w-4(i)(1)) is amended--
                    (A) in subparagraph (D), by striking ``and'' at the 
                end;
                    (B) in subparagraph (E), by striking the period at 
                the end and inserting ``, and''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(F) the collection and use of information in the 
                determination of relative values under subsection 
                (c)(2)(M).''.
    (b) Authority for Alternative Approaches To Establishing Practice 
Expense Relative Values.--Section 1848(c)(2) of the Social Security Act 
(42 U.S.C. 1395w-4(c)(2)), as amended by subsection (a), is amended by 
adding at the end the following new subparagraph:
                    ``(N) Authority for alternative approaches to 
                establishing practice expense relative values.--The 
                Secretary may establish or adjust practice expense 
                relative values under this subsection using cost, 
                charge, or other data from suppliers or providers of 
                services, including information collected or obtained 
                under subparagraph (M).''.
    (c) Revised and Expanded Identification of Potentially Misvalued 
Codes.--Section 1848(c)(2)(K)(ii) of the Social Security Act (42 U.S.C. 
1395w-4(c)(2)(K)(ii)) is amended to read as follows:
                            ``(ii) Identification of potentially 
                        misvalued codes.--For purposes of identifying 
                        potentially misvalued codes pursuant to clause 
                        (i)(I), the Secretary shall examine codes (and 
                        families of codes as appropriate) based on any 
                        or all of the following criteria:
                                    ``(I) Codes that have experienced 
                                the fastest growth.
                                    ``(II) Codes that have experienced 
                                substantial changes in practice 
                                expenses.
                                    ``(III) Codes that describe new 
                                technologies or services within an 
                                appropriate time period (such as 3 
                                years) after the relative values are 
                                initially established for such codes.
                                    ``(IV) Codes which are multiple 
                                codes that are frequently billed in 
                                conjunction with furnishing a single 
                                service.
                                    ``(V) Codes with low relative 
                                values, particularly those that are 
                                often billed multiple times for a 
                                single treatment.
                                    ``(VI) Codes that have not been 
                                subject to review since implementation 
                                of the fee schedule.
                                    ``(VII) Codes that account for the 
                                majority of spending under the 
                                physician fee schedule.
                                    ``(VIII) Codes for services that 
                                have experienced a substantial change 
                                in the hospital length of stay or 
                                procedure time.
                                    ``(IX) Codes for which there may be 
                                a change in the typical site of service 
                                since the code was last valued.
                                    ``(X) Codes for which there is a 
                                significant difference in payment for 
                                the same service between different 
                                sites of service.
                                    ``(XI) Codes for which there may be 
                                anomalies in relative values within a 
                                family of codes.
                                    ``(XII) Codes for services where 
                                there may be efficiencies when a 
                                service is furnished at the same time 
                                as other services.
                                    ``(XIII) Codes with high intra-
                                service work per unit of time.
                                    ``(XIV) Codes with high practice 
                                expense relative value units.
                                    ``(XV) Codes with high cost 
                                supplies.
                                    ``(XVI) Codes as determined 
                                appropriate by the Secretary.''.
    (d) Target for Relative Value Adjustments for Misvalued Services.--
            (1) In general.--Section 1848(c)(2) of the Social Security 
        Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a) 
        and (b), is amended by adding at the end the following new 
        subparagraph:
                    ``(O) Target for relative value adjustments for 
                misvalued services.--With respect to fee schedules 
                established for each of 2015 through 2018, the 
                following shall apply:
                            ``(i) Determination of net reduction in 
                        expenditures.--For each year, the Secretary 
                        shall determine the estimated net reduction in 
                        expenditures under the fee schedule under this 
                        section with respect to the year as a result of 
                        adjustments to the relative values established 
                        under this paragraph for misvalued codes.
                            ``(ii) Budget neutral redistribution of 
                        funds if target met and counting overages 
                        towards the target for the succeeding year.--If 
                        the estimated net reduction in expenditures 
                        determined under clause (i) for the year is 
                        equal to or greater than the target for the 
                        year--
                                    ``(I) reduced expenditures 
                                attributable to such adjustments shall 
                                be redistributed for the year in a 
                                budget neutral manner in accordance 
                                with subparagraph (B)(ii)(II); and
                                    ``(II) the amount by which such 
                                reduced expenditures exceeds the target 
                                for the year shall be treated as a 
                                reduction in expenditures described in 
                                clause (i) for the succeeding year, for 
                                purposes of determining whether the 
                                target has or has not been met under 
                                this subparagraph with respect to that 
                                year.
                            ``(iii) Exemption from budget neutrality if 
                        target not met.--If the estimated net reduction 
                        in expenditures determined under clause (i) for 
                        the year is less than the target for the year, 
                        reduced expenditures in an amount equal to the 
                        target recapture amount shall not be taken into 
                        account in applying subparagraph (B)(ii)(II) 
                        with respect to fee schedules beginning with 
                        2015.
                            ``(iv) Target recapture amount.--For 
                        purposes of clause (iii), the target recapture 
                        amount is, with respect to a year, an amount 
                        equal to the difference between--
                                    ``(I) the target for the year; and
                                    ``(II) the estimated net reduction 
                                in expenditures determined under clause 
                                (i) for the year.
                            ``(v) Target.--For purposes of this 
                        subparagraph, with respect to a year, the 
                        target is calculated as 0.5 percent of the 
                        estimated amount of expenditures under the fee 
                        schedule under this section for the year.''.
            (2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the 
        Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is amended 
        by adding at the end the following new subclause:
                                    ``(VIII) Reductions for misvalued 
                                services if target not met.--Effective 
                                for fee schedules beginning with 2015, 
                                reduced expenditures attributable to 
                                the application of the target recapture 
                                amount described in subparagraph 
                                (O)(iii).''.
    (e) Phase-in of Significant Relative Value Unit (RVU) Reductions.--
            (1) In general.--Section 1848(c) of the Social Security Act 
        (42 U.S.C. 1395w-4(c)) is amended by adding at the end the 
        following new paragraph:
            ``(7) Phase-in of significant relative value unit (rvu) 
        reductions.--Effective for fee schedules established beginning 
        with 2015, if the total relative value units for a service for 
        a year would otherwise be decreased by an estimated amount 
        equal to or greater than 20 percent as compared to the total 
        relative value units for the previous year, the applicable 
        adjustments in work, practice expense, and malpractice relative 
        value units shall be phased-in over a 2-year period.''.
            (2) Conforming amendments.--Section 1848(c)(2) of the 
        Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
                    (A) in subparagraph (B)(ii)(I), by striking 
                ``subclause (II)'' and inserting ``subclause (II) and 
                paragraph (7)''; and
                    (B) in subparagraph (K)(iii)(VI)--
                            (i) by striking ``provisions of 
                        subparagraph (B)(ii)(II)'' and inserting 
                        ``provisions of subparagraph (B)(ii)(II) and 
                        paragraph (7)''; and
                            (ii) by striking ``under subparagraph 
                        (B)(ii)(II)'' and inserting ``under 
                        subparagraph (B)(ii)(I)''.
    (f) Authority To Smooth Relative Values Within Groups of 
Services.--Section 1848(c)(2)(C) of the Social Security Act (42 U.S.C. 
1395w-4(c)(2)(C)) is amended--
            (1) in each of clauses (i) and (iii), by striking ``the 
        service'' and inserting ``the service or group of services'' 
        each place it appears; and
            (2) in the first sentence of clause (ii), by inserting ``or 
        group of services'' before the period.
    (g) GAO Study and Report on Relative Value Scale Update 
Committee.--
            (1) Study.--The Comptroller General of the United States 
        (in this subsection referred to as the ``Comptroller General'') 
        shall conduct a study of the processes used by the Relative 
        Value Scale Update Committee (RUC) to provide recommendations 
        to the Secretary of Health and Human Services regarding 
        relative values for specific services under the Medicare 
        physician fee schedule under section 1848 of the Social 
        Security Act (42 U.S.C. 1395w-4).
            (2) Report.--Not later than 1 year after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report containing the results of the study conducted 
        under paragraph (1).
    (h) Adjustment to Medicare Payment Localities.--
            (1) In general.--Section 1848(e) of the Social Security Act 
        (42 U.S.C. 1395w-4(e)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Use of msas as fee schedule areas in california.--
                    ``(A) In general.--Subject to the succeeding 
                provisions of this paragraph and notwithstanding the 
                previous provisions of this subsection, for services 
                furnished on or after January 1, 2017, the fee schedule 
                areas used for payment under this section applicable to 
                California shall be the following:
                            ``(i) Each Metropolitan Statistical Area 
                        (each in this paragraph referred to as an 
                        `MSA'), as defined by the Director of the 
                        Office of Management and Budget as of December 
                        31 of the previous year, shall be a fee 
                        schedule area.
                            ``(ii) All areas not included in an MSA 
                        shall be treated as a single rest-of-State fee 
                        schedule area.
                    ``(B) Transition for msas previously in rest-of-
                state payment locality or in locality 3.--
                            ``(i) In general.--For services furnished 
                        in California during a year beginning with 2017 
                        and ending with 2021 in an MSA in a transition 
                        area (as defined in subparagraph (D)), subject 
                        to subparagraph (C), the geographic index 
                        values to be applied under this subsection for 
                        such year shall be equal to the sum of the 
                        following:
                                    ``(I) Current law component.--The 
                                old weighting factor (described in 
                                clause (ii)) for such year multiplied 
                                by the geographic index values under 
                                this subsection for the fee schedule 
                                area that included such MSA that would 
                                have applied in such area (as estimated 
                                by the Secretary) if this paragraph did 
                                not apply.
                                    ``(II) MSA-based component.--The 
                                MSA-based weighting factor (described 
                                in clause (iii)) for such year 
                                multiplied by the geographic index 
                                values computed for the fee schedule 
                                area under subparagraph (A) for the 
                                year (determined without regard to this 
                                subparagraph).
                            ``(ii) Old weighting factor.--The old 
                        weighting factor described in this clause--
                                    ``(I) for 2017, is \5/6\; and
                                    ``(II) for each succeeding year, is 
                                the old weighting factor described in 
                                this clause for the previous year minus 
                                \1/6\.
                            ``(iii) MSA-based weighting factor.--The 
                        MSA-based weighting factor described in this 
                        clause for a year is 1 minus the old weighting 
                        factor under clause (ii) for that year.
                    ``(C) Hold harmless.--For services furnished in a 
                transition area in California during a year beginning 
                with 2017, the geographic index values to be applied 
                under this subsection for such year shall not be less 
                than the corresponding geographic index values that 
                would have applied in such transition area (as 
                estimated by the Secretary) if this paragraph did not 
                apply.
                    ``(D) Transition area defined.--In this paragraph, 
                the term `transition area' means each of the following 
                fee schedule areas for 2013:
                            ``(i) The rest-of-State payment locality.
                            ``(ii) Payment locality 3.
                    ``(E) References to fee schedule areas.--Effective 
                for services furnished on or after January 1, 2017, for 
                California, any reference in this section to a fee 
                schedule area shall be deemed a reference to a fee 
                schedule area established in accordance with this 
                paragraph.''.
            (2) Conforming amendment to definition of fee schedule 
        area.--Section 1848(j)(2) of the Social Security Act (42 U.S.C. 
        1395w-4(j)(2)) is amended by striking ``The term'' and 
        inserting ``Except as provided in subsection (e)(6)(D), the 
        term''.

SEC. 6. PROMOTING EVIDENCE-BASED CARE.

    (a) Recognizing Appropriate Use Criteria for Certain Imaging 
Services.--
            (1) In general.--Section 1834 of the Social Security Act 
        (42 U.S.C. 1395m) is amended by adding at the end the following 
        new subsection:
    ``(p) Recognizing Appropriate Use Criteria for Certain Imaging 
Services.--
            ``(1) Program established.--
                    ``(A) In general.--The Secretary shall establish a 
                program to promote the use of appropriate use criteria 
                (as defined in subparagraph (B)) for applicable imaging 
                services (as defined in subparagraph (C)) furnished in 
                an applicable setting (as defined in subparagraph (D)) 
                by ordering professionals and furnishing professionals 
                (as defined in subparagraphs (E) and (F), 
                respectively).
                    ``(B) Appropriate use criteria defined.--In this 
                subsection, the term `appropriate use criteria' means 
                criteria to assist ordering professionals and 
                furnishing professionals in making the most appropriate 
                treatment decision for a specific clinical condition. 
                To the extent feasible, such criteria shall be 
                evidence-based.
                    ``(C) Applicable imaging service defined.--In this 
                subsection, the term `applicable imaging service' means 
                an advanced diagnostic imaging service (as defined in 
                subsection (e)(1)(B)) for which the Secretary 
                determines--
                            ``(i) one or more applicable appropriate 
                        use criteria specified under paragraph (2) 
                        apply;
                            ``(ii) there are one or more qualified 
                        clinical decision support mechanisms listed 
                        under paragraph (3)(C); and
                            ``(iii) one or more of such mechanisms is 
                        available free of charge.
                    ``(D) Applicable setting defined.--In this 
                subsection, the term `applicable setting' means a 
                physician's office, a hospital outpatient department 
                (including an emergency department), an ambulatory 
                surgical center, and any other outpatient setting 
                determined appropriate by the Secretary.
                    ``(E) Ordering professional defined.--In this 
                subsection, the term `ordering professional' means a 
                physician (as defined in section 1861(r)) or a 
                practitioner described in section 1842(b)(18)(C) who 
                orders an applicable imaging service for an individual.
                    ``(F) Furnishing professional defined.--In this 
                subsection, the term `furnishing professional' means a 
                physician (as defined in section 1861(r)) or a 
                practitioner described in section 1842(b)(18)(C) who 
                furnishes an applicable imaging service for an 
                individual.
            ``(2) Establishment of applicable appropriate use 
        criteria.--
                    ``(A) In general.--Not later than November 15, 
                2015, the Secretary shall through rulemaking, and in 
                consultation with physicians, practitioners, and other 
                stakeholders, specify applicable appropriate use 
                criteria for applicable imaging services from among 
                appropriate use criteria developed or endorsed by 
                national professional medical specialty societies or 
                other entities.
                    ``(B) Considerations.--In specifying applicable 
                appropriate use criteria under subparagraph (A), the 
                Secretary shall take into account whether the 
                criteria--
                            ``(i) have stakeholder consensus;
                            ``(ii) have been determined to be 
                        scientifically valid and are evidence based; 
                        and
                            ``(iii) are in the public domain.
                    ``(C) Revisions.--The Secretary shall periodically 
                update and revise (as appropriate) such specification 
                of applicable appropriate use criteria.
                    ``(D) Treatment of multiple applicable appropriate 
                use criteria.--In the case where the Secretary 
                determines that more than one appropriate use criteria 
                applies with respect to an applicable imaging service, 
                the Secretary shall specify one or more applicable 
                appropriate use criteria under this paragraph for the 
                service.
            ``(3) Mechanisms for consultation with applicable 
        appropriate use criteria.--
                    ``(A) Identification of mechanisms to consult with 
                applicable appropriate use criteria.--
                            ``(i) In general.--The Secretary shall 
                        specify one or more qualified clinical decision 
                        support mechanisms that could be used by 
                        ordering professionals to consult with 
                        applicable appropriate use criteria for 
                        applicable imaging services.
                            ``(ii) Consultation.--The Secretary shall 
                        consult with physicians, practitioners, and 
                        other stakeholders in specifying mechanisms 
                        under this paragraph.
                            ``(iii) Inclusion of certain mechanisms.--
                        Mechanisms specified under this paragraph may 
                        include any or all of the following that meet 
                        the requirements described in subparagraph 
                        (B)(ii):
                                    ``(I) Use of clinical decision 
                                support modules in certified EHR 
                                technology (as defined in section 
                                1848(o)(4)).
                                    ``(II) Use of private sector 
                                clinical decision support mechanisms 
                                that are independent from certified EHR 
                                technology, which may include use of 
                                clinical decision support mechanisms 
                                available from medical specialty 
                                organizations.
                                    ``(III) Use of a clinical decision 
                                support mechanism established by the 
                                Secretary.
                    ``(B) Qualified clinical decision support 
                mechanisms.--
                            ``(i) In general.--For purposes of this 
                        subsection, a qualified clinical decision 
                        support mechanism is a mechanism that the 
                        Secretary determines meets the requirements 
                        described in clause (ii).
                            ``(ii) Requirements.--The requirements 
                        described in this clause are the following:
                                    ``(I) The mechanism makes available 
                                to the ordering professional applicable 
                                appropriate use criteria specified 
                                under paragraph (2) and the supporting 
                                documentation for the applicable 
                                imaging service ordered.
                                    ``(II) In the case where there are 
                                more than one applicable appropriate 
                                use criteria specified under such 
                                paragraph for an applicable imaging 
                                service, the mechanism indicates the 
                                criteria that it uses for the service.
                                    ``(III) The mechanism determines 
                                the extent to which an applicable 
                                imaging service ordered is consistent 
                                with the applicable appropriate use 
                                criteria so specified.
                                    ``(IV) The mechanism generates and 
                                provides to the ordering professional a 
                                certification or documentation that 
                                documents that the qualified clinical 
                                decision support mechanism was 
                                consulted by the ordering professional.
                                    ``(V) The mechanism is updated on a 
                                timely basis to reflect revisions to 
                                the specification of applicable 
                                appropriate use criteria under such 
                                paragraph.
                                    ``(VI) The mechanism meets privacy 
                                and security standards under applicable 
                                provisions of law.
                                    ``(VII) The mechanism performs such 
                                other functions as specified by the 
                                Secretary, which may include a 
                                requirement to provide aggregate 
                                feedback to the ordering professional.
                    ``(C) List of mechanisms for consultation with 
                applicable appropriate use criteria.--
                            ``(i) Initial list.--Not later than April 
                        1, 2016, the Secretary shall publish a list of 
                        mechanisms specified under this paragraph.
                            ``(ii) Periodic updating of list.--The 
                        Secretary shall periodically update the list of 
                        qualified clinical decision support mechanisms 
                        specified under this paragraph.
            ``(4) Consultation with applicable appropriate use 
        criteria.--
                    ``(A) Consultation by ordering professional.--
                Beginning with January 1, 2017, subject to subparagraph 
                (C), with respect to an applicable imaging service 
                ordered by an ordering professional that would be 
                furnished in an applicable setting and paid for under 
                an applicable payment system (as defined in 
                subparagraph (D)), an ordering professional shall--
                            ``(i) consult with a qualified decision 
                        support mechanism listed under paragraph 
                        (3)(C); and
                            ``(ii) provide to the furnishing 
                        professional the information described in 
                        clauses (i) through (iii) of subparagraph (B).
                    ``(B) Reporting by furnishing professional.--
                Beginning with January 1, 2017, subject to subparagraph 
                (C), with respect to an applicable imaging service 
                furnished in an applicable setting and paid for under 
                an applicable payment system (as defined in 
                subparagraph (D)), payment for such service may only be 
                made if the claim for the service includes the 
                following:
                            ``(i) Information about which qualified 
                        clinical decision support mechanism was 
                        consulted by the ordering professional for the 
                        service.
                            ``(ii) Information regarding--
                                    ``(I) whether the service ordered 
                                would adhere to the applicable 
                                appropriate use criteria specified 
                                under paragraph (2);
                                    ``(II) whether the service ordered 
                                would not adhere to such criteria; or
                                    ``(III) whether such criteria was 
                                not applicable to the service ordered.
                            ``(iii) The national provider identifier of 
                        the ordering professional (if different from 
                        the furnishing professional).
                    ``(C) Exceptions.--The provisions of subparagraphs 
                (A) and (B) and paragraph (6)(A) shall not apply to the 
                following:
                            ``(i) Emergency services.--An applicable 
                        imaging service ordered for an individual with 
                        an emergency medical condition (as defined in 
                        section 1867(e)(1)).
                            ``(ii) Inpatient services.--An applicable 
                        imaging service ordered for an inpatient and 
                        for which payment is made under part A.
                            ``(iii) Alternative payment models.--An 
                        applicable imaging service ordered by an 
                        ordering professional with respect to an 
                        individual attributed to an alternative payment 
                        model (as defined in section 1833(z)(3)(C)).
                            ``(iv) Significant hardship.--An applicable 
                        imaging service ordered by an ordering 
                        professional who the Secretary may, on a case-
                        by-case basis, exempt from the application of 
                        such provisions if the Secretary determines, 
                        subject to annual renewal, that consultation 
                        with applicable appropriate use criteria would 
                        result in a significant hardship, such as in 
                        the case of a professional who practices in a 
                        rural area without sufficient Internet access.
                    ``(D) Applicable payment system defined.--In this 
                subsection, the term `applicable payment system' means 
                the following:
                            ``(i) The physician fee schedule 
                        established under section 1848(b).
                            ``(ii) The prospective payment system for 
                        hospital outpatient department services under 
                        section 1833(t).
                            ``(iii) The ambulatory surgical center 
                        payment systems under section 1833(i).
            ``(5) Identification of outlier ordering professionals.--
                    ``(A) In general.--With respect to applicable 
                imaging services furnished beginning with 2017, the 
                Secretary shall determine, on a periodic basis (which 
                may be annually), ordering professionals who are 
                outlier ordering professionals.
                    ``(B) Outlier ordering professionals.--The 
                determination of an outlier ordering professional 
                shall--
                            ``(i) be based on low adherence to 
                        applicable appropriate use criteria specified 
                        under paragraph (2), which may be based on 
                        comparison to other ordering professionals; and
                            ``(ii) include data for ordering 
                        professionals for whom prior authorization 
                        under paragraph (6)(A) applies.
                    ``(C) Use of two years of data.--The Secretary 
                shall use two years of data to identify outlier 
                ordering professionals under this paragraph.
                    ``(D) Consultation with stakeholders.--The 
                Secretary shall consult with physicians, practitioners 
                and other stakeholders in developing methods to 
                identify outlier ordering professionals under this 
                paragraph.
            ``(6) Prior authorization for ordering professionals who 
        are outliers.--
                    ``(A) In general.--Beginning January 1, 2020, 
                subject to paragraph (4)(C), with respect to services 
                furnished during a year, the Secretary shall, for a 
                period determined appropriate by the Secretary, apply 
                prior authorization for applicable imaging services 
                that are ordered by an outlier ordering professional 
                identified under paragraph (5).
                    ``(B) Funding.--For purposes of carrying out this 
                paragraph, the Secretary shall provide for the 
                transfer, from the Federal Supplementary Medical 
                Insurance Trust Fund under section 1841, of $5,000,000 
                to the Centers for Medicare & Medicaid Services Program 
                Management Account for each of fiscal years 2019 
                through 2021. Amounts transferred under the preceding 
                sentence shall remain available until expended.''.
            (2) Conforming amendment.--Section 1833(t)(16) of the 
        Social Security Act (42 U.S.C. 1395l(t)(16)) is amended by 
        adding at the end the following new subparagraph:
                    ``(E) Application of appropriate use criteria for 
                certain imaging services.--For provisions relating to 
                the application of appropriate use criteria for certain 
                imaging services, see section 1834(p).''.
    (b) Establishment of Appropriate Use Program for Other Part B 
Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m), 
as amended by subsection (a), is amended by adding at the end the 
following new subsection:
    ``(q) Establishment of Appropriate Use Program for Other Part B 
Services.--
            ``(1) Establishment.--
                    ``(A) In general.--The Secretary may establish an 
                appropriate use program for services under this part 
                (other than applicable imaging services under 
                subsection (p)) using a process similar to the process 
                under such subsection.
                    ``(B) Requirements.--In determining whether to 
                establish a program under subparagraph (A), the 
                Secretary shall take into consideration--
                            ``(i) the implementation of appropriate use 
                        criteria for applicable imaging services under 
                        subsection (p); and
                            ``(ii) the report under paragraph (2).
                    ``(C) Input from stakeholders in advance of 
                rulemaking.--Before issuing a notice of proposed 
                rulemaking to establish a program under subparagraph 
                (A), the Secretary shall issue an advance notice of 
                proposed rulemaking.
            ``(2) Report on experience of imaging appropriate use 
        criteria program.--Not later than 18 months after the date of 
        the enactment of this subsection, the Comptroller General of 
        the United States shall submit to Congress a report that 
        includes a description of the extent to which appropriate use 
        criteria could be used for other services under this part, such 
        as radiation therapy and clinical diagnostic laboratory 
        services.''.

SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO INFORMATION ON 
              PHYSICIANS' SERVICES.

    (a) Transferring Freestanding Physician Compare Provision to the 
Social Security Act.--
            (1) In general.--Section 10331 of Public Law 111-148 is 
        transferred and redesignated as subsection (t) of section 1848 
        of the Social Security Act (42 U.S.C. 1395w-4), as amended by 
        subsections (c) and (h) of section 2 and by section 3.
            (2) Conforming redesignations.--Section 1848(t) of the 
        Social Security Act (42 U.S.C. 1395w-4(t)), as transferred and 
        redesignated by paragraph (1), is further amended--
                    (A) by striking the subsection heading and 
                inserting the following new subsection heading: 
                ``Public Reporting of Performance and Other Information 
                on Physician Compare.--'';
                    (B) by redesignating subsections (a) through (i) as 
                paragraphs (1) through (9), respectively, and indenting 
                appropriately;
                    (C) in paragraph (1), as redesignated by 
                subparagraph (B)--
                            (i) by redesignating paragraphs (1) and (2) 
                        as subparagraphs (A) and (B), respectively, and 
                        indenting appropriately;
                            (ii) in subparagraph (B), as redesignated 
                        by clause (i), by redesignating subparagraphs 
                        (A) through (G) as clauses (i) through (vii), 
                        respectively, and indenting appropriately;
                    (D) in paragraph (2), as redesignated by 
                subparagraph (B), by redesignating paragraphs (1) 
                through (7) as subparagraphs (A) through (G), 
                respectively, and indenting appropriately; and
                    (E) in paragraph (9), as redesignated by 
                subparagraph (B), by redesignating paragraphs (1) 
                through (4) as subparagraphs (A) through (D), 
                respectively, and indenting appropriately.
            (3) Conforming amendments.--Section 1848(t) of the Social 
        Security Act (42 U.S.C. 1395w-4(t)), as amended by paragraph 
        (2), is further amended--
                    (A) in paragraph (1)--
                            (i) in subparagraph (A)--
                                    (I) by striking ``the Medicare 
                                program under section 1866(j) of the 
                                Social Security Act (42 U.S.C. 
                                1395cc(j))'' and inserting ``the 
                                program under this title under section 
                                1866(j)''; and
                                    (II) by striking ``of such Act (42 
                                U.S.C. 1395w-4)''; and
                            (ii) in subparagraph (B), in the matter 
                        preceding clause (i)--
                                    (I) by striking ``subsection (c)'' 
                                and inserting ``paragraph (3)'';
                                    (II) by striking ``the Medicare 
                                program under such section 1866(j)'' 
                                and inserting ``the program under this 
                                title under section 1866(j)''; and
                                    (III) by striking ``this section'' 
                                and inserting ``this subsection'';
                    (B) in paragraph (2)--
                            (i) in the matter preceding subparagraph 
                        (A), by striking ``subsection (a)(2)'' and 
                        inserting ``paragraph (1)(B)'';
                            (ii) in subparagraph (D), by striking ``the 
                        Medicare program'' and inserting ``the program 
                        under this title''; and
                            (iii) in each of subparagraphs (F) and (G), 
                        by striking ``this section'' and inserting 
                        ``this subsection'';
                    (C) in paragraph (3), by striking ``this section'' 
                and inserting ``this subsection'';
                    (D) in paragraph (4)--
                            (i) by striking ``of the Social Security 
                        Act, as added by section 3014 of this Act''; 
                        and
                            (ii) by striking ``this section'' and 
                        inserting ``this subsection'';
                    (E) in paragraph (5)--
                            (i) by striking ``this subsection (a)(2)'' 
                        and inserting ``paragraph (1)(B)''; and
                            (ii) by striking ``(Public Law 110-275)'';
                    (F) in paragraph (6), by striking ``subsection 
                (a)(1)'' and inserting ``paragraph (1)(A)'';
                    (G) in paragraph (7)--
                            (i) by striking ``subsection (f)'' and 
                        inserting ``paragraph (6)''; and
                            (ii) by striking ``title XVIII of the 
                        Social Security Act'' and inserting ``this 
                        title'';
                    (H) in paragraph (8)--
                            (i) by striking ``subparagraphs (A) through 
                        (G) of subsection (a)(2)'' and inserting 
                        ``clauses (i) through (vii) of paragraph 
                        (1)(B)'';
                            (ii) by striking ``title XVIII of the 
                        Social Security Act'' and inserting ``this 
                        title''; and
                            (iii) by striking ``such title'' and 
                        inserting ``this title''; and
                    (I) in paragraph (9)--
                            (i) in the matter preceding subparagraph 
                        (A), by striking ``this section'' and inserting 
                        ``this subsection'';
                            (ii) in subparagraph (A), by striking ``of 
                        the Social Security Act (42 U.S.C. 1395w-4)'';
                            (iii) in subparagraph (B), by striking ``of 
                        such Act (42 U.S.C. 1395x(r))'';
                            (iv) in subparagraph (C), by striking 
                        ``subsection (a)(1)'' and inserting ``paragraph 
                        (1)(A)''; and
                            (v) by striking subparagraph (D).
    (b) Public Availability of Medicare Data.--Section 1848(t) of the 
Social Security Act (42 U.S.C. 1395w-4(t)), as amended by subsection 
(a), is further amended--
            (1) by redesignating paragraph (9) as paragraph (10);
            (2) by inserting after paragraph (8) the following new 
        paragraph:
            ``(9) Public availability of eligible professional claims 
        data.--
                    ``(A) In general.--The Secretary shall make 
                publicly available on Physician Compare the information 
                described in subparagraph (B) with respect to eligible 
                professionals.
                    ``(B) Information described.--The following 
                information, with respect to an eligible professional, 
                is described in this subparagraph:
                            ``(i) Information on the number of services 
                        furnished by the eligible professional, which 
                        may include information on the most frequent 
                        services furnished or groupings of services.
                            ``(ii) Information on submitted charges and 
                        payments for services under this part.
                            ``(iii) A unique identifier for the 
                        eligible professional that is available to the 
                        public, such as a national provider identifier.
                    ``(C) Searchability.--The information made 
                available under this paragraph shall be searchable by 
                at least the following:
                            ``(i) The specialty or type of the eligible 
                        professional.
                            ``(ii) Characteristics of the services 
                        furnished, such as volume or groupings of 
                        services.
                            ``(iii) The location of the eligible 
                        professional.
                    ``(D) Disclosure.--The information made available 
                under this paragraph shall indicate, where appropriate, 
                that publicized information may not be representative 
                of the eligible professional's entire patient 
                population, the variety of services furnished by the 
                eligible professional, or the health conditions of 
                individuals treated.
                    ``(E) Implementation.--
                            ``(i) Initial implementation.--Physician 
                        Compare shall include the information described 
                        in subparagraph (B)--
                                    ``(I) with respect to physicians, 
                                by not later than July 1, 2015; and
                                    ``(II) with respect to other 
                                eligible professionals, by not later 
                                than July 1, 2016.
                            ``(ii) Annual updating.--The information 
                        made available under this paragraph shall be 
                        updated on Physician Compare not less 
                        frequently than on an annual basis.
                    ``(F) Opportunity to review and submit 
                corrections.--The Secretary shall provide for an 
                opportunity for an eligible professional to review, and 
                submit corrections for, the information to be made 
                public with respect to the eligible professional under 
                this paragraph prior to such information being made 
                public.''; and
            (3) in paragraph (10)(C), as redesignated by paragraph (1), 
        by inserting ``(or a successor website)'' before the period at 
        the end.

SEC. 8. EXPANDING CLAIMS DATA AVAILABILITY TO IMPROVE CARE.

    (a) Expansion of Uses of Claims Data by Qualified Entities.--
Section 1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is 
amended by adding at the end the following new paragraph:
            ``(5) Expansion of uses of claims data by qualified 
        entities.--
                    ``(A) Expansion.--To the extent consistent with 
                applicable information, privacy, security, and 
                disclosure laws, beginning July 1, 2014, 
                notwithstanding paragraph (4)(B) (other than clause 
                (iii) of such paragraph) and the second sentence of 
                paragraph (4)(D), a qualified entity may, as determined 
                appropriate by the Secretary, do any or all of the 
                following:
                            ``(i)(I) Use the combined data described in 
                        paragraph (4)(B)(iii) to conduct analyses, 
                        other than for reports described in paragraph 
                        (4), for entities described in subparagraph (B) 
                        for non-public uses, as determined appropriate 
                        by the Secretary, such as for the purposes 
                        described in subclause (II).
                            ``(II) The purposes described in this 
                        subclause are assisting providers of services 
                        and suppliers in developing and participating 
                        in quality and patient care improvement 
                        activities (including developing new models of 
                        care), population health management, and 
                        disease monitoring, and the purposes described 
                        in subparagraph (C).
                            ``(ii) Provide or sell such analyses to 
                        entities described in subparagraph (B).
                            ``(iii) Provide entities described in 
                        clauses (i), (ii), (v), and (vi) of 
                        subparagraph (B) with access to the combined 
                        data described in paragraph (4)(B)(iii) through 
                        a qualified data enclave (as defined in 
                        subparagraph (F)) that is maintained by the 
                        qualified entity in order for entities 
                        described in such clauses to conduct analyses 
                        for non-public uses, such as for the purposes 
                        described in clause (i)(II).
                    ``(B) Entities described.--For the purpose of 
                subparagraph (A) clauses (i) and (ii), the entities 
                described in this subparagraph are the following:
                            ``(i) A provider of services.
                            ``(ii) A supplier.
                            ``(iii) Subject to subparagraph (C), an 
                        employer (as defined in section 3(5) of the 
                        Employee Retirement Insurance Security Act of 
                        1974).
                            ``(iv) A health insurance issuer (as 
                        defined in section 2791 of the Public Health 
                        Service Act) that provides data under paragraph 
                        (4)(B)(iii).
                            ``(v) A medical society or hospital 
                        association.
                            ``(vi) Other entities approved by the 
                        Secretary (other than an employer (as so 
                        defined) and a health insurance issuer (as so 
                        defined)).
                    ``(C) Limitation with respect to employers.--Any 
                analyses provided or sold under this paragraph to an 
                employer (as so defined) may only be used by such 
                employer for purposes of providing health insurance to 
                employees and retirees of the employer.
                    ``(D) Protection of patient identification.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), an analysis provided or sold under 
                        this paragraph shall not contain information 
                        that individually identifies a patient.
                            ``(ii) Information on patients of the 
                        provider of services or supplier.--An analysis 
                        that is provided or sold under this paragraph 
                        to a provider of services or supplier may 
                        contain data that individually identifies a 
                        patient of such provider or supplier but only 
                        with respect to items and services furnished by 
                        such provider or supplier to such patient.
                            ``(iii) Opportunity for providers of 
                        services and suppliers to review.--Prior to a 
                        qualified entity providing or selling an 
                        analysis under this paragraph to an entity 
                        described in subparagraph (B), to the extent 
                        that such analysis would individually identify 
                        a provider of services or supplier who is not 
                        being provided or sold such analysis, such 
                        qualified entity shall provide an opportunity 
                        for such provider or supplier to review and 
                        submit corrections to such analysis.
                    ``(E) No redisclosure.--An entity described in 
                subparagraph (B) that is provided or sold an analysis 
                under this paragraph shall not redisclose or make 
                public such an analysis.
                    ``(F) Requirements for a qualified data enclave.--
                            ``(i) Definition.--For purposes of this 
                        paragraph, the term `qualified data enclave' 
                        means a data enclave that the Secretary 
                        determines meets the following:
                                    ``(I) The data enclave is a web-
                                based portal or comparable mechanism.
                                    ``(II) Subject to the requirements 
                                described in clause (ii) and such other 
                                requirements as the Secretary may 
                                specify, the data enclave is capable of 
                                providing access to the combined data 
                                described in subparagraph (A)(iii).
                            ``(ii) Enclave access requirements.--The 
                        requirements described in this clause are the 
                        following:
                                    ``(I) A qualified data enclave 
                                shall preclude any entity that obtains 
                                access to the data from removing or 
                                extracting the data from such enclave.
                                    ``(II) Subject to the succeeding 
                                sentence, the enclave shall preclude 
                                access to data that individually 
                                identifies a patient, including data on 
                                the patient's name and date of birth 
                                and such other data as the Secretary 
                                shall specify. Such data enclave may 
                                provide providers of services and 
                                suppliers with access to such 
                                individually identifiable patient data 
                                but only with respect to items and 
                                services furnished by such provider or 
                                supplier to such patient.
                                    ``(III) Access to data in the 
                                enclave shall not be provided to any 
                                entity unless the qualified entity and 
                                the entity have entered into a data use 
                                agreement, the terms of which contain 
                                the requirements of this paragraph and 
                                such other terms the Secretary may 
                                specify.
                    ``(G) Annual reports.--Any qualified entity that 
                provides or sells analyses pursuant to subparagraph 
                (A)(ii) or provides access to a qualified data enclave 
                pursuant to subparagraph (A)(iii) shall annually submit 
                to the Secretary a report that includes--
                            ``(i) a summary of the analyses provided or 
                        sold, including the number of such analyses, 
                        the number of purchasers of such analyses, and 
                        the total amount of fees received for such 
                        analyses;
                            ``(ii) a description of the topics and 
                        purposes of such analyses;
                            ``(iii) information on the entities who 
                        obtained access to the qualified data enclave, 
                        the uses of the data, and the total amount of 
                        fees received for providing such access; and
                            ``(iv) other information determined 
                        appropriate by the Secretary.''.
    (b) Expansion of Data Available to Qualified Entities.--Section 
1874(e) of the Social Security Act (42 U.S.C. 1395kk(e)) is amended--
            (1) in the subsection heading, by striking ``Medicare''; 
        and
            (2) in paragraph (3)--
                    (A) by inserting after the first sentence the 
                following new sentence: ``Effective July 1, 2014, if 
                the Secretary determines appropriate, the data 
                described in this paragraph may also include 
                standardized extracts (as determined by the Secretary) 
                of claims data under titles XIX and XXI for assistance 
                provided under such titles for one or more specified 
                geographic areas and time periods requested by a 
                qualified entity.''; and
                    (B) in the last sentence, by inserting ``or under 
                titles XIX or XXI'' before the period at the end.
    (c) Access to Medicare Data by Qualified Clinical Data Registries 
to Facilitate Quality Improvement.--Section 1848(m)(3)(E) of the Social 
Security Act (42 U.S.C. 1395w-4(m)(3)(E)) is amended by adding at the 
end the following new clause:
                            ``(vi) Access to medicare data to 
                        facilitate quality improvement.--
                                    ``(I) In general.--To the extent 
                                consistent with applicable information, 
                                privacy, security, and disclosure laws, 
                                and subject to other requirements as 
                                the Secretary may specify, beginning 
                                July 1, 2014, the Secretary shall, if 
                                requested by a qualified clinical data 
                                registry under this subparagraph, 
                                subject to subclauses (II) and (III), 
                                provide data as described in section 
                                1874(e)(3) (in a form and manner 
                                determined to be appropriate) to such 
                                registry for purposes of linking such 
                                data with clinical data and performing 
                                analyses and research to support 
                                quality improvement or patient safety.
                                    ``(II) Protection.--A qualified 
                                clinical data registry may not publicly 
                                report any data made available under 
                                subclause (I) (or any analyses or 
                                research described in such subclause) 
                                that individually identifies a provider 
                                of services, supplier, or individual 
                                unless the registry obtains the consent 
                                of such provider, supplier, or 
                                individual prior to such reporting.
                                    ``(III) Fee.--The data described in 
                                subclause (I) shall be made available 
                                to qualified clinical data registries 
                                at a fee equal to the cost of making 
                                such data available. Any fee collected 
                                pursuant to the preceding sentence 
                                shall be deposited in the Centers for 
                                Medicare & Medicaid Services Program 
                                Management Account.''.
    (d) Revision of Placement of Fees.--Section 1874(e)(4)(A) of the 
Social Security Act (42 U.S.C. 1395kk(e)(4)(A)) is amended, in the 
second sentence--
            (1) by inserting ``, for periods prior to July 1, 2014,'' 
        after ``deposited''; and
            (2) by inserting the following before the period at the 
        end: ``, and, beginning July 1, 2014, into the Centers for 
        Medicare & Medicaid Services Program Management Account''.

SEC. 9. REDUCING ADMINISTRATIVE BURDEN AND OTHER PROVISIONS.

    (a) Medicare Physician and Practitioner Opt-out to Private 
Contract.--
            (1) Indefinite, continuing automatic extension of opt out 
        election.--
                    (A) In general.--Section 1802(b)(3) of the Social 
                Security Act (42 U.S.C. 1395a(b)(3)) is amended--
                            (i) in subparagraph (B)(ii), by striking 
                        ``during the 2-year period beginning on the 
                        date the affidavit is signed'' and inserting 
                        ``during the applicable 2-year period (as 
                        defined in subparagraph (D))'';
                            (ii) in subparagraph (C), by striking 
                        ``during the 2-year period described in 
                        subparagraph (B)(ii)'' and inserting ``during 
                        the applicable 2-year period''; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(D) Applicable 2-year periods for effectiveness 
                of affidavits.--In this subsection, the term 
                `applicable 2-year period' means, with respect to an 
                affidavit of a physician or practitioner under 
                subparagraph (B), the 2-year period beginning on the 
                date the affidavit is signed and includes each 
                subsequent 2-year period unless the physician or 
                practitioner involved provides notice to the Secretary 
                (in a form and manner specified by the Secretary), not 
                later than 30 days before the end of the previous 2-
                year period, that the physician or practitioner does 
                not want to extend the application of the affidavit for 
                such subsequent 2-year period.''.
                    (B) Effective date.--The amendments made by 
                subparagraph (A) shall apply to affidavits entered into 
                on or after the date that is 60 days after the date of 
                the enactment of this Act.
            (2) Public availability of information on opt-out 
        physicians and practitioners.--Section 1802(b) of the Social 
        Security Act (42 U.S.C. 1395a(b)) is amended--
                    (A) in paragraph (5), by adding at the end the 
                following new subparagraph:
                    ``(D) Opt-out physician or practitioner.--The term 
                `opt-out physician or practitioner' means a physician 
                or practitioner who has in effect an affidavit under 
                paragraph (3)(B).'';
                    (B) by redesignating paragraph (5) as paragraph 
                (6); and
                    (C) by inserting after paragraph (4) the following 
                new paragraph:
            ``(5) Posting of information on opt-out physicians and 
        practitioners.--
                    ``(A) In general.--Beginning not later than 
                February 1, 2015, the Secretary shall make publicly 
                available through an appropriate publicly accessible 
                website of the Department of Health and Human Services 
                information on the number and characteristics of opt-
                out physicians and practitioners and shall update such 
                information on such website not less often than 
                annually.
                    ``(B) Information to be included.--The information 
                to be made available under subparagraph (A) shall 
                include at least the following with respect to opt-out 
                physicians and practitioners:
                            ``(i) Their number.
                            ``(ii) Their physician or professional 
                        specialty or other designation.
                            ``(iii) Their geographic distribution.
                            ``(iv) The timing of their becoming opt-out 
                        physicians and practitioners, relative to when 
                        they first entered practice and with respect to 
                        applicable 2-year periods.
                            ``(v) The proportion of such physicians and 
                        practitioners who billed for emergency or 
                        urgent care services.''.
    (b) Medicare Non-participating Physicians Demonstration Project.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this subsection referred to as the ``Secretary'') shall 
        establish and implement a demonstration project (in this 
        section referred to as the ``demonstration project'') under 
        title XVIII of the Social Security Act to provide that payments 
        for services under such title furnished by non-participating 
        physicians (as defined in section 1861(r)(1) of the Social 
        Security Act (42 U.S.C. 1395x(r)(1))) to individuals entitled 
        to benefits under part A or enrolled under part B of such title 
        are paid directly to such physicians. The Secretary shall carry 
        out the demonstration project in a geographic area that is a 
        statistically significant area no larger than a State.
            (2) Advance notice to physicians.--The Secretary shall, in 
        a timely manner and prior to the beginning of the year in which 
        payment will be made under the demonstration project, notify 
        physicians in the geographic area described in paragraph (1) of 
        the option to participate in the demonstration project.
            (3) Timetable for implementation.--
                    (A) Demonstration start date.--The demonstration 
                project shall apply with respect to services furnished 
                beginning on January 1, 2015.
                    (B) 1-year duration.--The Secretary shall implement 
                the demonstration project such that payments are made 
                under such demonstration project for a period of 1 
                year.
            (4) Report.--Not later than 18 months after the date of the 
        conclusion of the demonstration project, the Secretary shall 
        submit to Congress a report analyzing the impact of the 
        demonstration project. Such report shall include an analysis of 
        the impact, if any, of the demonstration project upon the--
                    (A) percentage and number of physicians who choose 
                not to participate under title XVIII of the Social 
                Security Act and a comparison of such percentage and 
                number to the previous year;
                    (B) percentage of claims submitted by and payments 
                made to physicians in the demonstration that are 
                unassigned and a comparison of unassigned claims and 
                payments by non-participating physicians in the 
                previous year;
                    (C) percentage and number of the physicians in the 
                demonstration by specialty designation; and
                    (D) access to services for which payment is made 
                under such title for individuals entitled to benefits 
                under part A or enrolled under part B of such title.
            (5) Beneficiary notice.--
                    (A) Notice by secretary to beneficiaries.--The 
                Secretary shall notify individuals entitled to benefits 
                under part A or enrolled under part B of title XVIII of 
                the Social Security Act in the geographic area in which 
                the demonstration project is conducted of the 
                implications of physician participation in the 
                demonstration project.
                    (B) Notice by physicians to patients.--A physician 
                who elects to participate in the demonstration project 
                shall notify individuals to whom the physician 
                furnishes services for which payment will be provided 
                under the demonstration project of such election. Such 
                notification shall be provided prior to the provision 
                of service and include a notification, with respect to 
                each such individual, that--
                            (i) the right of the individual to payment 
                        is being reassigned to the physician;
                            (ii) payment for services furnished by the 
                        physician to such individual will be made 
                        directly to the physician; and
                            (iii) the individual is responsible for the 
                        remaining amount, which may be higher than 
                        would be the case if the physician participated 
                        in the Medicare program.
    (c) Gainsharing Study and Report.--Not later than 6 months after 
the date of the enactment of this Act, the Secretary of Health and 
Human Services, in consultation with the Inspector General of the 
Department of Health and Human Services, shall submit to Congress a 
report with legislative recommendations to amend existing fraud and 
abuse laws, through exceptions, safe harbors, or other narrowly 
targeted provisions, to permit gainsharing or similar arrangements 
between physicians and hospitals that improve care while reducing waste 
and increasing efficiency. The report shall--
            (1) consider whether such provisions should apply to 
        ownership interests, compensation arrangements, or other 
        relationships; and
            (2) describe how the recommendations address 
        accountability, transparency, and quality, including how best 
        to limit inducements to stint on care, discharge patients 
        prematurely, or otherwise reduce or limit medically necessary 
        care; and
            (3) consider whether a portion of any savings generated by 
        such arrangements should accrue to the Medicare program under 
        title XVIII of the Social Security Act.
    (d) Promoting Interoperability of Electronic Health Record 
Systems.--
            (1) Recommendations for achieving widespread ehr 
        interoperability.--
                    (A) Objective.--As a consequence of a significant 
                Federal investment in the implementation of health 
                information technology through the Medicare EHR 
                incentive programs, Congress declares it a national 
                objective to achieve widespread and nationwide exchange 
                of health information through interoperable certified 
                EHR technology by December 31, 2019.
                    (B) Definitions.--In this paragraph:
                            (i) Widespread interoperability.--The term 
                        ``widespread interoperability'' means 
                        nationwide interoperability between certified 
                        EHR technology systems employed by meaningful 
                        EHR users under the Medicare EHR incentive 
                        programs and other clinicians and health care 
                        providers.
                            (ii) Interoperability.--The term 
                        ``interoperability'' means the ability of two 
                        or more health information systems or 
                        components to exchange clinical and other 
                        information and to use the information that has 
                        been exchanged using common standards as to 
                        provide access to longitudinal information for 
                        health care providers in order to facilitate 
                        coordinated care and improved patient outcomes.
                    (C) Establishment of metrics.--Not later than 
                December 31, 2015, and in consultation with 
                stakeholders, the Secretary shall establish metrics to 
                be used to determine if and to the extent that the 
                objective described in subparagraph (A) has been 
                achieved.
                    (D) Recommendations if objective not achieved.--If 
                the Secretary of Health and Human Services determines 
                that the objective described in subparagraph (A) has 
                not been achieved by December 31, 2017, then the 
                Secretary shall submit to Congress a report, by not 
                later than December 31, 2018, that identifies barriers 
                to such objective and recommends actions that the 
                Federal Government can take to achieve such objective. 
                Such recommended actions may include recommendations--
                            (i) to adjust payments for meaningful EHR 
                        users under the Medicare EHR incentive 
                        programs; and
                            (ii) for criteria for decertifying 
                        certified EHR technology products.
            (2) Preventing blocking the sharing of information.--
                    (A) For meaningful ehr professionals.--Section 
                1848(o)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
                1395w-4(o)(2)(A)(ii)) is amended by inserting before 
                the period at the end the following: ``, and the 
                professional demonstrates (through a process specified 
                by the Secretary, such as the use of an attestation 
                similar to that required in the health information 
                technology donation safe harbor established under 
                regulations under section 1128B(b)(3)(E)) that the 
                professional has not and will not take any deliberate 
                action to limit or restrict the use, compatibility, or 
                interoperability of the certified EHR technology''.
                    (B) For meaningful ehr hospitals.--Section 
                1886(n)(3)(A)(ii) of the Social Security Act (42 U.S.C. 
                1395ww(n)(3)(A)(ii)) is amended by inserting before the 
                period at the end the following: ``, and the hospital 
                demonstrates (through a process specified by the 
                Secretary, such as the use of an attestation referred 
                to in section 1848(o)(2)(A)(ii)) that the hospital has 
                not and will not take any deliberate action to limit or 
                restrict the use, compatibility, or interoperability of 
                the certified EHR technology''.
                    (C) Effective date.--The amendments made by this 
                subsection shall apply to meaningful EHR users as of 
                the date that is 6 months after the date of the 
                enactment of this Act.
            (3) Study and report on the feasibility of establishing a 
        website to compare certified ehr technology products.--
                    (A) Study.--The Secretary shall conduct a study to 
                examine the feasibility of establishing a website (in 
                this subsection referred to as the ``website'') that 
                includes aggregated results of surveys of meaningful 
                EHR users on the functionality of certified EHR 
                technology products to enable such users to directly 
                compare the functionality and other features of such 
                products. Such information may be made available 
                through contracts with physician, hospital, or other 
                organizations that maintain such comparative 
                information.
                    (B) Report.--Not later than 1 year after the date 
                of the enactment of this Act, the Secretary shall 
                submit to Congress a report on the website. The report 
                shall include information on the benefits and resources 
                of such a website.
            (4) Definitions.--In this subsection:
                    (A) The term ``certified EHR technology'' has the 
                meaning given such term in section 1848(o)(4) of the 
                Social Security Act (42 U.S.C. 1395w-4(o)(4)).
                    (B) The term ``meaningful EHR hospital'' means an 
                eligible hospital (as defined in section 1886(n)(6)(A) 
                of the Social Security Act (42 U.S.C. 1395ww(n)(6)(A)) 
                that is a meaningful EHR user.
                    (C) The term ``meaningful EHR professional'' means 
                an eligible professional (as defined in section 
                1848(o)(5)(C) of the Social Security Act (42 U.S.C. 
                1395w-4(o)(5)(C)) who is a meaningful EHR user.
                    (D) The term ``meaningful EHR user'' has the 
                meaning given such term under the Medicare EHR 
                incentive programs.
                    (E) The term ``Medicare EHR incentive programs'' 
                means the incentive programs under section 1848(o), 
                subsections (l) and (m) of section 1853, and section 
                1886(n) of the Social Security Act (42 U.S.C. 1395w-
                4(o), 1395w-23, 1395ww(n)).
                    (F) The term ``Secretary'' means the Secretary of 
                Health and Human Services.
    (e) GAO Study and Report on the Use of Telehealth Under Federal 
Programs.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the following:
                    (A) How the definition of telehealth across various 
                Federal programs and federal efforts can inform the use 
                of telehealth in the Medicare program under title XVIII 
                of the Social Security Act (42 U.S.C. 1395 et seq.).
                    (B) Issues that can facilitate or inhibit the use 
                of telehealth under the Medicare program under such 
                title, including oversight and professional licensure, 
                changing technology, privacy and security, 
                infrastructure requirements, and varying needs across 
                urban and rural areas.
                    (C) Potential implications of greater use of 
                telehealth with respect to payment and delivery system 
                transformations under the Medicare program under such 
                title XVIII and the Medicaid program under title XIX of 
                such Act (42 U.S.C. 1396 et seq.).
                    (D) How the Centers for Medicare & Medicaid 
                Services conducts oversight of payments made under the 
                Medicare program under such title XVIII to providers 
                for telehealth services.
            (2) Report.--Not later than 24 months after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report containing the results of the study conducted 
        under paragraph (1), together with recommendations for such 
        legislation and administrative action as the Comptroller 
        General determines appropriate.
    (f) Rule of Construction Regarding Health Care Provider Standards 
of Care.--
            (1) In general.--The development, recognition, or 
        implementation of any guideline or other standard under any 
        Federal health care provision shall not be construed to 
        establish the standard of care or duty of care owed by a health 
        care provider to a patient in any medical malpractice or 
        medical product liability action or claim.
            (2) Definitions.--For purposes of this subsection:
                    (A) The term ``Federal health care provision'' 
                means any provision of the Patient Protection and 
                Affordable Care Act (Public Law 111-148), title I and 
                subtitle B of title III of the Health Care and 
                Education Reconciliation Act of 2010 (Public Law 111-
                152), and titles XVIII and XIX of the Social Security 
                Act.
                    (B) The term ``health care provider'' means any 
                individual or entity--
                            (i) licensed, registered, or certified 
                        under Federal or State laws or regulations to 
                        provide health care services; or
                            (ii) required to be so licensed, 
                        registered, or certified but that is exempted 
                        by other statute or regulation.
                    (C) The term ``medical malpractice or medical 
                liability action or claim'' means a medical malpractice 
                action or claim (as defined in section 431(7) of the 
                Health Care Quality Improvement Act of 1986 (42 U.S.C. 
                11151(7))) and includes a liability action or claim 
                relating to a health care provider's prescription or 
                provision of a drug, device, or biological product (as 
                such terms are defined in section 201 of the Federal 
                Food, Drug, and Cosmetic Act or section 351 of the 
                Public Health Service Act).
                    (D) The term ``State'' includes the District of 
                Columbia, Puerto Rico, and any other commonwealth, 
                possession, or territory of the United States.
            (3) No preemption.--No provision of the Patient Protection 
        and Affordable Care Act (Public Law 111-148), title I or 
        subtitle B of title III of the Health Care and Education 
        Reconciliation Act of 2010 (Public Law 111-152), or title XVIII 
        or XIX of the Social Security Act shall be construed to preempt 
        any State or common law governing medical professional or 
        medical product liability actions or claims.
                                                 Union Calendar No. 283

113th CONGRESS

  2d Session

                               H. R. 2810

                  [Report No. 113-257, Parts I and II]

_______________________________________________________________________

                                 A BILL

     To amend title XVIII of the Social Security Act to reform the 
sustainable growth rate and Medicare payment for physicians' services, 
                        and for other purposes.

_______________________________________________________________________

                             March 14, 2014

   Reported from the Committee on Ways and Means with an amendment, 
   committed to the Committee of the Whole House on the State of the 
                    Union, and ordered to be printed