[Congressional Record Volume 160, Number 43 (Friday, March 14, 2014)]
[House]
[Pages H2439-H2470]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SGR REPEAL AND MEDICARE PROVIDER PAYMENT MODERNIZATION ACT OF 2014
Mr. PITTS. Mr. Speaker, pursuant to House Resolution 515, I call up
the bill (H.R. 4015) to amend title XVIII of the Social Security Act to
repeal the Medicare sustainable growth rate and improve Medicare
payments for physicians and other professionals, and for other purposes
to amend section 530D of title 28, United States Code, and ask for its
immediate consideration in the House.
The Clerk read the title of the bill.
The SPEAKER pro tempore. Pursuant to House Resolution 515, the
amendment printed in part B of House Report 113-379 is adopted and the
bill, as amended, is considered read.
The text of the bill, as amended, is as follows:
H.R. 4015
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 ``SGR Repeal
and Medicare Provider Payment Modernization Act of 2014''.
(b) Table of Contents.--The table of contents of 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 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 availability of Medicare data.
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), in the matter preceding subparagraph
(A), by inserting ``and ending with 2013'' after ``beginning
with 2000''.
(2) Update of rates for april through december of 2014,
2015, and subsequent years.--Subsection (d) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4) is amended by
striking paragraph (15) and inserting the following new
paragraphs:
``(15) Update for 2014 through 2018.--The update to the
single conversion factor established in paragraph (1)(C) for
2014 and each subsequent year through 2018 shall be 0.5
percent.
``(16) Update for 2019 through 2023.--The update to the
single conversion factor established in paragraph (1)(C) for
2019 and each subsequent year 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,
1.0 percent; and
``(B) for other items and services, 0.5 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.
(C) Report on update to physicians' services under
medicare.--Not later than July 1, 2018, the Medicare Payment
Advisory Commission shall submit to Congress a report on--
(i) the payment update for professional services applied
under the Medicare program under title XVIII of the Social
Security Act for the period of years 2014 through 2018;
(ii) the effect of such update on the efficiency, economy,
and quality of care provided under such program;
(iii) the effect of such update on ensuring a sufficient
number of providers to maintain access to care by Medicare
beneficiaries; and
(iv) recommendations for any future payment updates for
professional services under such program to ensure adequate
access to care is maintained for Medicare beneficiaries.
(b) Consolidation of Certain Current Law Performance
Programs With New Merit-Based Incentive Payment System.--
(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 2017'';
(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
mips.--Section 1848(o)(2) of
[[Page H2440]]
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 mips.--With
respect to 2018 and each subsequent payment year, the
Secretary shall, for purposes of subsection (q) and in
accordance with paragraph (1)(F) of such subsection,
determine whether an eligible professional who is a MIPS
eligible professional (as defined in subsection (q)(1)(C))
for such year is a meaningful EHR user under this paragraph
for the performance period under subsection (q) for such
year.''.
(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 2017''; and
(ii) in clause (ii)(II), by striking ``and each subsequent
year''.
(B) Continuation of quality measures and processes for
mips.--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 mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
provisions of this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS eligible
professionals (as defined in subsection (q)(1)(C)) for the
year involved.''; and
(ii) in subsection (m)--
(I) by redesignating 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 mips and for
certain professionals volunteering to report.--The Secretary
shall, in accordance with subsection (q)(1)(F), carry out the
processes under this subsection--
``(A) for purposes of subsection (q); and
``(B) for eligible professionals who are not MIPS eligible
professionals (as defined in subsection (q)(1)(C)) for the
year involved.''.
(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, 2018, 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, 2018.''.
(B) Continuation of value-based payment modifier measures
for mips.--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 mips.--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 2018 and each subsequent year, the
Secretary shall, in accordance with subsection (q)(1)(F),
carry out this paragraph for purposes of subsection (q).''.
(c) Merit-Based Incentive Payment System.--
(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) Merit-Based Incentive Payment System.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall establish an eligible
professional Merit-based Incentive Payment System (in this
subsection referred to as the `MIPS') under which the
Secretary shall--
``(i) develop a methodology for assessing the total
performance of each MIPS eligible professional according to
performance standards under paragraph (3) for a performance
period (as established under paragraph (4)) for a year;
``(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 MIPS
eligible professional for a performance period for a year to
determine and apply a MIPS adjustment factor (and, as
applicable, an additional MIPS adjustment factor) under
paragraph (6) to the professional for the year.
``(B) Program implementation.--The MIPS shall apply to
payments for items and services furnished on or after January
1, 2018.
``(C) MIPS eligible professional defined.--
``(i) In general.--For purposes of this subsection, subject
to clauses (ii) and (iv), the term `MIPS eligible
professional' means--
``(I) for the first and second years for which the MIPS
applies to payments (and for the performance period for such
first and second year), a physician (as defined in section
1861(r)), a physician assistant, nurse practitioner, and
clinical nurse specialist (as such terms are defined in
section 1861(aa)(5)), and a certified registered nurse
anesthetist (as defined in section 1861(bb)(2)) and a group
that includes such professionals; and
``(II) for the third year for which the MIPS applies to
payments (and for the performance period for such third year)
and for each succeeding year (and for the performance period
for each such year), the professionals described in subclause
(I) and such other eligible professionals (as defined in
subsection (k)(3)(B)) as specified by the Secretary and a
group that includes such professionals.
``(ii) Exclusions.--For purposes of clause (i), the term
`MIPS eligible professional' does not include, with respect
to a year, an eligible professional (as defined in subsection
(k)(3)(B)) who--
``(I) is a qualifying APM participant (as defined in
section 1833(z)(2));
``(II) subject to clause (vii), is a partial qualifying APM
participant (as defined in clause (iii)) for the most recent
period for which data are available and who, for the
performance period with respect to such year, does not report
on applicable measures and activities described in paragraph
(2)(B) that are required to be reported by such a
professional under the MIPS; or
``(III) 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 2018 and 2019, the reference in
subparagraph (A) of such paragraph to 25 percent was instead
a reference to 20 percent;
``(II) with respect to 2020 and 2021--
``(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 2022 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 a low-volume threshold to apply for
purposes of clause (ii)(III), which may include one or more
or a combination of the following:
``(I) The minimum number (as determined by the Secretary)
of individuals enrolled under this part who are treated by
the eligible professional for the performance period
involved.
``(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 MIPS 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 MIPS
eligible professional (including pursuant to clauses (ii) and
(v)) with respect to a year, in no case shall a MIPS
adjustment factor (or additional MIPS adjustment factor)
under paragraph (6) apply to such individual for such year.
``(vii) Partial qualifying apm participant
clarifications.--
``(I) Treatment as mips eligible professional.--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
[[Page H2441]]
the MIPS, such eligible professional is considered to be a
MIPS eligible professional with respect to such year.
``(II) Not eligible for qualifying apm participant
payments.--In no case shall an eligible professional who is a
partial qualifying APM participant, with respect to a year,
be considered a qualifying APM participant (as defined in
paragraph (2) of section 1833(z)) for such year or be
eligible for the additional payment under paragraph (1) of
such section for such year.
``(D) Application to group practices.--
``(i) In general.--Under the MIPS:
``(I) Quality performance category.--The Secretary shall
establish and apply a process that includes features of the
provisions of subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with respect to assessing
performance of such group with respect to the performance
category described in clause (i) of paragraph (2)(A).
``(II) Other performance categories.--The Secretary may
establish and apply a process that includes features of the
provisions of subsection (m)(3)(C) for MIPS eligible
professionals in a group practice with respect to assessing
the performance of such group with respect to the performance
categories described in clauses (ii) through (iv) of such
paragraph.
``(ii) Ensuring comprehensiveness of group practice
assessment.--The process established under clause (i) shall
to the extent practicable reflect the range of items and
services furnished by the MIPS eligible professionals in the
group practice involved.
``(iii) Clarification.--MIPS eligible professionals
electing to be a virtual group under paragraph (5)(I) shall
not be considered MIPS eligible professionals in a group
practice for purposes of applying this subparagraph.
``(E) Use of registries.--Under the MIPS, the Secretary
shall encourage the use of qualified clinical data registries
pursuant to subsection (m)(3)(E) in carrying out this
subsection.
``(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.
``(G) Accounting for risk factors.--
``(i) Risk factors.--Taking into account the relevant
studies conducted and recommendations made in reports under
section 2(f)(1) of the SGR Repeal and Medicare Provider
Payment Modernization Act of 2014, 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 MIPS.
``(ii) Accounting for other factors in payment
adjustments.--Taking into account the studies conducted and
recommendations made in reports under section 2(f)(1) of the
SGR Repeal and Medicare Provider Payment Modernization Act of
2014 and other information as appropriate, the Secretary
shall account for identified factors with an effect on
quality and resource use outcome measures when determining
payment adjustments, composite performance scores, scores for
performance categories, or scores for measures or activities
under the MIPS.
``(2) Measures and activities under performance
categories.--
``(A) Performance categories.--Under the MIPS, the
Secretary shall use the following performance categories
(each of which is referred to in this subsection as a
performance category) in determining the composite
performance score under paragraph (5):
``(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 included in the
final measures list published under subparagraph (D)(i) for
such year and the list of quality measures described in
subparagraph (D)(vi) used by qualified clinical data
registries under subsection (m)(3)(E).
``(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 drugs
under part D.
``(iii) Clinical practice improvement activities.--For the
performance category described in subparagraph (A)(iii),
clinical practice improvement activities (as defined in
subparagraph (C)(v)(III)) under subcategories specified by
the Secretary for such period, which shall include at least
the following:
``(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 assessment and 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 15 or fewer professionals) and
practices located in rural areas and in health professional
shortage areas (as designated under section 332(a)(1)(A) of
the Public Health Service Act).
``(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 the 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, such as measures for inpatient
hospitals, for purposes of the performance categories
described in clauses (i) and (ii) of subparagraph (A). For
purposes of the previous sentence, the Secretary may not use
measures for hospital outpatient departments, except in the
case of emergency physicians.
``(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) Application of measures and activities to non-
patient-facing professionals.--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 furnish
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 MIPS eligible professionals of
such professional types or subcategories, alternative
measures or activities that fulfill the goals of the
applicable performance category.
In carrying out the previous sentence, the Secretary shall
consult with professionals of such professional types or
subcategories.
``(v) Clinical practice improvement activities.--
``(I) Request for information.--In initially applying
subparagraph (B)(iii), the Secretary shall use a request for
information to solicit recommendations from stakeholders to
identify activities described in such subparagraph and
specifying criteria for such activities.
``(II) 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--
``(aa) identifying activities described in subparagraph
(B)(iii);
``(bb) specifying criteria for such activities; and
``(cc) determining whether a MIPS eligible professional
meets such criteria.
``(III) Clinical practice improvement activities defined.--
For purposes of this subsection, the term `clinical practice
improvement activity' means an activity that relevant
eligible professional organizations and other relevant
stakeholders identify as improving clinical practice or care
delivery and that the Secretary determines, when effectively
executed, is likely to result in improved outcomes.
``(D) Annual list of quality measures available for mips
assessment.--
``(i) In general.--Under the MIPS, the Secretary, through
notice and comment rulemaking and subject to the succeeding
clauses of this subparagraph, shall, with respect to the
performance period for a year, establish an annual final list
of quality measures from which MIPS eligible professionals
may choose for purposes of assessment under this subsection
for such performance period. Pursuant to the previous
sentence, the Secretary shall--
[[Page H2442]]
``(I) not later than November 1 of the year prior to the
first day of the first performance period under the MIPS,
establish and publish in the Federal Register a final list of
quality measures; and
``(II) not later than November 1 of the year prior to the
first day of each subsequent performance period, update the
final list of quality measures from the previous year (and
publish such updated final list in the Federal Register),
by--
``(aa) removing from such list, as appropriate, quality
measures, which may include the removal of measures that are
no longer meaningful (such as measures that are topped out);
``(bb) adding to such list, as appropriate, new quality
measures; and
``(cc) determining whether or not quality measures on such
list that have undergone substantive changes should be
included in the updated list.
``(ii) Call for quality measures.--
``(I) In general.--Eligible professional organizations and
other relevant stakeholders shall be requested to identify
and submit quality measures to be considered for selection
under this subparagraph in the annual list of quality
measures published under clause (i) and to identify and
submit updates to the measures on such list. For purposes of
the previous sentence, measures may be submitted regardless
of whether such measures were previously published in a
proposed rule or endorsed by an entity with a contract under
section 1890(a).
``(II) Eligible professional organization defined.--In this
subparagraph, the term `eligible professional organization'
means a professional organization as defined by nationally
recognized multispecialty boards of certification or
equivalent certification boards.
``(iii) Requirements.--In selecting quality measures for
inclusion in the annual final list under clause (i), the
Secretary shall--
``(I) provide that, to the extent practicable, all quality
domains (as defined in subsection (s)(1)(B)) are addressed by
such measures; and
``(II) ensure that such selection is consistent with the
process for selection of measures under subsections (k), (m),
and (p)(2).
``(iv) Peer review.--Before including a new measure or a
measure described in clause (i)(II)(cc) in the final list of
measures published under clause (i) for a year, the Secretary
shall submit for publication in applicable specialty-
appropriate peer-reviewed journals such measure and the
method for developing and selecting such measure, including
clinical and other data supporting such measure.
``(v) Measures for inclusion.--The final list of quality
measures published under clause (i) shall include, as
applicable, measures under subsections (k), (m), and (p)(2),
including quality measures from among--
``(I) measures endorsed by a consensus-based entity;
``(II) measures developed under subsection (s); and
``(III) measures submitted under clause (ii)(I).
Any measure selected for inclusion in such list that is not
endorsed by a consensus-based entity shall have a focus that
is evidence-based.
``(vi) Exception for qualified clinical data registry
measures.--Measures used by a qualified clinical data
registry under subsection (m)(3)(E) shall not be subject to
the requirements under clauses (i), (iv), and (v). The
Secretary shall publish the list of measures used by such
qualified clinical data registries on the Internet website of
the Centers for Medicare & Medicaid Services.
``(vii) Exception for existing quality measures.--Any
quality measure specified by the Secretary under subsection
(k) or (m), including under subsection (m)(3)(E), and any
measure of quality of care established under subsection
(p)(2) for the reporting period under the respective
subsection beginning before the first performance period
under the MIPS--
``(I) shall not be subject to the requirements under clause
(i) (except under items (aa) and (cc) of subclause (II) of
such clause) or to the requirement under clause (iv); and
``(II) shall be included in the final list of quality
measures published under clause (i) unless removed under
clause (i)(II)(aa).
``(viii) Consultation with relevant eligible professional
organizations and other relevant stakeholders.--Relevant
eligible professional organizations and other relevant
stakeholders, including State and national medical societies,
shall be consulted in carrying out this subparagraph.
``(ix) Optional application.--The process under section
1890A is not required to apply to the selection of measures
under this subparagraph.
``(3) Performance standards.--
``(A) Establishment.--Under the MIPS, the Secretary shall
establish performance standards with respect to measures and
activities specified under paragraph (2)(B) for a performance
period (as established under paragraph (4)) for a year.
``(B) Considerations in establishing standards.--In
establishing such performance standards with respect to
measures and activities specified under paragraph (2)(B), the
Secretary shall consider the following:
``(i) Historical performance standards.
``(ii) Improvement.
``(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 taking into account, as available and
applicable, paragraph (1)(G), the Secretary shall develop a
methodology for assessing the total performance of each MIPS
eligible professional according to performance standards
under paragraph (3) with respect to applicable measures and
activities specified in paragraph (2)(B) with respect to each
performance category applicable to such professional for a
performance period (as established under paragraph (4)) for a
year. Using such methodology, the Secretary shall provide for
a composite assessment (using a scoring scale of 0 to 100)
for each such professional for the performance period for
such year. In this subsection such a composite assessment for
such a professional with respect to a performance period
shall be referred to as the `composite performance score' for
such professional for such performance period.
``(B) 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 MIPS eligible professional who
fails to report on an applicable measure or activity that is
required to be reported by the professional, the professional
shall be treated as achieving the lowest potential score
applicable to such measure or activity.
``(ii) Encouraging use of certified ehr technology and
qualified clinical data registries for reporting quality
measures.--Under the methodology established under
subparagraph (A), the Secretary shall--
``(I) encourage MIPS eligible professionals to report on
applicable measures with respect to the performance category
described in paragraph (2)(A)(i) through the use of certified
EHR technology and qualified clinical data registries; and
``(II) with respect to a performance period, with respect
to a year, for which a MIPS eligible professional reports
such measures through the use of such EHR technology, treat
such professional as satisfying the clinical quality measures
reporting requirement described in subsection (o)(2)(A)(iii)
for such year.
``(C) Clinical practice improvement activities performance
score.--
``(i) Rule for accreditation.--A MIPS 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 MIPS eligible
professional in an alternative payment model (as defined in
section 1833(z)(3)(C)) with respect to a performance period
shall earn such eligible professional a minimum score of one-
half of the highest potential score for the performance
category described in paragraph (2)(A)(iii) for such
performance period.
``(iii) Subcategories.--A MIPS eligible professional shall
not be required to perform activities in each subcategory
under paragraph (2)(B)(iii) or participate in an alternative
payment model in order to achieve the highest potential score
for the performance category described in paragraph
(2)(A)(iii).
``(D) Achievement and improvement.--
``(i) Taking into account improvement.--Beginning with the
second year to which the MIPS applies, in addition to the
achievement of a MIPS eligible professional, if data
sufficient to measure improvement is available, the
methodology developed under subparagraph (A)--
``(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 MIPS applies, under the
methodology developed under subparagraph (A), the Secretary
may assign a higher scoring weight under subparagraph (F)
with respect to the achievement of a MIPS eligible
professional than with respect to any improvement of such
professional applied under clause (i) with respect to a
measure, activity, or category described in paragraph (2).
``(E) Weights for the performance categories.--
``(i) In general.--Under the methodology developed under
subparagraph (A), subject to subparagraph (F)(i) and clauses
(ii) and (iii), the composite performance score shall be
determined as follows:
``(I) Quality.--
``(aa) In general.--Subject to item (bb), thirty percent of
such score shall be based on performance with respect to the
category described in clause (i) of paragraph (2)(A). In
[[Page H2443]]
applying the previous sentence, the Secretary shall, as
feasible, encourage the application of outcome measures
within such category.
``(bb) First 2 years.--For the first and second years for
which the MIPS applies to payments, the percentage applicable
under item (aa) shall be increased in a manner such that the
total percentage points of the increase under this item for
the respective year equals the total number of percentage
points by which the percentage applied under subclause
(II)(bb) for the respective year is less than 30 percent.
``(II) Resource use.--
``(aa) In general.--Subject to item (bb), thirty percent of
such score shall be based on performance with respect to the
category described in clause (ii) of paragraph (2)(A).
``(bb) First 2 years.--For the first year for which the
MIPS applies to payments, not more than 10 percent of such
score shall be based on performance with respect to the
category described in clause (ii) of paragraph (2)(A). For
the second year for which the MIPS applies to payments, not
more than 15 percent of such score shall be based on
performance with respect to the category described in clause
(ii) of paragraph (2)(A).
``(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, subject to
subclauses (I)(bb) and (II)(bb) of clause (i), the
percentages applicable under one or more of subclauses (I),
(II), and (III) of clause (i) for such year shall be
increased in a manner such that the total percentage points
of the increase under this clause for such year equals the
total number of percentage points reduced under the preceding
sentence for such year.
``(F) Certain flexibility for weighting performance
categories, measures, and activities.--Under the methodology
under subparagraph (A), if there are not sufficient measures
and clinical practice improvement activities applicable and
available to each type of eligible professional involved, the
Secretary shall assign different scoring weights (including a
weight of 0)--
``(i) which may vary from the scoring weights specified in
subparagraph (E), for each performance category based on the
extent to which the category is applicable to the type of
eligible professional involved; and
``(ii) for each measure and activity specified under
paragraph (2)(B) with respect to each such category based on
the extent to which the measure or activity is applicable and
available to the type of eligible professional involved.
``(G) 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.
``(H) Inclusion of quality measure data from other
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 MIPS eligible
professionals with respect to items and services furnished to
individuals who are not individuals entitled to benefits
under part A or enrolled under part B.
``(I) Use of voluntary virtual groups for certain
assessment purposes.--
``(i) In general.--In the case of MIPS eligible
professionals electing to be a virtual group under clause
(ii) with respect to a performance period for a year, for
purposes of applying the methodology under subparagraph (A)--
``(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 MIPS 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 MIPS
eligible professional or a group practice consisting of not
more than 10 MIPS eligible professionals to elect, with
respect to a performance period for a year, for such
individual MIPS eligible professional or all such MIPS
eligible professionals in such group practice, respectively,
to be a virtual group under this subparagraph with at least
one other such individual MIPS eligible professional or group
practice making such an election. Such a virtual group may be
based on geographic areas or on provider specialties defined
by nationally recognized multispecialty boards of
certification or equivalent certification boards and such
other eligible professional groupings in order to capture
classifications of providers across eligible professional
organizations and other practice areas or categories.
``(iii) Requirements.--The process under clause (ii)--
``(I) shall provide that an election under such clause,
with respect to a performance period, shall be made before or
during the beginning of such performance period and may not
be changed during such performance period;
``(II) shall provide that a practice described in such
clause, and each MIPS eligible professional in such practice,
may elect to be in no more than one virtual group for a
performance period; and
``(III) may provide that a virtual group may be combined at
the tax identification number level.
``(6) MIPS payments.--
``(A) MIPS adjustment factor.--Taking into account
paragraph (1)(G), the Secretary shall specify a MIPS
adjustment factor for each MIPS eligible professional for a
year. Such MIPS adjustment factor for a MIPS eligible
professional for a year shall be in the form of a percent and
shall be determined--
``(i) by comparing the composite performance score of the
eligible professional for such year to the performance
threshold established under subparagraph (D)(i) for such
year;
``(ii) in a manner such that the adjustment factors
specified under this subparagraph for a year result in
differential payments under this paragraph reflecting that--
``(I) MIPS eligible professionals with composite
performance scores for such year at or above such performance
threshold for such year receive zero or positive incentive
payment adjustment factors for such year in accordance with
clause (iii), with such professionals having higher composite
performance scores receiving higher adjustment factors; and
``(II) MIPS eligible professionals with composite
performance scores for such year below such performance
threshold for such year receive negative payment adjustment
factors for such year in accordance with clause (iv), with
such professionals having lower composite performance scores
receiving lower adjustment factors;
``(iii) in a manner such that MIPS eligible professionals
with composite scores described in clause (ii)(I) for such
year, subject to clauses (i) and (ii) of subparagraph (F),
receive a zero or positive adjustment factor on a linear
sliding scale such that an adjustment factor of 0 percent is
assigned for a score at the performance threshold and an
adjustment factor of the applicable percent specified in
subparagraph (B) is assigned for a score of 100; and
``(iv) in a manner such that--
``(I) subject to subclause (II), MIPS eligible
professionals with composite performance scores described in
clause (ii)(II) for such year receive a negative payment
adjustment factor on a linear sliding scale such that an
adjustment factor of 0 percent is assigned for a score at the
performance threshold and an adjustment factor of the
negative of the applicable percent specified in subparagraph
(B) is assigned for a score of 0; and
``(II) MIPS eligible professionals with composite
performance scores that are equal to or greater than 0, but
not greater than \1/4\ of the performance threshold specified
under subparagraph (D)(i) for such year, receive a negative
payment adjustment factor that is equal to the negative of
the applicable percent specified in subparagraph (B) for such
year.
``(B) Applicable percent defined.--For purposes of this
paragraph, the term `applicable percent' means--
``(i) for 2018, 4 percent;
``(ii) for 2019, 5 percent;
``(iii) for 2020, 7 percent; and
``(iv) for 2021 and subsequent years, 9 percent.
``(C) Additional mips adjustment factors for exceptional
performance.--
``(i) In general.--In the case of a MIPS eligible
professional with a composite performance score for a year at
or above the additional performance threshold under
subparagraph (D)(ii) for such year, in addition to the MIPS
adjustment factor under subparagraph (A) for the eligible
professional for such year, subject to the availability of
funds under clause (ii), the Secretary shall specify an
additional positive MIPS adjustment factor for such
professional and year. Such additional MIPS adjustment
factors shall be determined by the Secretary in a manner such
that professionals having higher composite performance scores
above the additional performance threshold receive higher
additional MIPS adjustment factors.
``(ii) Additional funding pool.--For 2018 and each
subsequent year through 2023, there is appropriated from the
Federal Supplementary Medical Insurance Trust Fund
$500,000,000 for MIPS payments under this paragraph resulting
from the application of the additional MIPS adjustment
factors under clause (i).
``(D) Establishment of performance thresholds.--
[[Page H2444]]
``(i) Performance threshold.--For each year of the MIPS,
the Secretary shall compute a performance threshold with
respect to which the composite performance score of MIPS
eligible professionals shall be compared for purposes of
determining adjustment factors under subparagraph (A) that
are positive, negative, and zero. Such performance threshold
for a year shall be the mean or median (as selected by the
Secretary) of the composite performance scores for all MIPS
eligible professionals with respect to a prior period
specified by the Secretary. The Secretary may reassess the
selection under the previous sentence every 3 years.
``(ii) Additional performance threshold for exceptional
performance.--In addition to the performance threshold under
clause (i), for each year of the MIPS, the Secretary shall
compute an additional performance threshold for purposes of
determining the additional MIPS adjustment factors under
subparagraph (C)(i). For each such year, the Secretary shall
apply either of the following methods for computing such
additional performance threshold for such a year:
``(I) The threshold shall be the score that is equal to the
25th percentile of the range of possible composite
performance scores above the performance threshold with
respect to the prior period described in clause (i).
``(II) The threshold shall be the score that is equal to
the 25th percentile of the actual composite performance
scores for MIPS eligible professionals with composite
performance scores at or above the performance threshold with
respect to the prior period described in clause (i).
``(iii) Special rule for initial 2 years.--With respect to
each of the first two years to which the MIPS applies, the
Secretary shall, prior to the performance period for such
years, establish a performance threshold for purposes of
determining MIPS adjustment factors under subparagraph (A)
and a threshold for purposes of determining additional MIPS
adjustment factors under subparagraph (C)(i). Each such
performance threshold shall--
``(I) be based on a period prior to such performance
periods; and
``(II) take into account--
``(aa) data available with respect to performance on
measures and activities that may be used under the
performance categories under subparagraph (2)(B); and
``(bb) other factors determined appropriate by the
Secretary.
``(E) Application of mips adjustment factors.--In the case
of items and services furnished by a MIPS eligible
professional during a year (beginning with 2018), the amount
otherwise paid under this part with respect to such items and
services and MIPS eligible professional for such year, shall
be multiplied by--
``(i) 1, plus
``(ii) the sum of--
``(I) the MIPS adjustment factor determined under
subparagraph (A) divided by 100, and
``(II) as applicable, the additional MIPS adjustment factor
determined under subparagraph (C)(i) divided by 100.
``(F) Aggregate application of mips adjustment factors.--
``(i) Application of scaling factor.--
``(I) In general.--With respect to positive MIPS adjustment
factors under subparagraph (A)(ii)(I) for eligible
professionals whose composite performance score is above the
performance threshold under subparagraph (D)(i) for such
year, subject to subclause (II), the Secretary shall increase
or decrease such adjustment factors by a scaling factor in
order to ensure that the budget neutrality requirement of
clause (ii) is met.
``(II) Scaling factor limit.--In no case may be the scaling
factor applied under this clause exceed 3.0.
``(ii) Budget neutrality requirement.--
``(I) In general.--Subject to clause (iii), the Secretary
shall ensure that the estimated amount described in subclause
(II) for a year is equal to the estimated amount described in
subclause (III) for such year.
``(II) Aggregate increases.--The amount described in this
subclause is the estimated increase in the aggregate allowed
charges resulting from the application of positive MIPS
adjustment factors under subparagraph (A) (after application
of the scaling factor described in clause (i)) to MIPS
eligible professionals whose composite performance score for
a year is above the performance threshold under subparagraph
(D)(i) for such year.
``(III) Aggregate decreases.--The amount described in this
subclause is the estimated decrease in the aggregate allowed
charges resulting from the application of negative MIPS
adjustment factors under subparagraph (A) to MIPS eligible
professionals whose composite performance score for a year is
below the performance threshold under subparagraph (D)(i) for
such year.
``(iii) Exceptions.--
``(I) In the case that all MIPS eligible professionals
receive composite performance scores for a year that are
below the performance threshold under subparagraph (D)(i) for
such year, the negative MIPS adjustment factors under
subparagraph (A) shall apply with respect to such MIPS
eligible professionals and the budget neutrality requirement
of clause (ii) shall not apply for such year.
``(II) In the case that, with respect to a year, the
application of clause (i) results in a scaling factor equal
to the maximum scaling factor specified in clause (i)(II),
such scaling factor shall apply and the budget neutrality
requirement of clause (ii) shall not apply for such year.
``(iv) Additional incentive payment adjustments.--In
specifying the MIPS additional adjustment factors under
subparagraph (C)(i) for each applicable MIPS eligible
professional for a year, the Secretary shall ensure that the
estimated increase in payments under this part resulting from
the application of such additional adjustment factors for
MIPS eligible professionals in a year shall be equal (as
estimated by the Secretary) to the additional funding pool
amount for such year under subparagraph (C)(ii).
``(7) Announcement of result of adjustments.--Under the
MIPS, the Secretary shall, not later than 30 days prior to
January 1 of the year involved, make available to MIPS
eligible professionals the MIPS adjustment factor (and, as
applicable, the additional MIPS adjustment factor) under
paragraph (6) applicable to the eligible professional for
items and services furnished by the professional for such
year. The Secretary may include such information in the
confidential feedback under paragraph (12).
``(8) No effect in subsequent years.--The MIPS adjustment
factors and additional MIPS adjustment factors under
paragraph (6) shall apply only with respect to the year
involved, and the Secretary shall not take into account such
adjustment factors in making payments to a MIPS eligible
professional under this part in a subsequent year.
``(9) Public reporting.--
``(A) In general.--The Secretary shall, in an easily
understandable format, make available on the Physician
Compare Internet website of the Centers for Medicare &
Medicaid Services the following:
``(i) Information regarding the performance of MIPS
eligible professionals under the MIPS, which--
``(I) shall include the composite score for each such MIPS
eligible professional and the performance of each such MIPS
eligible professional with respect to each performance
category; and
``(II) may include the performance of each such MIPS
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 MIPS, including the range of
composite scores for all MIPS eligible professionals and the
range of the performance of all MIPS eligible professionals
with respect to each performance category.
``(10) Consultation.--The Secretary shall consult with
stakeholders in carrying out the MIPS, including for the
identification of measures and activities under paragraph
(2)(B) and the methodologies developed under paragraphs
(5)(A) and (6) and regarding the use of qualified clinical
data registries. Such consultation shall include the use of a
request for information or other mechanisms determined
appropriate.
``(11) 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 MIPS eligible professionals in practices of
15 or fewer professionals (with priority given to such
practices located in rural areas, health professional
shortage areas (as designated under in section 332(a)(1)(A)
of such Act), and medically underserved areas, and practices
with low composite scores) with respect to--
``(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.--
``(i) In general.--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
$40,000,000 for each of fiscal years 2015 through 2019.
[[Page H2445]]
Amounts transferred under this subparagraph for a fiscal year
shall be available until expended.
``(ii) Technical assistance.--Of the amounts transferred
pursuant to clause (i) for each of fiscal years 2015 through
2019, not less than $10,000,000 shall be made available for
each such year for technical assistance to small practices in
health professional shortage areas (as so designated) and
medically underserved areas.
``(12) Feedback and information to improve performance.--
``(A) Performance feedback.--
``(i) In general.--Beginning July 1, 2016, the Secretary--
``(I) shall make available timely (such as quarterly)
confidential feedback to MIPS eligible professionals on the
performance of such professionals with respect to the
performance categories under clauses (i) and (ii) of
paragraph (2)(A); and
``(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. With respect to the
performance category described in paragraph (2)(A)(i),
feedback under this subparagraph shall, to the extent an
eligible professional chooses to participate in a data
registry for purposes of this subsection (including
registries under subsections (k) and (m)), be provided based
on performance on quality measures reported through the use
of such registries. With respect to any other performance
category described in paragraph (2)(A), the Secretary shall
encourage provision of feedback through qualified clinical
data registries as described in subsection (m)(3)(E)).
``(iii) Use of data.--For purposes of clause (i), the
Secretary may use data, with respect to a MIPS eligible
professional, from periods prior to the current performance
period and may use rolling periods in order to make
illustrative calculations about the performance of such
professional.
``(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, 2017, the Secretary
shall make available to each MIPS eligible professional
information, with respect to individuals who are patients of
such MIPS 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 may be made available under the
previous sentence to such MIPS eligible professionals by
mechanisms determined appropriate by the Secretary, which may
include use of a web-based portal. Such information may be
made available in accordance with the same or similar terms
as data are made available to accountable care organizations
participating in the shared savings program under section
1899, 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 MIPS eligible professional, by another
supplier or provider of services during the most recent
period for which data are available (such as the most recent
three-month period), such as the name of such providers
furnishing such items and services to such patients during
such period, the types of such items and services so
furnished, and the dates such items and services were so
furnished.
``(II) Historical data, such as averages and other measures
of the distribution if appropriate, of the total, and
components of, allowed charges (and other figures as
determined appropriate by the Secretary).
``(13) Review.--
``(A) Targeted review.--The Secretary shall establish a
process under which a MIPS eligible professional may seek an
informal review of the calculation of the MIPS adjustment
factor applicable to such eligible professional under this
subsection for a year. The results of a review conducted
pursuant to the previous sentence shall not be taken into
account for purposes of paragraph (6) with respect to a year
(other than with respect to the calculation of such eligible
professional's MIPS adjustment factor for such year or
additional MIPS adjustment factor for such year) after the
factors determined in subparagraph (A) and subparagraph (C)
of such paragraph have been determined for such year.
``(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
MIPS adjustment factor under paragraph (6)(A) and the amount
of the additional MIPS adjustment factor under paragraph
(6)(C)(i) and the determination of such amounts.
``(ii) The establishment of the performance standards under
paragraph (3) and the performance period under paragraph (4).
``(iii) The identification of measures and activities
specified under paragraph (2)(B) and information made public
or posted on the Physician Compare Internet website of the
Centers for Medicare & Medicaid Services under paragraph (9).
``(iv) 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 mips.--Not later
than October 1, 2019, and October 1, 2022, the Comptroller
General of the United States shall submit to Congress a
report evaluating the eligible professional Merit-based
Incentive Payment System under subsection (q) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4), as added by
paragraph (1). Such report shall--
(i) examine the distribution of the composite performance
scores and MIPS adjustment factors (and additional MIPS
adjustment factors) for MIPS eligible professionals (as
defined in subsection (q)(1)(c) of such section) under such
program, and patterns relating to such scores and adjustment
factors, including based on type of provider, practice size,
geographic location, and patient mix;
(ii) provide recommendations for improving such program;
(iii) evaluate the impact of technical assistance funding
under section 1848(q)(11) of the Social Security Act, as
added by paragraph (1), on the ability of professionals to
improve within such program or successfully transition to an
alternative payment model (as defined in section 1833(z)(3)
of the Social Security Act, as added by subsection (e)), with
priority for such evaluation given to practices located in
rural areas, health professional shortage areas (as
designated in section 332(a)(1)(a) of the Public Health
Service Act), and medically underserved areas; and
(iv) provide recommendations for optimizing the use of such
technical assistance funds.
(B) Study to examine alignment of quality measures used in
public and private programs.--
(i) In general.--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, selected State Medicaid programs under title XIX
of such Act, and private payer arrangements; and
(II) makes recommendations on how to reduce the
administrative burden involved in applying such quality
measures.
(ii) Requirements.--The report under clause (i) shall--
(I) consider those measures applicable to individuals
entitled to, or enrolled for, benefits under such part A, or
enrolled under such part B and individuals under the age of
65; and
(II) focus on those measures that comprise the most
significant component of the quality performance category of
the eligible professional MIPS incentive program under
subsection (q) of section 1848 of the Social Security Act (42
U.S.C. 1395w-4), as added by paragraph (1).
(C) Study on role of independent risk managers.--Not later
than January 1, 2016, the Comptroller General of the United
States shall submit to Congress a report examining whether
entities that pool financial risk for physician practices,
such as independent risk managers, can play a role in
supporting physician practices, particularly small physician
practices, in assuming financial risk for the treatment of
patients. Such report shall examine barriers that small
physician practices currently face in assuming financial risk
for treating patients, the types of risk management entities
that could assist physician practices in participating in
two-sided risk payment models, and how such entities could
assist with risk management and with quality improvement
activities. Such report shall also include an analysis of any
existing legal barriers to such arrangements.
(D) Study to examine rural and health professional shortage
area alternative payment models.--Not later than October 1,
2020, and October 1, 2022, the Comptroller General of the
United States shall submit to Congress a report that examines
the transition of professionals in rural areas, health
professional shortage areas (as designated in section
332(a)(1)(A) of the Public Health Service Act), or medically
underserved areas to an alternative payment model (as defined
in section 1833(z)(3) of the Social Security Act, as added by
subsection (e)). Such report shall make recommendations for
removing administrative barriers to practices, including
small practices consisting of 15 or fewer professionals, in
rural areas, health professional shortage areas, and
medically underserved areas to participation in such models.
(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 $80,000,000 from the
Supplementary Medical Insurance Trust Fund established under
section 1841 of
[[Page H2446]]
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 2018. 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 2015 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 2014''; and
(B) by inserting ``and, for reporting periods occurring in
2015 and subsequent years, the Secretary may establish''
following ``shall establish''.
(3) Physician feedback program reports succeeded by reports
under mips.--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)(12) for reports under the eligible professionals Merit-
based Incentive Payment System.''.
(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)(B)(ii)(II)'' after ``Subject to
subparagraph (B)(ii)''.
(e) Promoting Alternative Payment Models.--
(1) Increasing transparency of physician focused payment
models.--Section 1868 of the Social Security Act (42 U.S.C.
1395ee) is amended by adding at the end the following new
subsection:
``(c) Physician Focused Payment Models.--
``(1) Technical advisory committee.--
``(A) Establishment.--There is established an ad hoc
committee to be known as the `Payment Model Technical
Advisory Committee' (referred to in this subsection as the
`Committee').
``(B) Membership.--
``(i) Number and appointment.--The Committee shall be
composed of 11 members appointed by the Comptroller General
of the United States.
``(ii) Qualifications.--The membership of the Committee
shall include individuals with national recognition for their
expertise in payment models and related delivery of care. No
more than 5 members of the Committee shall be providers of
services or suppliers, or representatives of providers of
services or suppliers.
``(iii) Prohibition on federal employment.--A member of the
Committee shall not be an employee of the Federal Government.
``(iv) Ethics disclosure.--The Comptroller General shall
establish a system for public disclosure by members of the
Committee of financial and other potential conflicts of
interest relating to such members. Members of the Committee
shall be treated as employees of Congress for purposes of
applying title I of the Ethics in Government Act of 1978
(Public Law 95-521).
``(v) Date of initial appointments.--The initial
appointments of members of the Committee shall be made by not
later than 180 days after the date of enactment of this
subsection.
``(C) Term; vacancies.--
``(i) Term.--The terms of members of the Committee shall be
for 3 years except that the Comptroller General shall
designate staggered terms for the members first appointed.
``(ii) Vacancies.--Any member appointed to fill a vacancy
occurring before the expiration of the term for which the
member's predecessor was appointed shall be appointed only
for the remainder of that term. A member may serve after the
expiration of that member's term until a successor has taken
office. A vacancy in the Committee shall be filled in the
manner in which the original appointment was made.
``(D) Duties.--The Committee shall meet, as needed, to
provide comments and recommendations to the Secretary, as
described in paragraph (2)(C), on physician-focused payment
models.
``(E) Compensation of members.--
``(i) In general.--Except as provided in clause (ii), a
member of the Committee shall serve without compensation.
``(ii) Travel expenses.--A member of the Committee shall be
allowed travel expenses, including per diem in lieu of
subsistence, at rates authorized for an employee of an agency
under subchapter I of chapter 57 of title 5, United States
Code, while away from the home or regular place of business
of the member in the performance of the duties of the
Committee.
``(F) Operational and technical support.--
``(i) In general.--The Assistant Secretary for Planning and
Evaluation shall provide technical and operational support
for the Committee, which may be by use of a contractor. The
Office of the Actuary of the Centers for Medicare & Medicaid
Services shall provide to the Committee actuarial assistance
as needed.
``(ii) Funding.--The Secretary shall provide for the
transfer, from the Federal Supplementary Medical Insurance
Trust Fund under section 1841, such amounts as are necessary
to carry out clause (i) (not to exceed $5,000,000) for fiscal
year 2014 and each subsequent fiscal year. Any amounts
transferred under the preceding sentence for a fiscal year
shall remain available until expended.
``(G) Application.--Section 14 of the Federal Advisory
Committee Act (5 U.S.C. App.) shall not apply to the
Committee.
``(2) Criteria and process for submission and review of
physician-focused payment models.--
``(A) Criteria for assessing physician-focused payment
models.--
``(i) Rulemaking.--Not later than November 1, 2015, the
Secretary shall, through notice and comment rulemaking,
following a request for information, establish criteria for
physician-focused payment models, including models for
specialist physicians, that could be used by the Committee
for making comments and recommendations pursuant to paragraph
(1)(D).
``(ii) MedPAC submission of comments.--During the comment
period for the proposed rule described in clause (i), the
Medicare Payment Advisory Commission may submit comments to
the Secretary on the proposed criteria under such clause.
``(iii) Updating.--The Secretary may update the criteria
established under this subparagraph through rulemaking.
``(B) Stakeholder submission of physician focused payment
models.--On an ongoing basis, individuals and stakeholder
entities may submit to the Committee proposals for physician-
focused payment models that such individuals and entities
believe meet the criteria described in subparagraph (A).
``(C) TAC review of models submitted.--The Committee shall,
on a periodic basis, review models submitted under
subparagraph (B), prepare comments and recommendations
regarding whether such models meet the criteria described in
subparagraph (A), and submit such comments and
recommendations to the Secretary.
``(D) Secretary review and response.--The Secretary shall
review the comments and recommendations submitted by the
Committee under subparagraph (C) and post a detailed response
to such comments and recommendations on the Internet Website
of the Centers for Medicare & Medicaid Services.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to impact the development or testing of
models under this title or titles XI, XIX, or XXI.''.
(2) 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 2018 and ending with
2023 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
[[Page H2447]]
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) 2018 and 2019.--With respect to 2018 and 2019, 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) 2020 and 2021.--With respect to 2020 and 2021, 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, and other than payments made under title XIX in a
State in which no medical home or alternative payment model
is available under the State program under that title),
meet the requirement described in clause (iii)(I) with
respect to payments described in item (aa) and meet the
requirement described in clause (iii)(II) with respect to
payments described in item (bb);
``(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 (AA) bears more than
nominal financial risk if actual aggregate expenditures
exceeds expected aggregate expenditures; or (BB) is a medical
home (with respect to beneficiaries under title XIX) that
meets criteria comparable to medical homes expanded under
section 1115A(c).
``(C) Beginning in 2022.--With respect to 2022 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, and other than payments made under title XIX in a
State in which no medical home or alternative payment model
is available under the State program under that title),
meet the requirement described in clause (iii)(I) with
respect to payments described in item (aa) and meet the
requirement described in clause (iii)(II) with respect to
payments described in item (bb);
``(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 (AA) bears more than
nominal financial risk if actual aggregate expenditures
exceeds expected aggregate expenditures; or (BB) is a medical
home (with respect to beneficiaries under title XIX) that
meets criteria comparable to medical homes expanded under
section 1115A(c).
``(3) 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) The shared savings program 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).
``(4) 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.''.
(3) 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.''.
(4) 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:
[[Page H2448]]
``(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 15 or fewer
professionals.
``(xxiii) Focusing on risk-based models for small physician
practices which may involve two-sided risk and prospective
patient assignment, and which examine risk-adjusted decreases
in mortality rates, hospital readmissions rates, and other
relevant and appropriate clinical measures.
``(xxiv) Focusing primarily on title XIX, working in
conjunction with the Center for Medicaid and CHIP
Services.''; 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''.
(5) Construction regarding telehealth services.--Nothing in
the provisions of, or amendments made by, this Act shall be
construed as precluding an alternative payment model or a
qualifying APM participant (as those terms are defined in
section 1833(z) of the Social Security Act, as added by
paragraph (1)) from furnishing a telehealth service for which
payment is not made under section 1834(m) of the Social
Security Act (42 U.S.C. 1395m(m)).
(6) Integrating medicare advantage alternative payment
models.--Not later than July 1, 2015, the Secretary of Health
and Human Services shall submit to Congress a study that
examines the feasibility of integrating alternative payment
models in the Medicare Advantage payment system. The study
shall include the feasibility of including a value-based
modifier and whether such modifier should be budget neutral.
(7) Study and report on fraud related to alternative
payment models under the medicare program.--
(A) 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--
(i) 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)));
(ii) identifies aspects of such alternative payment models
that are vulnerable to fraudulent activity; and
(iii) examines the implications of waivers to such laws
granted in support of such alternative payment models,
including under any potential expansion of such models.
(B) 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
subparagraph (A). Such report shall include recommendations
for actions to be taken to reduce the vulnerability of such
alternative payment models to fraudulent activity. Such
report also shall include, as appropriate, recommendations of
the Inspector General for changes in Federal fraud prevention
laws to reduce such vulnerability.
(f) 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 Merit-based
Incentive Payment System 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 Supplementary Medical Insurance Trust Fund under
section 1841 of the Social Security Act 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, as the Secretary
determines appropriate, 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
provisions of title XVIII of the Social Security Act that are
similar to the eligible professional Merit-based Incentive
Payment System under section 1848(q) 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) and
other information as appropriate, the Secretary shall, as the
Secretary determines appropriate, account for identified
factors with an effect on quality and resource use outcome
measures when determining payment adjustment mechanisms under
provisions of title XVIII of the Social Security Act that are
similar to the eligible professional Merit-based Incentive
Payment System under section 1848(q) 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 Supplementary Medical Insurance Trust Fund under
section 1841 of the Social Security Act to the Secretary to
carry out this paragraph and the application of this
paragraph to the Merit-based Incentive Payment System under
section 1848(q) of such Act $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 Merit-based Incentive Payment System
under section 1848(q) of the Social Security Act and, as the
Secretary determines appropriate, other similar provisions of
title XVIII of such Act.
(g) 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 care episode groups and 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 120 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
[[Page H2449]]
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) care episode groups; and
``(ii) 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 care episode groups and patient condition
groups, which account for a target of an estimated \2/3\ 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 180 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 180 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 2017), 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 270 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 180 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 2017), 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, 2017, 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 charges for all
services under part A and this part (and, if the Secretary
determines appropriate, part D) for the analysis of patient
resource use, by care episode codes and by patient condition
codes; and
``(ii) may, as determined appropriate, use other measures
of allowed charges (such as subtotals for categories of items
and services) and measures of utilization of items and
services (such as frequency of specific items and services
and the ratio of specific items and services among attributed
patients or episodes).
[[Page H2450]]
``(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) Implementation.--To the extent that the Secretary
contracts with an entity to carry out any part of the
provisions of this subsection, the Secretary may not contract
with an entity or an entity with a subcontract if the entity
or subcontracting entity currently makes recommendations to
the Secretary on relative values for services under the fee
schedule for physicians' services under this section.
``(7) 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).
``(8) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(9) 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 a certified registered nurse
anesthetist (as defined in section 1861(bb)(2)); and
``(ii) beginning January 1, 2018, such other eligible
professionals (as defined in subsection (k)(3)(B)) as
specified by the Secretary.
``(10) Clarification.--The provisions of sections
1890(b)(7) and 1890A shall not apply to this subsection.''.
SEC. 3. PRIORITIES AND FUNDING FOR MEASURE DEVELOPMENT.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-
4), as amended by subsections (c) and (g) of section 2, is
further amended by inserting at the end the following new
subsection:
``(s) Priorities and Funding for Measure Development.--
``(1) Plan identifying measure development priorities and
timelines.--
``(A) Draft measure development plan.--Not later than
January 1, 2015, 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 (as
defined in paragraph (5)). Under such plan the Secretary
shall--
``(i) address how measures used by private payers and
integrated delivery systems could be incorporated under title
XVIII;
``(ii) describe how coordination, to the extent possible,
will occur across organizations developing such measures; and
``(iii) take into account how clinical best practices and
clinical practice guidelines should be used in the
development of quality measures.
``(B) Quality domains.--For purposes of this subsection,
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.
``(C) Consideration.--In developing the draft plan under
this paragraph, the Secretary shall consider--
``(i) gap analyses conducted by the entity with a contract
under section 1890(a) or other contractors or entities;
``(ii) whether measures are applicable across health care
settings;
``(iii) clinical practice improvement activities submitted
under subsection (q)(2)(C)(iv) for identifying possible areas
for future measure development and identifying existing gaps
with respect to such measures; and
``(iv) the quality domains applied under this subsection.
``(D) Priorities.--In developing the draft plan under this
paragraph, 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.
``(E) Stakeholder input.--The Secretary shall accept
through March 1, 2015, comments on the draft plan posted
under paragraph (1)(A) from the public, including health care
providers, payers, consumers, and other stakeholders.
``(F) Final measure development plan.--Not later than May
1, 2015, taking into account the comments received under this
subparagraph, the Secretary shall finalize the plan and post
on the Internet website of the Centers for Medicare &
Medicaid Services an operational plan for the development of
quality measures for use under the applicable provisions.
Such plan shall be updated as appropriate.
``(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 in accordance
with the plan under paragraph (1) quality measures for
application under the applicable provisions. Such entities
shall include organizations with quality measure development
expertise.
``(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)(D).
``(ii) Consideration.--In selecting measures for
development under this subsection, the Secretary shall
consider--
``(I) whether such measures would be electronically
specified; and
``(II) clinical practice guidelines to the extent that such
guidelines exist.
``(3) Annual report by the secretary.--
``(A) In general.--Not later than May 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
subparagraph (A) shall include the following:
``(i) A description of the Secretary's efforts to implement
this paragraph.
``(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) 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.
``(v) Other information the Secretary determines to be
appropriate.
``(4) Stakeholder input.--With respect to paragraph (1),
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)(D);
``(B) prioritizing quality measure development to address
such gaps; and
``(C) other areas related to quality measure development
determined appropriate by the Secretary.
``(5) Definition of applicable provisions.--In this
subsection, the term `applicable provisions' means the
following provisions:
``(A) Subsection (q)(2)(B)(i).
``(B) Section 1833(z)(2)(C).
``(6) 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.
(a) In General.--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
[[Page H2451]]
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.''.
(b) Education and Outreach.--
(1) Campaign.--
(A) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
conduct an education and outreach campaign to inform
professionals who furnish items and services under part B of
title XVIII of the Social Security Act and individuals
enrolled under such part of the benefits of chronic care
management services described in section 1848(b)(8) of the
Social Security Act, as added by subsection (a), and
encourage such individuals with chronic care needs to receive
such services.
(B) Requirements.--Such campaign shall--
(i) be directed by the Office of Rural Health Policy of the
Department of Health and Human Services and the Office of
Minority Health of the Centers for Medicare & Medicaid
Services; and
(ii) focus on encouraging participation by underserved
rural populations and racial and ethnic minority populations.
(2) Report.--
(A) In general.--Not later than December 31, 2017, the
Secretary shall submit to Congress a report on the use of
chronic care management services described in such section
1848(b)(8) by individuals living in rural areas and by racial
and ethnic minority populations. Such report shall--
(i) identify barriers to receiving chronic care management
services; and
(ii) make recommendations for increasing the appropriate
use of chronic care 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.''.
[[Page H2452]]
(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''.
(i) Disclosure of Data Used To Establish Multiple Procedure
Payment Reduction Policy.--The Secretary of Health and Human
Services shall make publicly available the information 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. 6. PROMOTING EVIDENCE-BASED CARE.
(a) 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, only developed or endorsed by national professional
medical specialty societies or other provider-led entities,
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--
[[Page H2453]]
``(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
provider-led 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 only from among appropriate use criteria developed
or endorsed by national professional medical specialty
societies or other provider-led 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) are scientifically valid and evidence based; and
``(iii) are based on studies that are published and
reviewable by stakeholders.
``(C) Revisions.--The Secretary shall review, on an annual
basis, the specified applicable appropriate use criteria to
determine if there is a need to update or revise (as
appropriate) such specification of applicable appropriate use
criteria and make such updates or revisions through
rulemaking.
``(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 permit
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 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, health care technology experts,
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
identify on an annual basis 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 an annual basis, no more than five percent of
the total number of 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) Process.--The Secretary shall establish a process for
determining when an outlier ordering professional is no
longer an outlier ordering professional.
``(E) 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
[[Page H2454]]
are ordered by an outlier ordering professional identified
under paragraph (5).
``(B) Appropriate use criteria in prior authorization.--In
applying prior authorization under subparagraph (A), the
Secretary shall utilize only the applicable appropriate use
criteria specified under this subsection.
``(C) 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.
``(7) Construction.--Nothing in this subsection shall be
construed as granting the Secretary the authority to develop
or initiate the development of clinical practice guidelines
or appropriate use criteria.''.
(b) 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).''.
(c) Report on Experience of Imaging Appropriate Use
Criteria Program.--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 includes
a description of the extent to which appropriate use criteria
could be used for other services under part B of title XVIII
of the Social Security Act (42 U.S.C. 1395j et seq.), such as
radiation therapy and clinical diagnostic laboratory
services.
SEC. 7. EMPOWERING BENEFICIARY CHOICES THROUGH ACCESS TO
INFORMATION ON PHYSICIANS' SERVICES.
(a) In General.--The Secretary shall make publicly
available on Physician Compare the information described in
subsection (b) with respect to eligible professionals.
(b) Information Described.--The following information, with
respect to an eligible professional, is described in this
subsection:
(1) Information on the number of services furnished by the
eligible professional under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.), which may
include information on the most frequent services furnished
or groupings of services.
(2) Information on submitted charges and payments for
services under such part.
(3) 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 section shall be searchable by at least the following:
(1) The specialty or type of the eligible professional.
(2) Characteristics of the services furnished, such as
volume or groupings of services.
(3) The location of the eligible professional.
(d) Disclosure.--The information made available under this
section 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.--
(1) Initial implementation.--Physician Compare shall
include the information described in subsection (b)--
(A) with respect to physicians, by not later than July 1,
2015; and
(B) with respect to other eligible professionals, by not
later than July 1, 2016.
(2) Annual updating.--The information made available under
this section 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 section prior to such information
being made public.
(g) Definitions.--In this section:
(1) Eligible professional; physician; secretary.--The terms
``eligible professional'', ``physician'', and ``Secretary''
have the meaning given such terms in section 10331(i) of
Public Law 111-148.
(2) Physician compare.--The term ``Physician Compare''
means the Physician Compare Internet website of the Centers
for Medicare & Medicaid Services (or a successor website).
SEC. 8. EXPANDING AVAILABILITY OF MEDICARE DATA.
(a) Expanding Uses of Medicare Data by Qualified
Entities.--
(1) Additional analyses.--
(A) In general.--Subject to subparagraph (B), to the extent
consistent with applicable information, privacy, security,
and disclosure laws (including paragraph (3)),
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, beginning July
1, 2015, a qualified entity may use the combined data
described in paragraph (4)(B)(iii) of such section received
by such entity under such section, and information derived
from the evaluation described in such paragraph (4)(D), to
conduct additional non-public analyses (as determined
appropriate by the Secretary) and provide or sell such
analyses to authorized users 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).
(B) Limitations with respect to analyses.--
(i) Employers.--Any analyses provided or sold under
subparagraph (A) to an employer described in paragraph
(9)(A)(iii) may only be used by such employer for purposes of
providing health insurance to employees and retirees of the
employer.
(ii) Health insurance issuers.--A qualified entity may not
provide or sell an analysis to a health insurance issuer
described in paragraph (9)(A)(iv) unless the issuer is
providing the qualified entity with data under section
1874(e)(4)(B)(iii) of the Social Security Act (42 U.S.C.
1395kk(e)(4)(B)(iii)).
(2) Access to certain data.--
(A) Access.--To the extent consistent with applicable
information, privacy, security, and disclosure laws
(including paragraph (3)), 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, beginning July 1, 2015, a qualified entity
may--
(i) provide or sell the combined data described in
paragraph (4)(B)(iii) of such section to authorized users
described in clauses (i), (ii), and (v) of paragraph (9)(A)
for non-public use, including for the purposes described in
subparagraph (B); or
(ii) subject to subparagraph (C), provide Medicare claims
data to authorized users described in clauses (i), (ii), and
(v), of paragraph (9)(A) for non-public use, including for
the purposes described in subparagraph (B).
(B) Purposes described.--The purposes described in this
subparagraph are assisting providers of services and
suppliers in developing and participating in quality and
patient care improvement activities, including developing new
models of care.
(C) Medicare claims data must be provided at no cost.--A
qualified entity may not charge a fee for providing the data
under subparagraph (A)(ii).
(3) Protection of information.--
(A) In general.--Except as provided in subparagraph (B), an
analysis or data that is provided or sold under paragraph (1)
or (2) shall not contain information that individually
identifies a patient.
(B) Information on patients of the provider of services or
supplier.--To the extent consistent with applicable
information, privacy, security, and disclosure laws, an
analysis or data that is provided or sold to a provider of
services or supplier under paragraph (1) or (2) may contain
information that individually identifies a patient of such
provider or supplier, including with respect to items and
services furnished to the patient by other providers of
services or suppliers.
(C) Prohibition on using analyses or data for marketing
purposes.--An authorized user shall not use an analysis or
data provided or sold under paragraph (1) or (2) for
marketing purposes.
(4) Data use agreement.--A qualified entity and an
authorized user described in clauses (i), (ii), and (v) of
paragraph (9)(A) shall enter into an agreement regarding the
use of any data that the qualified entity is providing or
selling to the authorized user under paragraph (2). Such
agreement shall describe the requirements for privacy and
security of the data and, as determined appropriate by the
Secretary, any prohibitions on using such data to link to
other individually identifiable sources of information. If
the authorized user is not a covered entity under the rules
promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, the agreement shall identify the
relevant regulations, as determined by the Secretary, that
the user shall comply with as if it were acting in the
capacity of such a covered entity.
(5) No redisclosure of analyses or data.--
(A) In general.--Except as provided in subparagraph (B), an
authorized user that is provided or sold an analysis or data
under paragraph (1) or (2) shall not redisclose or make
public such analysis or data or any analysis using such data.
(B) Permitted redisclosure.--A provider of services or
supplier that is provided or sold an analysis or data under
paragraph (1) or (2) may, as determined by the Secretary,
redisclose such analysis or data for the purposes of
performance improvement and care coordination activities but
shall not make public such analysis or data or any analysis
using such data.
(6) Opportunity for providers of services and suppliers to
review.--Prior to a qualified entity providing or selling an
analysis to an authorized user under paragraph (1), 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 such
provider or supplier with the opportunity to appeal and
correct errors in the manner described in section
1874(e)(4)(C)(ii) of the Social Security Act (42 U.S.C.
1395kk(e)(4)(C)(ii)).
(7) Assessment for a breach.--
(A) In general.--In the case of a breach of a data use
agreement under this section or section 1874(e) of the Social
Security Act (42 U.S.C. 1395kk(e)), the Secretary shall
impose
[[Page H2455]]
an assessment on the qualified entity both in the case of--
(i) an agreement between the Secretary and a qualified
entity; and
(ii) an agreement between a qualified entity and an
authorized user.
(B) Assessment.--The assessment under subparagraph (A)
shall be an amount up to $100 for each individual entitled
to, or enrolled for, benefits under part A of title XVIII of
the Social Security Act or enrolled for benefits under part B
of such title--
(i) in the case of an agreement described in subparagraph
(A)(i), for whom the Secretary provided data on to the
qualified entity under paragraph (2); and
(ii) in the case of an agreement described in subparagraph
(A)(ii), for whom the qualified entity provided data on to
the authorized user under paragraph (2).
(C) Deposit of amounts collected.--Any amounts collected
pursuant to this paragraph shall be deposited in Federal
Supplementary Medical Insurance Trust Fund under section 1841
of the Social Security Act (42 U.S.C. 1395t).
(8) Annual reports.--Any qualified entity that provides or
sells an analysis or data under paragraph (1) or (2) shall
annually submit to the Secretary a report that includes--
(A) 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;
(B) a description of the topics and purposes of such
analyses;
(C) information on the entities who received the data under
paragraph (2), the uses of the data, and the total amount of
fees received for providing, selling, or sharing the data;
and
(D) other information determined appropriate by the
Secretary.
(9) Definitions.--In this subsection and subsection (b):
(A) Authorized user.--The term ``authorized user'' means
the following:
(i) A provider of services.
(ii) A supplier.
(iii) 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).
(v) A medical society or hospital association.
(vi) Any entity not described in clauses (i) through (v)
that is approved by the Secretary (other than an employer or
health insurance issuer not described in clauses (iii) and
(iv), respectively, as determined by the Secretary).
(B) Provider of services.--The term ``provider of
services'' has the meaning given such term in section 1861(u)
of the Social Security Act (42 U.S.C. 1395x(u)).
(C) Qualified entity.--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)).
(D) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(E) Supplier.--The term ``supplier'' has the meaning given
such term in section 1861(d) of the Social Security Act (42
U.S.C. 1395x(d)).
(b) Access to Medicare Data by Qualified Clinical Data
Registries To Facilitate Quality Improvement.--
(1) Access.--
(A) In general.--To the extent consistent with applicable
information, privacy, security, and disclosure laws,
beginning July 1, 2015, the Secretary shall, at the request
of a qualified clinical data registry under section
1848(m)(3)(E) of the Social Security Act (42 U.S.C. 1395w-
4(m)(3)(E)), provide the data described in subparagraph (B)
(in a form and manner determined to be appropriate) to such
qualified clinical data registry for purposes of linking such
data with clinical outcomes data and performing risk-
adjusted, scientifically valid analyses and research to
support quality improvement or patient safety, provided that
any public reporting of such analyses or research that
identifies a provider of services or supplier shall only be
conducted with the opportunity of such provider or supplier
to appeal and correct errors in the manner described in
subsection (a)(6).
(B) Data described.--The data described in this
subparagraph is--
(i) claims data under the Medicare program under title
XVIII of the Social Security Act; and
(ii) if the Secretary determines appropriate, claims data
under the Medicaid program under title XIX of such Act and
the State Children's Health Insurance Program under title XXI
of such Act.
(2) Fee.--Data described in paragraph (1)(B) shall be
provided to a qualified clinical data registry under
paragraph (1) at a fee equal to the cost of providing such
data. Any fee collected pursuant to the preceding sentence
shall be deposited in the Centers for Medicare & Medicaid
Services Program Management Account.
(c) 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: ``Beginning July 1, 2015, 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.
(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, 2015,''
after ``deposited''; and
(2) by inserting the following before the period at the
end: ``, and, beginning July 1, 2015, 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) 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;
(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.
(c) Promoting Interoperability of Electronic Health Record
Systems.--
(1) Recommendations for achieving widespread ehr
interoperability.--
[[Page H2456]]
(A) Objective.--As a consequence of a significant Federal
investment in the implementation of health information
technology through the Medicare and Medicaid EHR incentive
programs, Congress declares it a national objective to
achieve widespread exchange of health information through
interoperable certified EHR technology nationwide by December
31, 2017.
(B) Definitions.--In this paragraph:
(i) Widespread interoperability.--The term ``widespread
interoperability'' means interoperability between certified
EHR technology systems employed by meaningful EHR users under
the Medicare and Medicaid EHR incentive programs and other
clinicians and health care providers on a nationwide basis.
(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 July 1, 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 not being 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) that the professional has
not knowingly and willfully taken any action to limit or
restrict the 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) that the hospital has not
knowingly and willfully taken any action to limit or restrict
the 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
one year 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 mechanisms 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 of, and resources needed to develop and
maintain, 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 user'' has the meaning given
such term under the Medicare EHR incentive programs.
(C) The term ``Medicare and Medicaid EHR incentive
programs'' means--
(i) in the case of the Medicare program under title XVIII
of the Social Security Act, the incentive programs under
section 1814(l)(3), section 1848(o), subsections (l) and (m)
of section 1853, and section 1886(n) of the Social Security
Act (42 U.S.C. 1395f(l)(3), 1395w-4(o), 1395w-23, 1395ww(n));
and
(ii) in the case of the Medicaid program under title XIX of
such Act, the incentive program under subsections (a)(3)(F)
and (t) of section 1903 of such Act (42 U.S.C. 1396b).
(D) The term ``Secretary'' means the Secretary of Health
and Human Services.
(d) GAO Studies and Reports on the Use of Telehealth Under
Federal Programs and on Remote Patient Monitoring Services.--
(1) Study on telehealth services.--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) Study on remote patient monitoring services.--
(A) In general.--The Comptroller General of the United
States shall conduct a study--
(i) of the dissemination of remote patient monitoring
technology in the private health insurance market;
(ii) of the financial incentives in the private health
insurance market relating to adoption of such technology;
(iii) of the barriers to adoption of such services under
the Medicare program under title XVIII of the Social Security
Act;
(iv) that evaluates the patients, conditions, and clinical
circumstances that could most benefit from remote patient
monitoring services; and
(v) that evaluates the challenges related to establishing
appropriate valuation for remote patient monitoring services
under the Medicare physician fee schedule under section 1848
of the Social Security Act (42 U.S.C. 1395w-4) in order to
accurately reflect the resources involved in furnishing such
services.
(B) Definitions.--For purposes of this paragraph:
(i) Remote patient monitoring services.--The term ``remote
patient monitoring services'' means services furnished
through remote patient monitoring technology.
(ii) Remote patient monitoring technology.--The term
``remote patient monitoring technology'' means a coordinated
system that uses one or more home-based or mobile monitoring
devices that automatically transmit vital sign data or
information on activities of daily living and may include
responses to assessment questions collected on the devices
wirelessly or through a telecommunications connection to a
server that complies with the Federal regulations (concerning
the privacy of individually identifiable health information)
promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996, as part of an
established plan of care for that patient that includes the
review and interpretation of that data by a health care
professional.
(3) Reports.--Not later than 24 months after the date of
the enactment of this Act, the Comptroller General shall
submit to Congress--
(A) a report containing the results of the study conducted
under paragraph (1); and
(B) a report containing the results of the study conducted
under paragraph (2).
A report required under this paragraph shall be submitted
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate. The Comptroller General may submit one report
containing the results described in subparagraphs (A) and (B)
and the recommendations described in the previous sentence.
(e) Rule of Construction Regarding Healthcare Provider
Standards of Care.--
(1) Maintenance of state standards.--The development,
recognition, or implementation of any guideline or other
standard under any Federal health care provision shall not be
construed--
(A) 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; or
(B) to preempt any standard of care or duty of care, owed
by a health care provider to a patient, duly established
under State or common law.
(2) Definitions.--For purposes of this subsection:
(A) Federal health care provision.--The term ``Federal
health care provision'' means any provision of the Patient
Protection and Affordable Care Act (Public Law 111-148),
title I or subtitle B of title II of the Health Care and
Education Reconciliation Act of 2010 (Public Law 111-152), or
title XVIII or XIX of the Social Security Act.
(B) Health care provider.--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) Medical malpractice or medical product liability action
or claim.--The term ``medical malpractice or medical product
liability action or claim'' means a medical malpractice
action or claim (as defined in section 431(7) of the Health
Care Quality
[[Page H2457]]
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) State.--The term ``State'' includes the District of
Columbia, Puerto Rico, and any other commonwealth,
possession, or territory of the United States.
(3) Preservation of state law.--No provision of the Patient
Protection and Affordable Care Act (Public Law 111-148),
title I or subtitle B of title II 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. 10. DELAY IN IMPLEMENTATION OF PENALTY FOR FAILURE TO
COMPLY WITH INDIVIDUAL HEALTH INSURANCE
MANDATE.
(a) In General.--Section 5000A(c) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new paragraph:
``(5) Delay in implementation of penalty.--Notwithstanding
any other provision of this subsection, the monthly penalty
amount with respect to any taxpayer for any month beginning
before January 1, 2019, shall be zero.''.
(b) Delay of Certain Phase Ins and Indexing.`
(1) Phase in of percentage of income limitation.--Section
5000A(c)(2)(B) of such Code is amended--
(A) by striking ``2014'' in clause (i) and inserting
``2019'', and
(B) by striking ``2015'' in clauses (ii) and (iii) and
inserting ``2020''.
(2) Phase in of applicable dollar amount.--Section
5000A(c)(3)(B) of such Code is amended--
(A) by striking ``2014'' and inserting ``2019'', and
(B) by striking ``2015'' (before amendment by subparagraph
(A)) and inserting ``2020''.
(3) Indexing of applicable dollar amount.--Section
5000A(c)(3)(D) of such Code is amended--
(A) by striking ``2016'' in the matter preceding clause (i)
and inserting ``2021'', and
(B) by striking ``2015'' in clause (ii) and inserting
``2020''.
(4) Indexing of exemption based on household income.--
Secton 5000A(e)(1)(D) of such Code is amended--
(A) by striking ``2014'' (before amendment by subparagraph
(B)) and inserting ``2019'', and
(B) by striking ``2013'' and inserting ``2018''.
(c) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2013.
The SPEAKER pro tempore. The gentleman from Pennsylvania (Mr. Pitts),
the gentleman from California (Mr. Waxman), the gentleman from Michigan
(Mr. Camp), and the gentleman from Michigan (Mr. Levin) each will
control 15 minutes.
The Chair recognizes the gentleman from Pennsylvania.
General Leave
Mr. PITTS. Mr. Speaker, I ask unanimous consent that all Members may
have 5 legislative days to revise and extend their remarks and to
include extraneous materials on H.R. 4015.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Pennsylvania?
There was no objection.
Mr. PITTS. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, the sustainable growth rate, or SGR, is the formula
through which Medicare reimburses physicians. Since 2003, Congress has
voted 17 times for temporary patches, or ``doc fixes,'' to avert ever
larger cuts to providers.
The uncertainty of the SGR threatens doctors' ability to continue
practicing medicine and accepting Medicare patients and endangers
seniors' access to care.
Absent congressional action, providers face a 24 percent cut on April
1, 2014. To stave off this cut, we can either pass another ``patch''
and kick the can down the road again, or we can repeal this flawed
formula for good.
Today's bill, H.R. 4015, firmly repeals the SGR and replaces it with
payment reform policy that has been agreed upon by the bipartisan
leaders of the Energy and Commerce, the Ways and Means, and Senate
Finance Committees.
As chairman of the Energy and Commerce Health Subcommittee, I have
been working for the past 3 years on legislation to permanently repeal
the SGR, and I am very pleased that on February 6, 2014, we reached a
bipartisan, bicameral agreement, embodied in today's legislation.
Unfortunately, since then, Senate Majority Leader Reid has refused to
negotiate with us on how to pay for this package. So we have brought
forward H.R. 4015, which is fully paid for by delaying implementation
of the individual mandate--a policy supported by both Republicans and
Democrats.
The bill enjoys more than 100 cosponsors and the support of over 700
national and State provider and stakeholder groups. So I urge all of my
colleagues to vote for H.R. 4015 to ensure that our seniors have access
to the doctors they know and trust.
I reserve the balance of my time.
Mr. WAXMAN. Mr. Speaker, to start the debate on our side, I yield 2
minutes to the gentleman from New York (Mr. Engel).
Mr. ENGEL. I thank my friend from California for yielding to me.
Mr. Speaker, I rise in strong opposition, not to the policy before
us, but to the poison pill pay-for attached to this much-needed SGR
repeal-and-replace legislation.
I support the bipartisan, bicameral agreement contained in H.R. 4015
for numerous reasons. There is almost universal agreement that the
sustainable growth rate is a flawed formula and, therefore, Congress
has been left to temporarily patch physician reimbursement for far too
long.
This bill permanently repeals the SGR and provides physicians with a
small increase in pay for the first 5 years. I want to see our
physician workforce fairly compensated for providing high-quality care
to our constituents. The SGR fails to adequately do this. This
legislation incentivizes physicians to focus on providing quality care
instead of a high quantity of care.
Finally, while it has always been extremely expensive to permanently
repeal and replace the SGR, it is now estimated to cost less than $140
billion. This is less than half the cost of what it would have been a
few years ago. While the costs remain significant, I believe that it is
imperative we permanently fix physician payment now.
That is why I am so furious Republicans are wasting valuable time by
pairing this much-needed legislation with yet another ridiculous
Affordable Care Act repeal vote. After more than 50 repeal votes, I
think it is clear to everyone where both Democrats and Republicans
stand on the Affordable Care Act. We don't need another repeal vote.
The current SGR patch expires in 17 days. We should be focused on
finding bipartisan pay-fors to permanently fix the SGR instead of
having Republicans push through yet another bill that will surely die
in the Senate.
Mr. PITTS. Mr. Speaker, at this time, I yield 2 minutes to the
gentleman from Georgia (Mr. Gingrey), one of the cochairs of the
Doctors Caucus, who has contributed a great deal to accomplish this
bipartisan agreement.
Mr. GINGREY of Georgia. Mr. Speaker, today we vote to repeal the
sustainable growth rate, a formula that was flawed from its 1997
beginning, and it has run its ugly course.
As cochairman of the House GOP Doctors Caucus, I would like to thank
the Energy and Commerce Committee, especially Chairman Upton, Ranking
Member Waxman, Health Subcommittee Chairman Pitts and Ranking Member
Pallone, and especially a member of the Doctors Caucus, Vice Chair Dr.
Michael Burgess, and, of course, the Ways and Means Committee and the
Senate Finance Committee and their staffs for their tireless work to
produce a policy which will help to ensure that seniors continue to
have access to quality providers.
Included in this legislation is my bill, and it is called the
Standard of Care Protection Act. It provides much-needed clarity to the
practice of medicine by confirming that Federal quality incentives are
no substitute in a medical malpractice case for the standards of care
developed by specialty societies and determined and practiced by
physicians. This is an extremely important determination that will
provide fairness to both patient plaintiffs and doctors.
With the vote today, we take an important step toward replacing the
flawed formula, while at the same time protecting Americans by delaying
the individual mandate of ObamaCare by 5 years. While the current
administration continues to add delays when it is politically
expedient, this policy gives certainty to individuals that they won't
be taxed or fined, Mr. Speaker, for not complying with a law that they
can't afford.
[[Page H2458]]
This may not be the final version of the bill, but it is time for the
Senate to pass their own version and appoint conferees. SGR repeal is
too important for both seniors and their doctors, and we have come too
far for this policy to not reach the President's desk this year.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. PITTS. Mr. Speaker, I yield the gentleman an additional 15
seconds.
Mr. GINGREY of Georgia. Let me just say again, we have come too far
for this policy to not reach the President's desk, and I mean this
year. The Senate Majority Leader needs to come to the table. Let's find
a suitable path forward, and let's repeal this unsustainable physician
payment policy.
Mr. WAXMAN. Mr. Speaker, at this time, I am pleased to yield 2
minutes to the gentlewoman from the State of Colorado (Ms. DeGette).
Ms. DeGETTE. Mr. Speaker, every year, sometimes more than once a
year, since 2003 Congress has had to step in to prevent a cut in
physician payments. With input from a wide variety of stakeholders, we
have tried to work together for many, many years on a solution to the
flawed system to the sustainable growth rate formula. Until this year,
we were out of luck, and the price tag for fixing the formula was ever
increasing.
The underlying legislation that we consider today was 11 years in the
making. I am very proud to cosponsor this bill because it is a
compromise solution for the formula we agreed on. But sadly--sadly--the
majority has prescribed a bitter pill to swallow for passage of this
important bill for patients and doctors. Instead of coming to the
negotiating table to discuss mutually acceptable ways to pay for this
bill, the majority has decided to pay for it by delaying important
provisions of the Affordable Care Act.
Everybody knows that this provision is a nonstarter. It is a
nonstarter in the other body and in my Caucus right here in the House.
Because of this shortsighted tactic, the Republicans have almost
guaranteed that we are going to need yet another short-term SGR patch
before the current one expires on March 31.
This is bad for the doctors of America. This is bad for the patients
of America. Let's get real. Let's fix this problem for good. And you
know, Mr. Gingrey just recognized that this bill is not going anywhere.
So let's sit down. Let's do what we did with the SGR itself, and let's
figure out how to pay for it.
Mr. PITTS. Mr. Speaker, may I inquire about how much time remains on
each side?
The SPEAKER pro tempore. The gentleman from Pennsylvania has 10\1/4\
minutes remaining. The gentleman from California has 11 minutes
remaining.
Mr. PITTS. Mr. Speaker, at this time, I yield 1 minute to the
gentleman from Florida (Mr. Bilirakis), a valuable member of the Health
Subcommittee.
Mr. BILIRAKIS. Thank you, Mr. Chairman.
Mr. Speaker, I rise today supporting repealing the SGR formula. The
SGR cuts would reduce doctors' compensation for treating Medicare
patients by 24 percent. H.R. 4015 repeals and replaces SGR with a
merit-based incentive payment system--MIPS--that pays doctors based on
quality, not volume.
Paying doctors based on quality incentivizes physicians to be as
efficient and effective as possible in keeping their patients healthy.
MIPS is fully paid for by a delay of ObamaCare's individual mandate--a
tax on Americans to force them to purchase more expensive health care
that doesn't meet their needs.
This bill will provide doctors who treat Medicare patients with
certainty, incentivize and reward doctors to keep seniors healthy with
better care, and provide individuals relief under ObamaCare.
Support our seniors, our doctors, and fairness for individuals under
ObamaCare. I urge my colleagues to support H.R. 4015.
Mr. WAXMAN. Mr. Speaker, at this time, I yield 2 minutes to the
gentlewoman from California (Mrs. Capps), my good friend.
Mrs. CAPPS. I thank my colleague for yielding.
Mr. Speaker, I have long been a supporter of a permanent fix to the
sustainable growth rate, or SGR. The flawed SGR harms providers and
consumers alike and keeps us from true innovation in the health care
sector, but for too long, the conversation has ended with everyone
recognizing a problem but no one willing to find a middle ground to fix
it.
{time} 0930
Instead, we lumber from patch to patch, kicking the can down the road
with piecemeal delays or fixes here in Congress, such as we are doing
today. These disagreements let the issue linger, causing more
instability in our communities while the cost of a fix continues to
rise. That is why I have been so proud to be part of crafting the
bipartisan, bicameral SGR fix policy.
This policy provides a positive payment update to our providers,
pushes us toward a system rewarding quality and fixing the GPCI,
ensuring that central coast providers and others will finally gain
accurate Medicare reimbursement.
But today, this bipartisan process is being derailed once again. By
tying a delay of the individual mandate to this policy, the House
majority has poisoned such a bipartisan process. Access to health care
for more than 50 million seniors and persons with disabilities is a
serious matter. These partisan games could very well end our Nation's
best shot at amending a bad policy.
I urge the majority to pull this bill, go back to the negotiating
table with all of us, and help us fix Medicare provider payments once
and for all.
Mr. PITTS. Mr. Speaker, I am pleased to yield 1 minute to the
gentleman from Nevada (Mr. Heck), another member of the Doctors Caucus.
Mr. HECK of Nevada. Mr. Speaker, I rise in support of H.R. 4015. I
have always stated that the number one threat to Medicare and seniors'
access to health care is the flawed SGR formula. At no time prior have
we been so close in a bipartisan, bicameral way to ensuring that our
seniors have access to the health care providers of their choosing, and
now when we are so close is not the time to derail the progress made by
using controversial pay-fors.
I will vote in favor of H.R. 4015 today because of the policy changes
it represents. I ask my friends on the other side of the aisle to vote
``aye'' so we can send this bill to the Senate, and I call on the
Senate to pass legislation that includes the agreed-to policy
provisions with the pay-for of their choosing. Then, let's go to
conference and fix the SGR once and for all.
Providing stability and predictability to our health care providers
will result in stability and predictability for our seniors. Passing
SGR reform is the fiscally responsible thing to do. The longer we
delay, the more it will cost.
Let's give seniors the peace of mind they deserve, so that they will
be able to see the Medicare provider of their choice. Let's pass H.R.
4015.
Mr. WAXMAN. Mr. Speaker, I yield 2 minutes to the gentleman from New
Jersey (Mr. Pallone), who is ranking member of the Health Subcommittee.
Mr. PALLONE. Mr. Speaker, I thank Mr. Waxman.
Mr. Speaker, today the Republican leadership once again chooses
politics over substance and what is good for the American people. The
current SGR patch will expire on March 31, at which point Medicare's
payment to physicians will be cut by almost 24 percent. It is critical
that we take meaningful action to fix the SGR before the end of the
month.
We all know that the SGR formula is flawed. After 10 years of
patching these cuts, after wasting $150 billion, enough is enough. It
is why we began last year seriously looking at this issue, and we came
up with a bipartisan, bicameral solution. In fact, if was quite the
lesson in legislating. Particularly, we ended up arriving at a
consensus bill on the SGR.
So I ask the Republican leadership: For what reason have you poisoned
this process with an unacceptable pay-for?
This bill will pass today and go nowhere. It will not be taken up by
the Senate or signed by the President. You have singlehandedly, in my
belief, stomped on months and months of hard work and effort by my
colleagues on both sides of the aisle and our staffs.
[[Page H2459]]
Late nights, weekends, hard compromises. We all saw the greater good in
finally getting a permanent policy replacement for the SGR. But instead
of working with our leadership, the Republicans have turned this into
their 51st vote to repeal or undermine the ACA, and you are going to
leave 13 million Americans uninsured if you were ever to succeed in
repealing the ACA.
This is just a poison pill. The pay-for is a poison pill for
something that we agreed on in terms of the substance of fixing the
SGR. You could have picked other ways of paying for this. I think we
are close to a consensus on the pay-for. Instead, you put in this
poison pill. You are wasting valuable time where you will basically do
nothing.
We only have 2 weeks left. Let's defeat this bill today, sit down
over the next 2 weeks and come up with a pay-for that makes sense, not
a pay-for that simply repeals the Affordable Care Act, which is working
well. More and more people are signing up. I had an enrollment event
this weekend in my district. People are signing up. Don't destroy the
process. We have a good SGR fix.
Mr. PITTS. Mr. Speaker, I am very pleased to yield 2 minutes to the
gentleman from Michigan (Mr. Upton), the distinguished chairman of the
Energy and Commerce Committee, one of the chief architects of this
bill.
Mr. UPTON. Mr. Speaker, first I want to commend Republicans and
Democrats for getting the policy right. This is a tough nut to crack.
It was 51-0 in our committee, led by Joe Pitts, Dr. Burgess, the Doc
Caucus, Mr. Waxman, Mr. Dingell, and Mr. Pallone. We worked long and
hard to get the policy right, and we worked with the other committees
to do it as well.
The difficulty we always knew was going to be on the pay-for. I would
suggest this: we want to work with the Senate; we want to get this
thing done; pay-for is the toughest part, but let's go to conference.
Let's work with the Senate to get a pay-for that can work.
Now, we know that there is a deadline coming up at the end of this
month. As we look to try and find a pay-for, let me go through some of
the other delays that this administration has already done:
Individual mandate delay, Americans with canceled coverage due to
ObamaCare; delayed.
Individual mandate, deadline for purchasing coverage; delayed.
Individual mandates for non-ACA compliant plans; delayed by the
administration.
Annual limit requirement; delayed.
MLR requirement; delayed.
MA cuts through demo bonus money; delayed.
Employer reporting; delayed.
Employer mandate; delayed.
Subsidies only in State-run exchanges; delayed.
High-risk pool closure; delayed.
Out-of-pocket waiver for group health plans; delayed.
Verification of eligibility for exchange subsidies; delayed.
Reinsurance fee for some unions; delayed.
Nondiscrimination requirement for employer coverage; delayed.
Subsidies only through the exchange; delayed.
Shop employee choice delay; delayed
Shop online purchasing; delayed.
Numerous HealthCare.gov technical; delayed.
This was never ready for prime time. We have said that from the
start. If the administration has decided to delay all these things,
almost two dozen, why not delay this, too? And why not use the savings
then not only to help the physicians, we have to think about the
seniors.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. PITTS. I yield an additional 30 seconds to the gentleman.
Mr. UPTON. This isn't just to help our physicians, it is to help the
most vulnerable, our seniors, because if we don't reimburse our docs,
the ``closed'' sign is going to come up where they go for services.
They are going to be denied the coverage that they have paid taxes for,
that they expect to have, and yet another broken promise will be there.
If the administration can delay these things, why don't we delay
this? Why don't we use the savings then to pay for a program that
works, and I would suggest that we vote for this. Let's work with the
Senate to get it done.
Mr. Speaker, we are here today to vote for a bill that would provide
certainty and peace of mind to our nation's seniors and fairness for
all Americans under the president's health care law. Repeal of the
system of physician cuts under Medicare, or SGR, has been a problem
that has plagued seniors, doctors, and Congress for well over a decade.
These cuts have threatened access to our seniors' health care and the
Medicare promise that our country has made to every American--both
those in the program today and those who count on it as part of their
future retirement.
Our purpose here today is Medicare reform so that we can keep the
promise made to all seniors, current and future. The Medicare program
is going insolvent, and Congress will need to act if we are to prevent
bankruptcy. Today is one step toward keeping the Medicare promise. Many
of us did roundtables with our doctors back home, I did so in Michigan,
and we visited with countless seniors. We heard their concerns loud and
clear and have acted.
H.R. 4015, the SGR Repeal and Medicare Provider Payment Modernization
Act, is the product of years of bipartisan efforts to remove the threat
of SGR. The legislation would once and for all repeal the broken SGR
and replace it with a system that promotes the highest quality of care
for seniors, eases the burden on physicians who are struggling under an
increasing number of government programs that take time away from
patients, and promotes new forms of health care delivery and innovation
with an eye on the future.
We stand here today on the House floor in no small part because of
our speaker, John Boehner, who charged the Energy and Commerce
Committee to find a workable solution to get rid of SGR. This has been
a long journey with many important players on both sides of the aisle,
and in both chambers. I do want to commend Health Subcommittee Chairman
Joe Pitts for helping lead the effort and the bill's sponsor Dr.
Michael Burgess, for his tireless commitment from day one. We also
would not be here without the efforts and support of the GOP Doctors
Caucus--a group who understands all too well the threat that SGR has
posed. And of course I appreciate our partnership with my good friend
Dave Camp and the Ways and Means Committee.
While this is a significant milestone, the cost of SGR repeal is not
insignificant. We have strived over the past few months to find common
ground with the Senate to identify a way to pay for this agreement that
both chambers can support. Time is not on our side as the current patch
is set to expire at the end of this month. So today the House has
chosen to act rather than stand idly by and is prepared to send a bill
to the Senate with a bipartisan payfor: relief for individual Americans
from the mandate that they purchase government-approved insurance.
The White House has already seen fit to delay many parts of the
president's health care law, including the employer mandate. And it has
also quietly delayed the individual mandate for the millions of
Americans whose health care plans the law cancelled. If Senate
Democratic colleagues don't want to afford individuals the same rights
as special interests with a direct line to the president, then I would
ask them to simply pass their own fully offset SGR package and let's go
to conference to iron out our differences. But make no mistake, SGR
must be paid for.
We have never come this far in finding a permanent solution. But
there is still much work to be done after today's vote, and I call on
my Chairman Ron Wyden to pick up the torch and work with Majority
Leader Harry Reid to put politics aside, stand up for our seniors and
doctors, and let's solve SGR this year.
I urge all my colleagues to support H.R. 4015 and the millions of
seniors who are watching us here today.
Mr. WAXMAN. Mr. Speaker, I want to point out that none of the delays
that Mr. Upton indicated on that chart would result in 13 million
people losing insurance coverage and raise premiums 10-20 percent. This
is not a delay that we can agree to. It hurts the Affordable Care Act,
and it is a betrayal of our working together on a bipartisan basis to
resolve this problem. We worked together on the policy, but we were
never brought in to work together on funding that policy.
At this time I yield 2 minutes to the gentleman from Texas (Mr. Gene
Green).
Mr. GENE GREEN of Texas. Mr. Speaker, I rise to express strong
objection to the decision to use the Affordable Care Act's individual
responsibility requirement to pay for the SGR reform.
This bill hijacks a thoughtful solution to a problem that has been
harming Medicare beneficiaries, providers, and our budget for years and
turns it
[[Page H2460]]
into a political stunt. This decision is a poison pill and nothing more
than more partisan politics.
Congress has overridden the SGR-mandated cuts to Medicare physician
payments each year since 2003. Year after year, these temporary patches
have been costly and disruptive. Reforming the system is long overdue.
Temporary fixes to SGR are a losing situation. The money still has to
be spent, but only to just maintain the broken status quo.
The bipartisan, bicameral SGR bill is the closest we have come to
fixing this problem once and for all, and this decision gets us further
from that goal. Repealing the ACA is a game we have played now 51
times. Holding SGR reform hostage to destroy the ACA and deny millions
of Americans access to managed care is disgraceful. Our seniors, our
doctors, including the AMA, the Texas Medical Association, the
California Medical Association, and the American people deserve better.
In order for our health care system to work, Americans must have
insurance. Delaying or repealing the requirement that individuals
obtain coverage would drive up premiums and leave millions uninsured.
Again, this is purely a partisan pay-for which proves that there is not
a sincere effort to finally enact SGR reform but rather just another
political game.
Mr. PITTS. Mr. Speaker, I submit for the Record a letter from the
Texas Medical Association in support of this legislation.
Texas Medical Association,
Austin, TX, March 13, 2014.
Hon. Michael C. Burgess, MD,
House of Representatives, Washington, DC.
Dear Representative Burgess: On behalf of the 47,000-plus
physician and medical student members of the Texas Medical
Association, I am writing to reiterate our strong support for
the work you have done to effectuate the repeal of Medicare's
Sustainable Growth Rate (SGR) formula. In conjunction with
your Texas colleague, Kevin Brady, you have gotten closer to
solving this challenging issue than ever before. And you have
done so with the support of every member of the Texas
delegation, both Democratic and Republican, on the Energy &
Commerce and Ways & Means Committees.
Perhaps more than anyone in Congress, you understand the
frustration and anxiety that the ongoing SGR uncertainty
creates for practicing physicians. You have worked tirelessly
to craft a piece of legislation that not only repeals the SGR
immediately, but also guarantees positive updates for
physicians for five years, removes potential causes of
liability against physicians, and eliminates some unnecessary
bureaucratic red tape that prevents physicians from
concentrating on patient care.
We especially appreciate your ongoing consultation and
dialogue with TMA and Texas physicians throughout this
process.
As you know well, the SGR Repeal and Medicare Provider
Payment Modernization Act of 2014 has made it this far
because of a bipartisan, bicameral agreement on the need to
replace the SGR. We are committed to helping you finish the
task.
Sincerely,
Stephen L. Brotherton, MD,
President.
Mr. Speaker, I yield 1 minute to the gentleman from Indiana (Mr.
Bucshon), another member of the Doctors Caucus.
Mr. BUCSHON. Mr. Speaker, I rise today in support of this
legislation. As a practicing physician for over 15 years, the majority
of my patients were Medicare patients. I know firsthand how flawed the
SGR is. By not repealing this flawed system, to remain in business,
many doctors across America will be forced to limit the number of
Medicare patients that they see, and many may refuse to see Medicare
patients all together.
Failing to act or voting ``no'' on this legislation will limit
seniors' access to their doctors. This will be especially dangerous in
rural areas where there are already physician shortages. It is time we
finally solve this problem and ensure that Medicare patients have
access to their chosen doctors.
I urge my colleagues to stand up for all of the seniors in America
and support this legislation.
Mr. WAXMAN. Mr. Speaker, I yield 2 minutes to the gentleman from
North Carolina (Mr. Butterfield).
Mr. BUTTERFIELD. Mr. Speaker, I rise in strong opposition to this
bill. This began as a bipartisan effort, but, predictably, this has
devolved into nothing but another attempt by House Republicans to
dismantle the Affordable Care Act. Here we go again. Over 4.2 million
people have signed up for affordable insurance so far, and the numbers
are growing.
We all support a permanent repeal of the sustainable growth rate
because the SGR in current law is anything but sustainable. We are
demanding more out of our doctors and health care professionals. We are
asking that they operate with maximum efficiency to play their part in
reining in health care spending, and they deserve the same from
Congress.
Unfortunately, my Republican colleagues don't share that view. That
is why they have offered a pay-for that they know will be completely
unacceptable to most Democrats and certainly stands no chance of
passage in the Senate. The President has even said he would veto this
bill, and rightfully so.
The American Medical Association, which represents most of the
doctors throughout the country, and I am disappointed that the Texas
Medical Association is at variance with their national association, but
the AMA and the AARP and a dozen other organizations representing
health care providers and hospitals and seniors have decried Republican
partisan tactics. They don't like this.
We have 5 legislative days before the last SGR extension runs out on
March 31. Five days. Should Republicans not come to their senses in
time, I want doctors to know that a nearly 30 percent cut to their
reimbursement should be laid squarely at the feet of my Republican
friends here in the House. Doctors need predictability and certainty so
they can best serve their patients. If a permanent solution to the SGR
is not reached soon, doctors will be forced to make tough decisions
about which patients they will see and those which they can no longer
afford to see.
Mr. PITTS. May I inquire of the time remaining.
The SPEAKER pro tempore. The gentleman from Pennsylvania has 4\3/4\
minutes remaining. The gentleman from California has 3\1/2\ minutes
remaining.
Mr. PITTS. Mr. Speaker, at this time I am pleased to yield 1 minute
to the gentleman from Tennessee (Mr. Roe), another cochair of the
Doctors Caucus.
Mr. ROE of Tennessee. Mr. Speaker, this physician rises in strong
support of H.R. 4015, the SGR repeal. This bicameral, bipartisan
compromise will preserve seniors' access to needed medical care and
give physicians certainty about how Medicare will pay them for their
services.
{time} 0945
This bill also lays the groundwork for a gradual transition to a
reimbursement system that rewards value instead of volume.
The House, by passing H.R. 4015, will take a big step toward the
permanent repeal of a flawed payment formula that has hampered
physicians since 1997, but we can't allow the process to stop here.
I encourage our Senate colleagues to pass a bill as soon as possible,
so that we can move into conference and find a mechanism to repeal this
bill.
I would like to thank the members and staff of the committees for
their tireless efforts on this bill, particularly my friend Dr. Mike
Burgess, who has long championed this reform.
I encourage my colleagues to support H.R. 4015. Mr. Speaker, the
American Medical Association represents less than 20 percent of the
physicians in this country.
Mr. WAXMAN. Mr. Speaker, I continue to reserve the balance of my
time.
Mr. PITTS. Mr. Speaker, at this time, I am pleased to yield 1 minute
to the gentlelady from North Carolina (Mrs. Ellmers), who is another
important member of the Health Subcommittee.
Mrs. ELLMERS. Mr. Speaker, I rise today in support of H.R. 4015, the
SGR repeal.
This has been a long time coming, and I am very excited to be part of
it. I want to see this legislation move forward.
I want to agree and disagree with my esteemed colleagues across the
aisle. This does boil down to patient care. This will negatively affect
our seniors if we do not solve this problem for Medicare reimbursement.
It is patient access that is the core of this issue.
However, when we speak about associations, such as the AMA--or the
American Medical Association--we are talking about a group who only
represents about 11 percent of physicians
[[Page H2461]]
across this country, and that number decreases every year.
There is a reason for that. They are not representing doctors in this
country, and their voice is not as strong as it once was and should be.
With that, Mr. Speaker, I thank you for this time, and I thank my
colleagues for this important message today. I hope all Members support
the SGR reform.
Mr. WAXMAN. Mr. Speaker, I yield myself 2 minutes.
This should be a moment of bipartisanship where we finally fix this
sustainable growth rate in Medicare physician reimbursement. None of us
think it is supportable. Doctors are always facing the peril of a deep
cut if we don't patch it up or fix it permanently. It is time to fix it
permanently.
We worked together on a bipartisan basis on our committee and came up
with a policy to replace the SGR. The Ways and Means Committee and the
Senate Finance Committee followed us, and they did their approach, and
we all worked out one uniform approach with the idea that we are
finally going to end this nonsense of threatening the doctors that take
care of Medicare patients.
This is an issue of patient access to medical care that has been
promised under Medicare; yet the Republicans are now insisting we pay
for the permanent fix. Well, this has come up many, many times.
Sometimes, we paid for it, but sometimes, we didn't pay for it; but we
always made sure that there was a fix on a bipartisan basis.
Instead, today, the Republicans, without talking to us--they wanted
to talk to us about the policy, but without talking to us--are trying
to pay for this by hurting the Affordable Care Act.
What they are doing is putting a partisan poison pill offset, an
offset that would cause 13 million people to lose insurance coverage
and would raise premiums by 10 to 20 percent for everybody else in the
exchange. They have to know this is not acceptable; we can't support
it.
They are now coming here to the floor saying that there is some
attempt by the Democrats to undermine our policy agreement. Well, let's
stop blaming each other. Let's get to work and resolve this problem and
vote down this bill.
I reserve the balance of my time.
Mr. PITTS. Mr. Speaker, may I inquire of the minority how many
speakers they have left?
Mr. WAXMAN. I have one more speaker.
Mr. PITTS. We have one more speaker. I reserve the balance of my
time.
Mr. WAXMAN. You have one more speaker? I yield back the balance of my
time.
Mr. PITTS. At this time then, Mr. Speaker, I yield the balance of my
time to the gentleman from Texas, Dr. Burgess, the prime sponsor of
this legislation, who has worked tirelessly to achieve this day.
Mr. BURGESS. Mr. Speaker, I want to thank my friend from Pennsylvania
for yielding me the time, the chairman of the subcommittee, for making
this possible to bring this bill to the floor today.
I want to thank Chairman Upton of the full committee and Ranking
Member Waxman of the full committee for also making this possible. It
has been a lot of hard work getting us to this point.
Chairman Upton talked about delays. I would just point out that there
has been yet another delay, the delay of the closure of the risk pools
because--let's be honest--the Affordable Care Act is not ready to take
on those people who have preexisting conditions, so they felt it
necessary to keep the risk pools open for an additional length of time.
I want to talk to my friends on the Democratic side of the aisle. I
particularly want to talk to those who have only been here one or two
terms. The last time we had a bill like this on the floor of the House,
Democrats were in charge.
Mr. Dingell was chairman of our Energy and Commerce Committee. He
brought a bill to the floor, H.R. 3961, which was an SGR repeal bill.
This bill had already been rejected by the Senate, so it really had
no chance of going anywhere. This bill was not paid for. The policy was
awful and would have given us two SGRs, instead of one; but
nevertheless, that bill came to the floor.
It only garnered one Republican vote. I was that vote. I was that
vote because I thought it was important that the Nation's doctors heard
that we were willing to work together across party lines, if need be,
to solve this problem for them. I wanted to preserve the process going
forward.
Ladies and gentlemen, the bill you have on the floor today, H.R.
4015, is not the destination. It is the key that gets you through the
door to get to that destination.
For 4\1/2\ weeks, since February 6, the policy has been out there for
all to see. We have awaited anyone from the Senate side who wanted to
talk to us about negotiating bipartisan pay-fors--radio silence.
Look, I don't know what rule XIV is over in the Senate, but it is
apparently pretty important. The majority leader in the other body has
brought this bill up under rule XIV; but they were doing nothing
before.
For 4 weeks, this policy languished without them picking it up. Now
that the House is moving--now that the House is moving a bill and will
likely pass the bill today with a decent pay-for that is, in fact,
bipartisan because 27 Democrats voted for this very pay-for last week
on the floor of this House--in fact, it was unanimous if we were
exempting firefighters or veterans from the individual mandate in the
Affordable Care Act.
This is a bipartisan pay-for. It has passed the floor of this House
in a bipartisan fashion. It is ready to go. We call upon our colleagues
in the other body. Use whatever Senate procedures you need to, but get
this done because the clock is ticking. The clock is ticking towards
March 31.
We all know what happens to the Nation's seniors on that date. We all
know what happens to their doctors. Let us get this done.
Mr. PITTS. I yield back the balance of my time.
Mr. CAMP. Mr. Speaker, I yield myself such time as I may consume.
I rise today, Mr. Speaker, to strongly support H.R. 4015, the SGR
Repeal and Provider Payment Modernization Act, as amended.
The Ways and Means Committee and Energy and Commerce Committee and
Senate Finance Committee have worked in a bipartisan manner to develop
a permanent physician payment fix repeal.
Years of hearings, discussion drafts, and ongoing dialogues with
stakeholders have resulted in H.R. 4015, a bipartisan, bicameral
agreement on SGR replacement policy.
This bill has over 100 cosponsors, has the support of 18 Members of
the House Doctors Caucus, and 600 national and State organizations
representing physicians and other professionals.
There is a reason for all of this support. H.R. 4015 has a lot to
like. It repeals the outdated SGR formula and gives seniors the
certainty that they will have access to their doctors.
It incentivizes better care and better results for seniors that rely
on the Medicare program, and it breaks the cycle of uncertainty for
doctors and their patients, providing permanent relief and improving
how Medicare pays doctors.
We must not let this opportunity pass by. Time is short. If we do not
act, in just 2 weeks, doctors will see a 24 percent cut in their
Medicare reimbursement, jeopardizing seniors' access to care.
We must safeguard taxpayer dollars. That is why we pay for permanent
repeal by delaying the health care law's individual mandate for 5
years. Americans across the country are facing higher costs, losing the
coverage they have and like, and are seeing smaller paychecks as a
result of ObamaCare.
Last week, the administration announced that it would continue to
expand certain exemptions from the individual mandate for 2 years. This
proposal would extend that further--would extend further what the
administration is already doing and give all Americans relief from the
mandates and penalties of ObamaCare. It is only fair.
I urge all members to support H.R. 4105. I reserve the balance of my
time.
Mr. Speaker, I ask unanimous consent that the gentleman from Texas
(Mr. Brady) control the remainder of the time.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Texas?
[[Page H2462]]
There was no objection.
Mr. LEVIN. Mr. Speaker, I yield myself such time as I may consume.
What is going on here? The Republicans are bringing up a totally
partisan bill to thwart a bipartisan bill. They are tossing aside
common ground for barren ground, another Affordable Care repeal vote.
They are throwing out a historic bipartisan breakthrough to permanently
end and replace the broken Medicare physician payment formula, once
again turning to totally partisan politics.
The breakthrough achieved by our committees would permanently replace
the deeply flawed SGR formula with a system designed to build on
delivery system reform, reforms that move Medicare physician payments
toward a more accountable value-driven system.
The underlying policy agreement is broadly supported by both provider
communities and beneficiaries; but today's exercise is opposed by
groups representing seniors, doctors, health plans, and others because
it guts the Affordable Care Act through a 5-year delay to the
individual mandate.
What would the result be? According to CBO and the Joint Task
Committee, the Republican bill would increase the number of uninsured
Americans by 13 million. What is more, the bill would raise individual
market health insurance premiums by 10 to 20 percent for those who
remain insured.
Last week, we saw the 50th vote. This is now the 51st vote to
undermine the Affordable Care Act. So much for good faith and so much
for good will.
Instead of working to find common ground to finish the job on a
bipartisan solution vital to fixing a problem in our health care
system, House Republicans are taking once again a cynical step in a
very familiar direction, concerned only about the November election.
I urge my colleagues to vote ``no,'' and I reserve the balance of my
time.
Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may
consume.
Enough really is enough. The unfair way Medicare pays our local
doctors to treat our seniors has gone on for far too long.
It is making it harder for seniors to see a doctor they know and who
knows them. It is chasing local doctors out of Medicare and out of
private practice, and it is encouraging too much waste and too many
unnecessary procedures within Medicare.
As chairman of the Health Subcommittee of Ways and Means, my top
priority has been to find a permanent, reliable 21st century solution
that both political parties and physicians can embrace.
{time} 1000
H.R. 4015 repeals the current flawed formula for reimbursing our
doctors, and it ends the yearly threat of massive cuts.
In working with America's physicians, it establishes a more patient-
centered approach that provides stability to our doctors, rewards them
for high-quality care, begins to streamline the red tape our physicians
face, and encourages better coordination and prevention. Over time, it
transitions to a model that rewards value over volume by using the
real-life approaches that doctors use, not what Washington wants.
H.R. 4015 is a solid foundation from which to build an even better
Medicare system, and it has overwhelming support from physicians. This
is a major step forward, but we need to finish the job. We need to work
together--Republicans and Democrats, the House and the Senate--to
figure out how to make this policy a reality in a way that doesn't
increase the deficit.
There may be disagreements over how to pay for this reform. That is
understandable as it is difficult, and today's bill is not the last
word. Let's continue to advance this long overdue solution and commit
to finding a bipartisan solution between the House and the Senate. The
clock is ticking, so let's act together today.
Mr. Speaker, I reserve the balance of my time.
Mr. LEVIN. Mr. Speaker, it is now my pleasure to yield 2 minutes to
the gentleman from New York (Mr. Rangel).
(Mr. RANGEL asked and was given permission to revise and extend his
remarks.)
Mr. RANGEL. Thank you, Chairman Levin.
Mr. Speaker, this bill has nothing to do with paying the doctors who
work every day in giving medical care to Medicare patients. It has to
do with destroying the Affordable Care Act for the 51st time.
I am certain that those who are listening to the debate and who know
what is going on believe it is ridiculous to try to defeat a bill that
has been signed into law, because they know that the Senate is not
going to pass it, and they know--the Republicans, that is--that the
President would veto it.
So why do they do it?
They do it because there is a small group of people in the Republican
Party that doesn't mind politically dying. I don't mind their taking
down the party if that is their intent, but they are taking down the
Democrats and the reputations of the House of Representatives as well.
Somewhere along the line, the Speaker has to do again what he has done
before, and that is to say, ``Enough of this. We are not going to allow
the wings of the Congress to be broken on one side just because some
people want their way.''
So I assume that nobody in these districts has insurance problems. I
assume that everyone is insured and is working in these districts in
which they are trying to destroy the Affordable Care Act and that they
don't have any preconditions that restrict them from getting health
care. They all are working and they all are happy. I just hope that,
one day before this year ends, the Republicans will come to their
senses and will try to gain the respectability and the credibility that
they once enjoyed.
I am a die-hard Democrat, but I don't want this country just to have
one party. We do need two responsible parties in order to guide this
Nation through its democratic process.
Mr. BRADY of Texas. Mr. Speaker, I am pleased to yield 3 minutes to
the gentleman from Louisiana (Mr. Boustany), a physician and a key
member of the Ways and Means Committee. I cannot describe how much of
an important role he has played in finding this new solution to how we
reimburse doctors under Medicare.
Mr. BOUSTANY. I applaud Chairman Brady's leadership on this issue. He
has been instrumental in getting us to this point.
Mr. Speaker, I rise in support of this bill after 3 long years of
working on the policy to actually get to a bipartisan, bicameral
agreement on policy and divided government. It has not been easy, but
we have managed to get an agreement on a policy to repeal automatic
annual cuts to physicians. A 24 percent cut in just a matter of weeks
is facing doctors under this flawed formula.
Now, Congress first promised to repeal this formula more than a
decade ago. Democrats repeated the promise when we were debating
ObamaCare. They failed to put it in there. They failed to address it in
ObamaCare. The passage of this important bipartisan legislation would
finally honor that promise, that of protecting seniors' access to
doctors. A doctor-patient relationship is built on trust and high
quality. It ensures quality measures going forward, and it creates
certainty for physicians and seniors.
I want to point out something because our friends have not given the
full story here.
We have agreed on the policy, but we have a problem in coming up with
the pay-fors. It is a tough conversation, but the talks have broken
down in a divided government. Senate leadership has refused to
negotiate in good faith and to discuss responsible ways to pay for the
bill's $138 billion price tag. We are going to pass this bill to get
those discussions started. Republicans proposed savings from the delay
of ObamaCare's very unpopular individual mandate.
Now, I don't think it is acceptable to do nothing, and I don't think
it is acceptable for the Senate Majority Leader and others in the
Senate to just put their heads in the sand on this. I hope that the
Senate will pass a version of H.R. 4015, giving us time to get together
to hash out the differences. We are so close. We are on the goal line
in this work that has been undone for years. It is time to get it done.
The President's own budget lists bipartisan Medicare reforms that the
President put on the table that could
[[Page H2463]]
easily raise the bulk of savings needed to repeal the SGR, and we could
do this without shifting more costs to our Nation's credit card and
without resorting to budget gimmicks or by imposing massive new cuts on
hospitals and other providers. We have a clear path. We can get this
done in a bipartisan way.
Mr. Speaker, as a heart surgeon who has cared for thousands of
seniors under the Medicare program, I urge my House and Senate
colleagues to pass this bill. Let's get down to the negotiations of how
we are going to pay for it in good faith, and let's finalize an
agreement on how to fix this longstanding problem, which has been a
thorn not only in the sides of doctors but which has been a real
problem for Medicare access, a real problem for seniors seeking access
to a high-quality doctor-patient relationship.
Mr. Speaker, I have had enough. It is time to get this done. Pass
this bill.
Mr. LEVIN. Mr. Speaker, I yield myself 15 seconds.
I say to my colleague that what you are doing, essentially, is
undercutting bipartisanship with pure partisan politics. Pointing to
the Senate is pure mythology.
I now yield 3 minutes to the gentleman from Washington (Mr.
McDermott), the ranking member on the Health Subcommittee.
(Mr. McDERMOTT asked and was given permission to revise and extend
his remarks.)
Mr. McDERMOTT. Mr. Speaker, this 51st attempt to repeal the ACA by
stopping the individual mandate is part of the long-term propaganda
campaign done by the Republicans to destroy the health care plan that
the President put together.
They know that we agree on the policy--everybody here agrees on the
policy--but they put a poison pill in it. They knew that this amendment
of how to pay for it--that is, by delaying the mandate--would kill any
Democratic support in the House. They have no intention of passing this
bill. This bill is directed at the propaganda campaign to the people at
Koch Brothers and at FOX News so that anybody who is watching this will
get the idea that somehow it is a bad bill.
The fact is that people are benefiting every single day. The AARP and
the American Medical Association have denounced this bill because they
want the SGR--the doctors' payment reform--to go through, and they know
that the Republicans have designed this to fail.
A mandate that has been supported even by the Tea Party--before the
Tea Party said ``we have got to be against it''--is what is at issue
here. Doctors and health insurance companies will not be able to
operate if you don't have an individual mandate. The Republicans said
this. The Heritage Institute said it. Everybody said it, but they want
to kill it.
This is an alternative universe that we are creating with this
propaganda campaign. We see wild claims about people who live in inner
cities in that they are somehow worthless and that they don't want to
take care of their families and feed them, and we hear things coming
out of the Speaker's office that clearly aren't true about the ACA.
Let's suppose that actually happened. What would happen if we
repealed and destroyed the ACA today?
We would get rid of 13 million people on the rolls by 2018. We would
take away health insurance. Health insurance premiums would rise 10 to
20 percent by 2018. Millions of Americans would not be able to afford
the health care they need.
This is a failure of leadership. They would rather run a propaganda
campaign to hold onto the House. We watched in Florida just in the last
week when $13 million, I guess, was spent on that campaign to tar the
Affordable Care Act. That is what this is all about. No one should be
the least bit confused. That is not what America wants. America wants
health security.
Vote ``no'' on this bill.
Mr. BRADY of Texas. Mr. Speaker, I am really pleased to yield 3
minutes to the gentleman from Pennsylvania (Mr. Kelly), a gentleman who
is one of the newest members of the Ways and Means Committee. He is a
businessman, but he is a real fighter for Pennsylvania's seniors and
doctors.
Mr. KELLY of Pennsylvania. I thank the gentleman.
Mr. Speaker, there are very few times in my life in which I have
really had the privilege of representing people who are so dear to me.
I just think, if you were to look at our generation, we would all have
to agree that we grew up in the greatest towns, at the greatest times,
with the greatest parents, preachers, teachers, and coaches, grandmas
and grandpas, and aunts and uncles.
This is the people's House. This is not a Republican House or a
Democrat House. This is the people's House. What are we talking about
today?
My goodness. This is so disappointing that we are so worried about
the next election that we can't see the direction that we are going
in--to be able to offer peace of mind to those folks who have made the
greatest sacrifices, who have made the greatest contributions, and who
have done the best that they could to make sure that the next
generation had the same opportunities they had.
This is not a doc fix. This is a senior fix.
As my mother lay dying and my sister and my father, they were
surrounded by a loving family, and they were also surrounded by caring
doctors. Why would we make this about an election? Why would we not
look inward to whom it is we are trying to protect? Why can we not
protect the most vulnerable in our society right now, especially in
their end days and in their end times and say, ``You can lay your head
on a pillow tonight, knowing that your doctor is going to be there for
you, that I will be beside you, that I will be by your bed, saying the
rosary; and when you have finally gone, I can't wait until the next
time we are able to meet each other again in Heaven''? Why would we
make their last days so difficult? Why would we make it so uncertain?
So we talk about an SGR, but where I come from, it is not bad, and it
is not a doc fix--it is a senior fix.
When can we possibly put politics behind us and start to look at what
is best for the people we represent?
I am a Representative of Pennsylvania's Third District--so privileged
and so proud to be able to do it, not boastful proud, but thankful
proud that I can actually go and do something for the people who raised
me, who taught me, who coached me, and who have walked me through the
most difficult parts of my life and that I can look back at their lives
and say, ``But you sacrificed so much that I could be here.''
Can we not just come together and do something that really is a big
thank-you and a kiss on the forehead as they lay there, wondering,
``Where are those folks that we did so much for?''
My goodness. My friends on the other side, this is not about
politics--this is about people. We are in the people's House, and these
are things that we must do.
Mr. Chairman, I thank you so much for doing this and for bringing
peace of mind to the people we represent, but I can't tell you how
disappointing it is today to hear this turn into some kind of political
debate that has nothing to do with the fate of those seniors and of
those people whom we love so much and who have done so much for us.
Mr. LEVIN. Mr. Speaker, I yield myself 15 seconds.
I say to the gentleman from Pennsylvania that the problem is your
bill is nothing but a political bill. It is nothing except about the
November election--nothing but.
I now yield 2 minutes to the gentleman from Oregon (Mr. Blumenauer),
an active, distinguished member of our committee.
{time} 1015
Mr. BLUMENAUER. Thank you, Mr. Levin.
I was somewhat embarrassed by the remarks of my friend, who is from
Butler, Pennsylvania, the hometown of my wife, because it is the
Republicans who have decided to make this bill about the next election.
There is no reason the House Republicans put the medical community
through this charade again and again, year after year, except to use
the SGR as a tool for power, partisan advantage, and fundraising.
This political tool disrupts the lives of millions of medical
providers and tens of millions of their patients who rely upon them.
[[Page H2464]]
We had, in fact, been making remarkable progress in both the Commerce
Committee and the Ways and Means Committee on a bipartisan solution.
Instead, the Republicans have hijacked this bipartisan solution and
made it so bad that even the American Medical Association rejects it.
What then should we do? First, we should reject this bill
overwhelmingly. It certainly will never be enacted into law.
What should we do then? I would argue that we ought to just reset the
baseline.
Remember the alternative minimum tax? We finally decided it would
never be imposed. Adjusted the budget to reflect the fact that it will
never happen. And if you won't do that, at least give the medical
community procedural fairness.
Kevin Brady said, Let's work in a bipartisan approach. He admits that
this isn't going to be the last word. Well, let's try procedural
fairness. Allow the bipartisan proposal on the floor under an open rule
for a full debate and amendment.
Now there is a novel thought. Let the legislative process work and
let the House work its will. Then this shameful charade will end.
Mr. BRADY of Texas. Mr. Speaker, may I inquire how much time is
remaining?
The SPEAKER pro tempore. Each side has 5 minutes remaining.
Mr. BRADY of Texas. Mr. Speaker, I yield 3 minutes to the gentleman
from New York (Mr. Reed), one of our key members of the Ways and Means
Committee, who has brought the concerns of New York doctors to our
attention.
Mr. REED. I thank Chairman Brady for yielding the time.
Mr. Speaker, I rise today to talk about the very important issue that
this bill is here to address. We have at the end of the month a cliff
where our providers under Medicare are going to be looking at a 24
percent cut in their reimbursements for caring for our seniors.
What are we doing today? The other side is engaging in political
theater rather than deal with the issue at hand.
We have an opportunity, Mr. Speaker, to fix a problem out of
Washington, D.C., that has repeatedly been coming up since 2003--and do
it on a long-term, permanent basis. We have spent $150 billion in minor
patches to the doc fix over that period of time.
Today, we have an opportunity--through the bipartisan work on the
policy that will resolve this issue once and for all--to do it at a
cost of $138 billion. That would take care of this threat to our
seniors and to the doctors that are providing for them on a permanent
basis. That is the right thing to do.
So what is the argument over? Well, how we are going to pay for it?
My friends in the other Chamber on the other side of this esteemed
building here feel we should continue the status quo of Washington,
D.C., and not pay for our policy decisions that we decide here in
Washington.
We have put forth a proposed solution on this side of the aisle to
say, Look, let's take what you are doing to the employer mandate under
the Affordable Care Act by extending a delay for the employer mandate
that they have already done for the White House to the individuals who
are subject to the Affordable Care Act.
Doesn't that make sense? Isn't that the fair thing to do? Isn't that
the right thing to do?
If you are going to delay it for Big Business, why don't you delay it
for moms and pops and sons and daughters across America and use that
money in savings to pay for a permanent solution here in Washington,
D.C., when it comes to paying for our doctors as they care for our
elderly and our seniors?
That is a commonsense proposal, and yet we play political theater on
this important issue. We can't do that. Our hardworking taxpayers back
home, Mr. Speaker, deserve better.
I came here to Washington, D.C., to do something: to change the
status quo. We have an opportunity to take an issue that has been
pending ad nauseam since 2003 and get it taken care of permanently and
give that certainty, that ability for our providers, for our seniors,
to know what they are going to get paid and to make sure that our
seniors have the comfort of knowing that their doctors are going to
have their doors open to take care of them when they need them the
most. That is what we should be focusing on, Mr. Speaker.
I encourage my colleagues to support this legislation and get this
permanent solution in place.
Mr. LEVIN. I yield 1\1/2\ minutes to the gentleman from New Jersey
(Mr. Pascrell), a member of our committee.
Mr. PASCRELL. Mr. Speaker, to quote a very famous President:
There they go again.
This is an alternative universe, through the Speaker, that you are
trying to create.
For years, we have been talking about how to reform SGR and how to
pay for our Medicare providers. I, along with my Democratic
colleagues--and some Republicans--supported past efforts to repeal and
replace SGR once and for all, but we have never been able to get it
done.
That changed late last year. The Energy and Commerce Committee passed
unanimously a bill to repeal and replace SGR. Building on that
proposal, Republicans and Democrats on the Senate Finance Committee and
in the Ways and Means Committee here, which I sit on, came together and
passed the bill that repeals SGR and replaces it with a payment system
that rewards providers for delivering quality care to our seniors.
What you have done, through the Speaker, is to take months of
thoughtful bipartisan policymaking and thrown it away in order to score
some really poor and cheap political points. All you are trying to do
is undermine affordable care.
What are you going to do with the 13 million people who can't get
affordable care if we delay the personal mandate? You have never come
up with an answer. You have never had an answer to what are you going
to do about health care. All you can do is criticize and criticize.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. LEVIN. I yield the gentleman an additional 30 seconds.
Mr. PASCRELL. Delaying the individual mandate will result in 13
million fewer Americans getting health insurance through the ACA and
higher premiums for those with health insurance.
You want it to fail. You don't want it to succeed. You forgot what
you did back 9 years ago when we passed the premium D. We went back to
our districts and made it work, even though we voted against it. That
is the American way.
Learn the American way. It works. Don't go on recess.
Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
The SPEAKER pro tempore. The Chair would ask Members to address their
remarks to the Chair and not to others in the second person.
Mr. LEVIN. Mr. Speaker, I yield 1 minute to the gentleman from
Minnesota (Mr. Nolan).
(Mr. NOLAN asked and was given permission to revise and extend his
remarks.)
Mr. NOLAN. Mr. Speaker, I rise in support of my colleague Dan
Kildee's efforts to reinstate the health care tax credit.
Unfortunately, it was rejected by the House Republicans under yet
another closed rule.
Having served in this Congress at an earlier time in my life, I am
astonished how undemocratic this institution has become. Back in the
day, if you had an amendment, you got an opportunity to offer it. You
had an opportunity to debate it until all the debate was exhausted and
then you had an opportunity to vote on it. What a tragedy that the
people's House seems to hardly be a democratic institution any longer.
When this program that I am talking about here, the health care tax
credit, expired in January, thousands of retired workers on the Iron
Range in my district of Minnesota saw their pensions cut in half. These
are former employees of companies like LTV and National Steel--giants
in American manufacturing. Some of these hardworking men and women are
responsible for pulling America out of the Great Depression, helping us
win World War II, supplying the world with superior products made in
America.
Mr. Speaker, let us have a vote. Let's start opening up the rules in
this Chamber.
[[Page H2465]]
Mr. BRADY of Texas. Mr. Speaker, I continue to reserve the balance of
my time.
Mr. LEVIN. It is now my pleasure to yield 1 minute to the gentlelady
from California (Ms. Pelosi), our very distinguished leader.
Ms. PELOSI. Mr. Speaker, I thank the gentleman for yielding, and I
thank him for his relentless and persistent leadership in helping
America's seniors, today manifested in his support for the SGR and his
opposition to this ill-designed approach by the Republicans.
Mr. Speaker, today, House Republicans are proving that their
obsession with tearing down the Affordable Care Act is blurring their
vision and that it has no boundaries.
For their 51st vote to repeal or undermine the Affordable Care Act,
Republicans are turning their partisanship against the health and
security of our Nation's seniors.
The House Republican leadership's political games are threatening to
derail months of bipartisan, bicameral--House and Senate--progress on a
permanent Medicare doc fix, threatening our seniors' ability to see
their doctors and get the health care they need.
Earlier this week, the AARP, the National Committee to Preserve
Social Security and Medicare, the National Council on Aging, and other
key seniors' advocacy groups wrote to congressional leadership to make
it clear that the Republicans' actions would ``inject partisan politics
into bipartisan legislation,'' and that this ``undermines the months of
hard work done by committees, their staffs, and concerned
stakeholders.''
The Republicans' approach has been rejected not only by the senior
advocacy groups but by providers, doctors, insurers, and seniors. Yet
they persist with their reckless partisan antics even as time quickly
runs down to address the sustainable growth rate formula before the end
of the month.
Twice this week, Republicans blocked the House from considering a
fully paid-for measure that includes the reforms to the SGR supported
by both Democrats and Republicans in the House and in the Senate and on
the committees.
Why have Republicans chosen to proceed in this manner after months of
bipartisan progress? Why didn't Republican leadership work with
Democrats to find acceptable offsets? We need to get this done--and
Republicans know that their badly partisan effort is a nonstarter.
If passed, it would spike health insurance premiums by 10 to 20
percent, according to the Congressional Budget Office. It would cause
13 million fewer Americans to be insured, says the Congressional Budget
Office.
What does this mean to families? If you have a child in your family
between the ages of 18 and 26, they would no longer be able to be on
their parents' policy. Under the Affordable Care Act, being a woman is
no longer a preexisting medical condition. The Republican actions here
today would reverse that and take us back to a time where women paid
more for policies simply because they were women.
It would, again, reject, eliminate the very important provision of
the Affordable Care Act about not being denied coverage because you
have a preexisting medical condition. Tens of millions of families--
probably a hundred million people--are affected by not being denied
coverage because of a preexisting medical condition. That is how many
people it would affect.
{time} 1030
It would eliminate the requirement of the Affordable Care Act that
there be no cap, either annual or lifetime limit, on the health
insurance that you would receive. For these and other reasons, this is
a really bad idea.
We may only hope that, after this 51st vote, Republicans' fever will
break, and they will return to work with Democrats to pass bipartisan,
bicameral legislation as a permanent doc fix that seniors need before
the end of the month.
We are going out today, again, with work undone; 10 days before we
come back the 24th of March. The SGR expires at the end of March.
We shouldn't be wasting time on this foolishness and recklessness. We
should be finding a solution. That is what the American people sent us
here to do.
The Republican fixation with destroying the health security of
millions of Americans through their efforts to destroy the Affordable
Care Act imperil the permanent ``doc fix,'' and that must stop.
Congress is wasting time again, as I said, on these endless, wasteful
votes. Time should be spent renewing emergency unemployment insurance,
raising the minimum wage, rebuilding America by investing in education
and building our infrastructure, creating jobs.
The American people deserve better than this. They deserve a Congress
that works to strengthen the middle class, tackle the opportunity gap,
create jobs, and build an economy that works for everyone.
I urge my colleagues to vote against this bill, and I hope that when
we return after the recess week, yet another recess week, Republicans
will be ready to get serious and be ready to get back to work for a
permanent doc fix so that our seniors will be served.
The SPEAKER pro tempore. The gentleman from Texas (Mr. Brady) has 2
minutes, and the gentleman from Michigan (Mr. Levin) has 1 minute
remaining.
Mr. BRADY of Texas. Mr. Speaker, I am prepared to close.
Mr. LEVIN. Mr. Speaker, I yield myself the balance of my time.
I will place into the Record the following letters from American
Health Insurance Plans, Blue Cross Blue Shield, the California Medical
Association, from AFSCME, and also from the Alliance for Retired
Americans. These are just a few of the examples of letters and
communications from opponents.
You know, you can just boil this down to a few words. The Republicans
are so intent on manipulating everything so that they think they can
strengthen themselves for November that they put a poison pill into a
bipartisan product, a product that we worked months to perfect.
So there is no shame. March is irrelevant; November seems to be
everything.
This bill cannot become law. This is an effort simply of a political
nature.
I very much urge you, at this last minute, rethink what you are
doing. It is so transparent. It is so transparent.
Mr. Speaker, I yield back the balance of my time.
March 11, 2014.
Hon. John Boehner,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
House Democratic Leader, House of Representatives
Washington, DC.
Dear Speaker Boehner and Leader Pelosi: On behalf of
America's Health Insurance Plans (AHIP) and the Blue Cross
Blue Shield Association (BCBSA), we are writing to express
our strong opposition to repealing or delaying the Affordable
Care Act's (ACA) individual mandate as part of the Medicare
physician payment reform bill.
Our members believe it is critically important to modernize
the Medicare physician payment system to promote improvements
in quality, value, and patient outcomes. However, we have
deep concerns about packaging the Medicare physician payment
bill with legislation that would sever the link between the
ACA's individual mandate and its market reforms. The
experience of states that attempted this in the 1990s
demonstrates that removing this important linkage will result
in more uninsured Americans, higher costs, and reduced
choices for individuals and families. To avoid these
outcomes, we are asking Congress to reject efforts to repeal
or delay the individual mandate in the debate on Medicare
physician payment reform.
Thank you for considering our views on these important
issues.
Sincerely,
Karen Ignagni,
President and CEO,
America's Health Insurance Plans.
Scott P. Serota,
President and CEO,
BlueCross BlueShield Association.
____
AFSCME,
Washington, DC, March 11, 2014.
Dear Representatives: On behalf of the 1.6 million workers
and retiree members of the American Federation of State,
County and Municipal Employees (AFSCME), I write with regret
to oppose legislation which reforms physician payments under
Medicare (H.R. 4015). AFSCME strongly supports repealing and
replacing the flawed Medicare payments system for physicians.
However, we oppose this bill because it pays for the needed
reforms by robbing seniors and millions of families of the
peace of mind that comes from having affordable health care
insurance.
For decades, Congress has had an annual ritual of blocking
a scheduled cut to physicians' Medicare reimbursement
payments as
[[Page H2466]]
required under the Sustainable Growth Rate. Each time
Congress has approved a short-term relief for the scheduled
cut to physicians' Medicare payments, it has increased
beneficiaries' Part B premiums. Congress should reform
Medicare payments for doctors, but it should hold seniors
harmless and not undermine the Affordable Care Act (ACA) in
the process.
The bill delays the individual mandate in the ACA. This
will hurt families trying to get affordable health coverage
through the health care exchanges in their states. H.R. 4015
threatens important consumer protections. The ACA prohibits
denying coverage due to a pre-existing condition, charging
individuals more for coverage based on health status and
dropping coverage if an individual becomes ill. Without a
required duty that the uninsured must get coverage, these
consumer protections become harder to sustain.
Medicare is a huge success story because it shares the cost
from unexpected illness and injury among a large group of
healthy and less healthy seniors. Like Medicare, the ACA
depends on a good balance of young and healthy individuals
along with older and sicker individuals. The required duty to
obtain coverage will drive more of the uninsured (including
the young and healthy) to seek information about the ACA.
When they do, they will discover that good quality,
affordable coverage is available to them at last. The so-
called savings from delaying the individual mandate creates
an imbalance in the population covered. This leads to higher
costs for everybody in the exchange.
By the end of February, four million individuals had
obtained private insurance coverage through the federal and
state exchanges. Every day, more families are gaining the
peace of mind that comes with comprehensive and affordable
health coverage. We urge you to oppose H.R. 4015 so that more
families can realize that peace of mind.
Sincerely,
Charles M. Loveless,
Director of Government Affairs.
____
California Medical
Association,
Washington, DC, March 10, 2014.
Re H.R. 4015 ``The SGR Repeal and Medicare Modernization Act
of 2014''
Hon. John Boehner,
Speaker, House of Representatives,
Washington, DC.
Hon. Nancy Pelosi,
Minority Leader, House of Representatives,
Washington, DC.
CMA Position: Support the Policy; Oppose the Offset as a Non-Viable,
Bicameral Option
Dear Speaker Boehner and Leader Pelosi: On behalf of the
California Medical Association, I want to express our strong
support for the hard-fought and long-awaited Medicare SGR
reform POLICY in the bipartisan and bicameral legislation,
H.R. 4015 ``The SGR Repeal and Medicare Modernization Act of
2014.'' We applaud the work and the perseverance of the House
and Senate Committees to achieve a bipartisan agreement to
repeal the flawed Medicare SGR and institute a reasonable new
payment system. Congress has not made this much progress in a
decade.
While we share the frustration that there is not a clear
legislative path for bipartisan funding offsets, we are
extremely disappointed with the recent decision to pursue a
partisan funding source--the repeal of the ACA's individual
mandate. Regardless of our position on the ACA, this is not
an acceptable, viable funding option in the U.S. Senate. And
therefore, it could result in another 9-month patch which is
simply unacceptable to California physicians.
Congress' failure to address this issue has harmed access
to care for all patients in California. It has forced
California physicians out of Medicare and some out of
practice. Medicare rates lag 25% behind the costs to provide
care. It has stifled innovation and left small practices
without the resources to invest in quality and electronic
health records. The cost of a decade of short-term patches
total $153 billion--more than the cost to adopt this
legislation. Even the Wall Street Journal has called the SGR
budgeting a ``sham'' and called upon Congress to ``simply
pass the bill as is and forgo the pretense of fake-paying for
it.''
We strongly urge Congress to build on the bipartisan,
bicameral process for finalizing this important legislation.
We urge a negotiation on bipartisan funding sources before
March 31.
Sincerely,
Richard E. Thorp, MD,
President.
____
Alliance for Retired
Americans,
Washington, DC, March 13, 2014.
Dear Representative: On behalf of the four million members
of the Alliance for Retired Americans, I am writing to oppose
the passage of H.R. 4015, the SGR Repeal and Medicare
Provider Payment Modernization Act. While the February 2014
agreement reached by the House and Senate to fix the
sustainable growth rate formula in Medicare's physician
reimbursement was bicameral and bipartisan, this legislation
is not.
This legislation turns its back on a good faith agreement
by including an irresponsible pay-for. Under this egregious
proposal, doctors would be paid on the backs of uninsured
Americans. This is simply unacceptable. To add insult to
injury, the legislation permanently fixes SGR and provides a
0.5 percent update for doctors, but does not permanently
extend the Qualified Individual (QI) program, an extender
that always accompanies the SGR patch.
The QI program pays the monthly Medicare Part B premiums
for seniors and individuals with disabilities who have
incomes of 120% to 135% of the Federal Poverty Level (FPL)--
about $13,700 to $15,300 for an individual--and assets no
higher than $7,080 for an individual. It is disturbing to us
that the authors of this proposal found money to provide an
update for physicians, who on average make upwards of
$200,000 per year, but not for low-income Medicare
beneficiaries.
The Alliance for Retired Americans is supportive of fixing
Medicare's physician payment formula and stands ready to work
with Congress to come up with an acceptable offset. Financing
options could include using the Overseas Contingency
Operations (OCO) funds or the Medicare Drug Discount Act,
which would save the government $141 billion over ten years.
These options would cover the permanent fix without shifting
costs on to Medicare beneficiaries.
However, as it currently stands, we cannot support this
legislation that slams uninsured Americans. We urge you to
oppose H.R. 4015.
Sincerely,
Richard J. Fiesta,
Executive Director.
Mr. BRADY of Texas. Mr. Speaker, I yield myself the balance of my
time.
First, I want to commend and thank our Democrat colleagues on the
Ways and Means Committee and the staff for working so hard, along with
Energy and Commerce and the Finance Committee in the Senate, to find a
good, solid solution. I think we have made a big step forward. We have
got some work to do. I know we can do it.
I went to see my doctor the other week. He is 66 years old, looks
like he is 46; kind of makes me mad. But he has got a successful
practice, a very good doctor.
He told me he would like to keep practicing for another 5 or 6 years,
and he said: But Kevin, I am not going to. This will probably be my
last year. Medicare has just made it too hard for him to stay this
practice.
As I left the examining room, I looked at his assistant who has been
with him 30-some years, all his professional staff, a full waiting
room, and I thought, what are we doing chasing a doctor like this out
of practice early? Who is going to replace him? Who is going to take
care of these people?
He is not alone. In Texas, less than half of Texas family physicians
take new Medicare patients. Many of them are rethinking their
relationship with Medicare. Others are closing their private practices.
So more and more seniors are chasing fewer and fewer doctors, and that
is the dilemma we face today.
Maybe I am an optimist, but I think we are 90 percent of the way
toward solving this solution. We have broad support for this policy and
this bill.
We have a duty to make sure our seniors have access to their doctors,
and Democrats and Republicans have been putting in a lot of work to
solve this problem. Yeah, we have some work to do.
Now is the time to permanently fix the way we reimburse our doctors.
As we move forward, let's work in a bipartisan way, across the
Chambers, across the parties to get it done. I am absolutely confident
we can do that.
Mr. Speaker, I yield back the balance of my time.
Mr. HOLT. Mr. Speaker, I rise in opposition to H.R. 4015, a
transparently phony attempt to fix the flawed Medicare payment system.
For 17 years, we have neglected to address the erring formula by
which we compensate Medicare physicians. By repealing and replacing the
inadequate Sustainable Growth Rate, we have the power to improve
Medicare for our seniors and more fairly reimburse their health care
providers.
Today's vote should be about redesigning the Medicare payment
structure so that we reward physicians for the quality of health care
provided, not the quantity of procedures performed. We should be
considering how to transform our health care system to one that
encourages value driven care and incentivizes the coordination of
critical services to meet the needs of our aging population.
But today's vote is not a sincere effort to improve the delivery of
care for the nearly 50 million seniors and people with disabilities who
rely on Medicare. In fact, today's vote is yet another attempt to
destabilize the private health insurance market and subvert the
Affordable Care Act. The Republicans have presented a false choice
between jeopardizing access to care for our seniors, or dangerously
[[Page H2467]]
increasing the cost of health care for all Americans by delaying the
Affordable Care Act's individual responsibility provision. Make no
mistake: shifting access to affordable health insurance farther and
farther out of reach for millions of Americans is not an ``offset''--
it is a scandal.
While I support the underlying attempt to replace the Sustainable
Growth Rate, I cannot in good conscience vote for this bill because
this ``fix'' creates far more problems than it solves.
Mr. HONDA. Mr. Speaker, I rise today in opposition to the version of
H.R. 4015 that Republican leadership has brought to the floor of the
House.
The Balanced Budget Act of 1997 created SGR in an attempt to control
spending in the Medicare program, and it was adopted for TRICARE as
well. For years, this methodology has consistently produced unrealistic
expenditure targets. These targets trigger untenable reductions in
payment rates to doctors providing services to Medicare patients.
As a result, Congress has buried the true cost of this policy through
annual Congressional overrides of these scheduled cuts. Each of these
short-term ``fixes'' has achieved the important goal of averting an
immediate crisis in access to physicians for Medicare beneficiaries,
but has exacerbated a longer-term crisis in Medicare financing.
Continued short term patches create instability in the health care
system and the economy as a whole. Doctors have been hamstrung by
yearly doubt about what reimbursement rates will be, and patients have
had to pay the eventual price in uneven, substandard quality of care.
The SGR needs to be repealed and the Medicare payment system needs to
be reformed now. To accomplish this, I signed on as a co-sponsor of the
original version of the bipartisan bill H.R. 4015, the SGR Repeal and
Medicare Provider Payment Modernization Act of 2014.
H.R. 4015 proposes five years of 0.5% payment increases for the
Medicare physician fee schedule before freezing payments at that level
for five additional years. It also supports alternative payment models,
and creates a new Merit-Based Incentive Payment System (MIPS) for those
who stay on the fee-for-service payment model.
Despite months of bipartisan work to forge this compromise, House
Republicans amended the bill to delay the individual mandate
requirement in the Affordable Care Act. This unconscionable political
stunt to undermine the Affordable Care Act puts our Medicare health
system in jeopardy at a critical time, with payment rates set to drop
dramatically on April 1, 2014.
I am committed to reforming our Medicare system and repealing the
SGR, but the bill House Republican leadership brought to the House
floor fails to strengthen Medicare, or help Americans get access to
affordable health care. I cannot support the flawed amended version of
the bill.
Medicare has guaranteed essential health protections to seniors and
certain disabled persons for nearly four decades. I believe Medicare is
more than just a program, it is a covenant that exists between the
government and the American people.
I support fixing and reforming this system permanently, but H.R. 4015
as amended is not the way to do that, and so I urge my colleagues to
oppose this bill.
Ms. SCHWARTZ. Mr. Speaker, I rise today in opposition of H.R. 4015,
legislation Republicans have introduced to gut the Affordable Care Act
to pay for a bipartisan, bicameral agreement to repeal Medicare's
broken Sustainable Growth Rate (SGR) formula.
For months, we have worked in a bipartisan, good-faith effort to
develop a permanent solution for Medicare's physician payment system
that has threatened seniors' access to care for more than a decade. In
February 2013, I introduced the bipartisan Medicare Physician Payment
Innovation Act (H.R. 574) with Rep. Joe Heck (R-NV) to repeal the SGR
and set out a clear path toward comprehensive reforms of Medicare
payment and delivery systems. Last month, three committees, including
Ways and Means, on which I serve, announced a bipartisan, bicameral
agreement that incorporates the overarching framework of my legislation
and includes several specific provisions.
Finding common ground on a responsible way to pay for a permanent SGR
fix was never going to be easy, but that does not mean it should be
used to score political points. Seniors must have access to their
doctors and time is running out. I strongly urge Republicans to join
Democrats to act on this significant bipartisan opportunity to enact a
permanent solution that provides more security and certainty for
seniors and their doctors.
Mr. COURTNEY. Mr. Speaker, I regret that I cannot be present for
today's session, as I am joining Admiral Mike Connor, Commander of our
nation's submarine forces, on a visit to an in-service Virginia class
submarine to see firsthand the skill of our submariners and the vital
role they play in our nation's defense. It will also give me a chance
to review and discuss the Navy's FY 15 request for Virginia class
submarine construction and the Ohio Class Replacement Program, critical
issues for the Second District of Connecticut. Had I been present,
however, I would have voted ``no'' on the SGR Repeal and Medicare
Provider Payment Modernization Act (H.R. 4015).
For too long, the sustainable growth rate (SGR) formula has created a
weight of uncertainty not only for Medicare beneficiaries and veterans,
but more broadly throughout our health care system. For the past
decade, health care providers from around the country have had to leave
their practices to travel to Washington and ask for relief from SGR's
automatic rescission. This is not right. It is counterproductive and
wasteful. And, a permanent fix--which I strongly support and have
worked on a bipartisan basis to achieve--is long overdue.
Committee efforts in the House and Senate to repeal the SGR formula
permanently have been a bipartisan, bicameral bright spot in the 113th
Congress. Unfortunately, the injection of a partisan fiscal offset into
H.R. 4015 has decimated previous, widespread endorsements of the
proposal, now generating opposition from the American Medical
Association (AMA) and the American Association of Retired People
(AARP). The White House has also announced that if President Obama were
presented with this measure, he would veto it. As amended, I too cannot
support H.R. 4015 and had I been present for the vote on the
legislation, I would have voted ``no.''
Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in support of
legislation to repeal the Sustainable Growth Rate and update Medicare's
payment system without the amendment to undermine the individual
mandate of the Affordable Care Act.
While there are positive provisions in H.R. 4015, the SGR Repeal and
Medicare Provider Payment Modernization Act of 2014, an amendment added
by Chairman Dave Camp would delay the Affordable Care Act's individual
mandate by five years.
Commonly referred to as the ``doc fix,'' SGR Repeal has been on the
table since the beginning of this Congress and desperately requires
action. This legislation would repeal the cuts to physician Medicare
payments and allow for small increases over 10 years. The second part
of this legislation would make MEDPAC and GAO report more to Congress,
including new payment rules that became final this year. There would
also be additional protections against Medicare fraud.
However, if this legislation passes with the Camp Amendment, the 5-
year delay of the individual mandate provision will increase the number
of uninsured Americans by 13 million in 2018. A CBO analysis said that
premiums would likely increase 10-20 percent in the individual
marketplace during the years without a mandate penalty.
I urge my colleagues to heed my warning about this new effort to
undermine the Affordable Care Act.
Ms. JACKSON LEE. Mr. Speaker, I rise to speak in strong opposition to
H.R. 4015, the SGR Repeal and Medicare Provider Payment Modernization
Act of 2014 because of the passage of the Rule to this bill.
I am not alone in opposing this irresponsible measure. I am joined by
AARP, Alliance for Retired Americans, American Academy of Family
Physicians, American Geriatrics Society, American Osteopathic
Association, Center for Medicare Advocacy, Inc., Families USA, Medicare
Rights Center, National Committee to Preserve Social Security and
Medicare, National Association of Area Agencies on Aging, and the
National Council on Aging.
I strongly support providing adequate compensation to our physicians
who serve Medicare patients. Medicare patients in very state make up 10
percent or more of those who have health insurance.
Medicare patients and the medical payments made to their physicians
and medical service providers is critical to our nation's health care
economy.
It is important for our seniors to know that Medicare will be there
when they need it. But it is equally important that there are
physicians who are willing to attend to them without going broke.
That is why we have a Sustainable Growth Rate or ``SGR.'' Medicare
reimbursement enables rural physicians and hospitals to remain open for
business.
As with any business, medical clinics and physician offices have
payrolls to meet, bills to pay, and expenses to meet as they become
due. If revenues are not sufficient to cover costs, the business will
not long survive.
Thus, it is critical that we not disrupt timely and adequate payment
to Medicare providers, but that is exactly what will happen at the end
of this month if the SGR is not approved by the House and the Senate
and signed into law by President Obama.
The problem with H.R. 4015 is what happened when the Rule for this
bill passed the House.
The rule for H.R. 4015 added language that would delay the Affordable
Care Act's implementation of the individual mandate.
[[Page H2468]]
I oppose the bill for two reasons:
It corrupts what was a strongly supported bipartisan bill to sustain
physician reimbursement rates for medical services approved under
Medicare, and
It is another attempt by the Republicans to mislead the public
regarding the Affordable Care Act.
I know that many predicted that the Affordable Care Act would cause
havoc on the nation's health care system. But it is not the ACA that is
causing havoc--it is the 50 desperate but futile attempts by the Tea
Party to scuttle a law that has been passed by Congress, signed by the
President, upheld by the Supreme Court.
The most threatening actions to our nation's healthcare system by Tea
Party Republicans are their attacks on Medicare.
In 2014, according to the Kaiser Foundation 16 percent of the
nation's people have medical insurance under Medicare:
Texas has 12 percent of its residents insured under Medicare;
Arkansas, Florida and Vermont have 19 percent of their residents
insured under Medicare;
West Virginia and Maine have 21 percent of their residents insured
under Medicare; and
Kentucky, Mississippi, Missouri, Ohio, Oklahoma, Oregon, South
Dakota, Tennessee, Wisconsin, Ohio, Oklahoma, and Oregon have 18
percent of their residents insured under Medicare.
Every state has more than 10 percent of their residents insured by
Medicare.
The uncertainly created by the majority regarding Medicare
reimbursement over the last several years has forced physicians to
reevaluate continuing their medical practice and frustrated hospitals
working to make budget projections over several years into the future--
this is critical to business decision making.
Because of uncertainty created by Medicare physician reimbursement--
physicians and hospitals have been forced to close their offices,
reduce services, or merge.
When patients find they cannot keep their physician or that their
options for health care are being affected--it is not because of the
Affordable Care Act.
Our nation has taken a momentous step in creating a mindset that good
health is a personal responsibility with the enactment of the
Affordable Care Act. The health care law did not automatically enroll
all citizens into the program; it was specifically designed to be an
opt-in process.
There are tens of thousands of visitors each day to the website and
despite problems with the initial rollout of the online health
insurance registration process, millions have enrolled and experience
the peace of mind that comes from having affordable, high quality
health insurance that is there when you need it.
So it is puzzling that with less than 70 legislative days remaining
in the Second Session of the 113th Congress, we are still seeing
attempts to end the Affordable Care Act.
It is very troubling that a bill critical to the provision of
payments to physicians that treat Medicare patients is not safe from
the partisan political games of the House of Republicans.
The House should be considering legislation to address the most
pressing needs of the American people. Today, we should be debating
legislation to extend emergency unemployment insurance benefits. The
House should be debating a jobs creation bill to put Americans who are
seeking employment back to work.
We know that for every person who gets a job--three others are still
searching for employment.
This is another attempt to undermine the Affordable Care Act. Instead
of trying to repeal the Affordable Care Act, House Republicans are now
seeking ways to impede or frustrate its implementation.
After shutting down the federal government last year in an attempt to
end the Affordable Care Act, they have resorted to their latest gimmick
of attaching to a critically needed piece of legislation to make sure
our nation's seniors continue to have access to physicians and
hospitals an attempt to harm Obamacare.
I ask my colleagues to support Medicare patients and their physicians
by rejecting the bill.
Mr. DeFAZIO. Mr. Speaker, today I will vote against H.R. 4015 despite
being a cosponsor of the original bill. It should not have been that
way. H.R. 4015 as originally drafted repealed the misguided SGR formula
and laid out a reasonable path toward reimbursing doctors based on the
quality of care that they provide. The bill had 118 bipartisan
cosponsors. I heard from medical professionals all over Oregon who were
hopeful that Congress would actually be able to pass H.R. 4015 and
finally do away with short term SGR fixes.
Unfortunately Republican House leadership squandered this
opportunity. Instead of finding a bipartisan way to pay for H.R. 4015,
House Republican leadership inserted an ideological pay-for that would
leave 13 million people uninsured according to the Congressional Budget
Office. Because of this partisan gimmick, the Senate will never take up
H.R. 4015. That leaves our nation's medical professionals exactly where
they were before the vote--facing an approximately 27% cut in Medicare
and TRICARE reimbursements if Congress doesn't fix the SGR before March
31st.
In 1997 I voted against creating the faulty SGR formula. I opposed
the 1997 law because it balanced the budget on the backs of seniors and
health care providers by substantially cutting Medicare. By delaying
these cuts instead of permanently fixing the SGR formula, the potential
cuts have grown every year.
Rather than cutting medical coverage for 13 million Americans,
Congress should pay for H.R. 4015 by allowing Medicare to negotiate
prescription drug prices. Every single other developed country in the
world permits their government to negotiate drug prices for all of
their citizens. In the U.S. private insurance companies negotiate
prices, and the Veterans Administration negotiates prices, but the
federal government is prevented from negotiating drug prices for
Medicare. This means that drug companies are free to charge Medicare
recipients higher prices than anyone else in the world. Allowing the
federal government to negotiate drug prices for Medicare would fully
pay for the SGR fix. The House could have ensured proper reimbursements
for doctors and reduced drug prices for seniors in one bill today.
Instead we voted on a bill that is going nowhere.
The SPEAKER pro tempore. All time for debate has expired.
Pursuant to House Resolution 515, the previous question is ordered on
the bill, as amended.
The question is on the engrossment and third reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.
Motion to Recommit
Mr. LOEBSACK. Mr. Speaker, I have a motion to recommit at the desk.
The SPEAKER pro tempore. Is the gentleman opposed to the bill?
Mr. LOEBSACK. I am opposed in its current form.
Mr. PITTS. Mr. Speaker, I reserve a point of order against the motion
to recommit.
The SPEAKER pro tempore. A point of order is reserved.
The Clerk will report the motion to recommit.
The Clerk read as follows:
Mr. Loebsack moves to recommit the bill H.R. 4015 to the
Committee on Ways and Means with instructions to report the
same back to the House forthwith with the following
amendment:
At the end of the bill, add the following:
SEC. __. PROHIBITION ON MEDICARE CUTS OR VOUCHERS.
Nothing in this Act shall reduce benefits under the
Medicare program under title XVIII of the Social Security
Act, eliminate guaranteed health insurance benefits available
to seniors or individuals with disabilities under such
program, or establish a Medicare voucher plan that provides
limited payments to Medicare beneficiaries in order to
purchase health care in the private sector.
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Iowa is recognized for 5 minutes in support of his motion.
Mr. LOEBSACK. Mr. Speaker, this is the final amendment to the bill,
which will not kill the bill or send it back to the committee. If
adopted, the bill will immediately proceed to final passage, as
amended.
I regularly meet with seniors across Iowa, and far too often I hear
that many of them are struggling to make ends meet, just as I am sure
that many of my colleagues hear from their seniors as well. They tell
me how much they rely on Medicare in order to stay healthy and just to
afford their daily necessities.
Mr. Speaker, our seniors did not get us into this fiscal mess that we
are in today, and I think we have to keep that in mind. It is unfair to
punish them for Washington's irresponsible behavior. That is why we
have got to protect Medicare for seniors who have worked a lifetime to
pay into it.
This also is an issue I will say that is personal to me. I grew up in
a family that struggled to make ends meet. I often talked about how I
grew up in poverty. My mom was a single parent who struggled with
mental illness, and literally, in the fourth grade, we landed at the
doorstep of my maternal grandmother.
My grandmother often relied on Social Security survivor benefits to
care for me and my siblings. Without the promise of health care through
Medicare, she would not have been able to afford to put food on the
table.
No senior--and I think all of us in this body can agree--no senior
should have to choose between paying their bills or paying for their
medication.
[[Page H2469]]
Mr. Speaker, replacing Medicare with a voucher system would end the
guarantee of health care and financial security for our seniors as
well. Vouchers would force seniors to pay more and more of their health
care costs out of pocket.
In these tough economic times, we need to find ways to be more
efficient while maintaining quality care.
I know that seniors don't want a voucher that forces them to buy
insurance that may not meet their needs because they tell me that every
single time I meet with them. They do not want their health care to be
subject to the whims of insurance companies looking to make a profit
when they, those seniors, get sick.
They don't want higher costs, and they certainly don't want reduced
benefits. They want to keep Medicare the way it is, a guaranteed
benefit they can count on when they need it. They paid into it, and
they deserve it.
Mr. Speaker, I ask my colleagues on both sides of the aisle to
support this final amendment to the bill.
I yield back the balance of my time.
Mr. PITTS. Mr. Speaker, I withdraw my point of order and claim the
time in opposition to the motion.
The SPEAKER pro tempore. The reservation is withdrawn.
The gentleman from Pennsylvania is recognized for 5 minutes.
Mr. PITTS. Mr. Speaker, to begin with, I would just like to
acknowledge all the good work on both sides of the aisle in reaching
the bipartisan policy agreement in the SGR, and especially want to
thank our staff, Clay Alspach and Robert Horne and Chris Pope, and
everyone on both sides of the aisle and their staff, for all the good
work.
Mr. Speaker, this bill before us presents each and every Member of
this body a simple choice: Do we patch Medicare, or do we fix it?
Do we choose to fight for the Medicare promise that this country has
made to every American, or do we vote against it?
My friends, I am voting today to keep the Medicare promise to
Americans. We must not let another opportunity to save Medicare for our
seniors fall by the wayside.
If Washington is broken, today is an opportunity to fix it. The bill
before us is bipartisan, and the pay-for is one President Obama has
used himself many times in the past.
My colleagues, did you scream hypocrisy when President Obama delayed
the mandate for special interests here in D.C.? Then why would you
scream hypocrisy now?
The time for political games is over. It is time for Members of this
body to choose. Are you on the side of seniors in your district that
depend on Medicare, or are you against them? Are you on the side of
younger Americans who keep telling us they are struggling under an
ObamaCare plan that forces them to choose between groceries and health
care? Are you for saving Medicare, or will you vote to let it go
bankrupt?
What kind of country are we living in when our own government has
reduced the American Dream to a choice between health care and
groceries?
This motion to recommit embraces the tired gimmicks of yesterday that
the public has grown to distrust. You have a clear choice. You either
vote ``no'' and stand up for what is right, to give our seniors the
peace of mind they deserve, or you can vote ``yes'' on this motion to
recommit and demonstrate to the American public that political games
are more important to you than their health and welfare.
I, for one, will be voting with seniors this morning, and I would
encourage all of my colleagues to do the same.
Vote ``no'' on the motion to recommit.
Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore. Without objection, the previous question is
ordered on the motion to recommit.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Mr. LOEBSACK. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 9 of rule XX, the Chair
will reduce to 5 minutes the minimum time for any electronic vote on
the question of passage of the bill.
The vote was taken by electronic device, and there were--yeas 191,
nays 226, not voting 14, as follows:
[Roll No. 134]
YEAS--191
Barber
Barrow (GA)
Beatty
Becerra
Bera (CA)
Bishop (GA)
Bishop (NY)
Blumenauer
Bonamici
Brady (PA)
Braley (IA)
Brown (FL)
Brownley (CA)
Bustos
Butterfield
Capps
Capuano
Cardenas
Carney
Carson (IN)
Cartwright
Castor (FL)
Castro (TX)
Chu
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Cohen
Connolly
Conyers
Cooper
Costa
Crowley
Cuellar
Cummings
Davis (CA)
DeFazio
DeGette
Delaney
DeLauro
DelBene
Deutch
Doggett
Doyle
Duckworth
Edwards
Ellison
Engel
Enyart
Eshoo
Esty
Farr
Fattah
Foster
Fudge
Gabbard
Gallego
Garamendi
Garcia
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hahn
Hanabusa
Hastings (FL)
Heck (WA)
Higgins
Himes
Hinojosa
Holt
Honda
Horsford
Hoyer
Huffman
Israel
Jackson Lee
Jeffries
Johnson (GA)
Johnson, E. B.
Kaptur
Keating
Kelly (IL)
Kennedy
Kildee
Kilmer
Kind
Kirkpatrick
Kuster
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis
Lipinski
Loebsack
Lofgren
Lowenthal
Lowey
Lujan Grisham (NM)
Lujan, Ben Ray (NM)
Lynch
Maffei
Maloney, Carolyn
Maloney, Sean
Matheson
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McIntyre
McNerney
Meeks
Meng
Michaud
Miller, George
Moore
Moran
Murphy (FL)
Nadler
Napolitano
Neal
Negrete McLeod
Nolan
O'Rourke
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Peters (CA)
Peters (MI)
Peterson
Pingree (ME)
Pocan
Polis
Price (NC)
Quigley
Rahall
Rangel
Richmond
Roybal-Allard
Ruiz
Ruppersberger
Ryan (OH)
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schiff
Schneider
Schrader
Schwartz
Scott (VA)
Scott, David
Serrano
Sewell (AL)
Shea-Porter
Sherman
Sinema
Sires
Slaughter
Speier
Swalwell (CA)
Takano
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Tsongas
Van Hollen
Vargas
Veasey
Vela
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Waxman
Welch
Yarmuth
NAYS--226
Aderholt
Amash
Bachus
Barletta
Barr
Barton
Benishek
Bentivolio
Bilirakis
Bishop (UT)
Black
Blackburn
Boustany
Brady (TX)
Bridenstine
Brooks (AL)
Brooks (IN)
Broun (GA)
Buchanan
Bucshon
Burgess
Byrne
Calvert
Camp
Campbell
Cantor
Capito
Carter
Cassidy
Chabot
Chaffetz
Coble
Coffman
Cole
Collins (GA)
Collins (NY)
Conaway
Cook
Cotton
Cramer
Crawford
Crenshaw
Daines
Davis, Rodney
Denham
Dent
DeSantis
DesJarlais
Diaz-Balart
Duffy
Duncan (SC)
Duncan (TN)
Ellmers
Farenthold
Fincher
Fitzpatrick
Fleischmann
Fleming
Flores
Forbes
Fortenberry
Foxx
Frelinghuysen
Gardner
Garrett
Gerlach
Gibbs
Gibson
Gingrey (GA)
Gohmert
Goodlatte
Gowdy
Granger
Graves (GA)
Graves (MO)
Griffin (AR)
Griffith (VA)
Grimm
Guthrie
Hall
Hanna
Harper
Harris
Hartzler
Hastings (WA)
Heck (NV)
Hensarling
Herrera Beutler
Holding
Hudson
Huelskamp
Huizenga (MI)
Hultgren
Hunter
Hurt
Issa
Jenkins
Johnson (OH)
Johnson, Sam
Jolly
Jones
Jordan
Joyce
Kelly (PA)
King (IA)
King (NY)
Kingston
Kinzinger (IL)
Kline
Labrador
LaMalfa
Lamborn
Lance
Lankford
Latham
Latta
LoBiondo
Long
Lucas
Luetkemeyer
Lummis
Marchant
Marino
Massie
McAllister
McCarthy (CA)
McCaul
McClintock
McHenry
McKeon
McKinley
McMorris Rodgers
Meadows
Meehan
Messer
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Mullin
Mulvaney
Murphy (PA)
Neugebauer
Noem
Nugent
Nunes
Nunnelee
Olson
Palazzo
Paulsen
Pearce
Perry
Petri
Pittenger
Pitts
Poe (TX)
Pompeo
Posey
Price (GA)
Reed
Reichert
Renacci
Ribble
Rice (SC)
Rigell
Roby
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Rothfus
Royce
Runyan
Ryan (WI)
Salmon
Sanford
Scalise
Schock
Schweikert
Scott, Austin
Sensenbrenner
Sessions
Shimkus
Shuster
Simpson
Smith (MO)
Smith (NE)
Smith (NJ)
Smith (TX)
Southerland
Stewart
Stivers
Stockman
Stutzman
Terry
Thompson (PA)
Thornberry
Tiberi
Tipton
Turner
Upton
Valadao
Wagner
Walberg
[[Page H2470]]
Walden
Walorski
Weber (TX)
Webster (FL)
Wenstrup
Westmoreland
Whitfield
Williams
Wilson (SC)
Wittman
Wolf
Womack
Woodall
Yoder
Yoho
Young (AK)
Young (IN)
NOT VOTING--14
Amodei
Bachmann
Bass
Courtney
Culberson
Davis, Danny
Dingell
Frankel (FL)
Franks (AZ)
Gosar
Rokita
Rush
Smith (WA)
Wilson (FL)
{time} 1107
Mr. MICA changed his vote from ``yea'' to ``nay.''
Ms. LOFGREN and Mr. CICILLINE changed their vote from ``nay'' to
``yea.''
So the motion to recommit was rejected.
The result of the vote was announced as above recorded.
Stated for:
Ms. FRANKEL of Florida. Mr. Speaker, on rollcall No. 134, the motion
to recommit for H.R. 4015, had I been present, I would have voted
``yes.''
The SPEAKER pro tempore. The question is on the passage of the bill.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Mr. LEVIN. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. This is a 5-minute vote.
The vote was taken by electronic device, and there were--yeas 238,
nays 181, not voting 12, as follows:
[Roll No. 135]
YEAS--238
Aderholt
Amash
Bachus
Barber
Barletta
Barr
Barrow (GA)
Barton
Benishek
Bentivolio
Bera (CA)
Bilirakis
Bishop (UT)
Black
Blackburn
Boustany
Brady (TX)
Bridenstine
Brooks (AL)
Brooks (IN)
Broun (GA)
Buchanan
Bucshon
Burgess
Byrne
Calvert
Camp
Campbell
Cantor
Capito
Carter
Cassidy
Chabot
Chaffetz
Coble
Coffman
Cole
Collins (GA)
Collins (NY)
Conaway
Cook
Cotton
Cramer
Crawford
Crenshaw
Daines
Davis, Rodney
Denham
Dent
DeSantis
DesJarlais
Diaz-Balart
Duffy
Duncan (SC)
Duncan (TN)
Ellmers
Farenthold
Fincher
Fitzpatrick
Fleischmann
Fleming
Flores
Forbes
Fortenberry
Foxx
Frelinghuysen
Garcia
Gardner
Garrett
Gerlach
Gibbs
Gibson
Gingrey (GA)
Gohmert
Goodlatte
Granger
Graves (GA)
Graves (MO)
Griffin (AR)
Griffith (VA)
Grimm
Guthrie
Hall
Hanna
Harper
Harris
Hartzler
Hastings (WA)
Heck (NV)
Hensarling
Herrera Beutler
Holding
Hudson
Huelskamp
Huizenga (MI)
Hultgren
Hunter
Hurt
Issa
Jenkins
Johnson (OH)
Johnson, Sam
Jolly
Jones
Jordan
Joyce
Kelly (PA)
King (IA)
King (NY)
Kingston
Kinzinger (IL)
Kline
Labrador
LaMalfa
Lamborn
Lance
Lankford
Latham
Latta
LoBiondo
Long
Lucas
Luetkemeyer
Lummis
Marchant
Marino
Massie
Matheson
McAllister
McCarthy (CA)
McCaul
McClintock
McHenry
McIntyre
McKeon
McKinley
McMorris Rodgers
Meadows
Meehan
Messer
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Mullin
Mulvaney
Murphy (FL)
Murphy (PA)
Neugebauer
Noem
Nugent
Nunes
Nunnelee
Olson
Palazzo
Paulsen
Pearce
Perry
Peters (CA)
Peterson
Petri
Pittenger
Pitts
Poe (TX)
Pompeo
Posey
Price (GA)
Rahall
Reed
Reichert
Renacci
Ribble
Rice (SC)
Rigell
Roby
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rokita
Rooney
Ros-Lehtinen
Roskam
Ross
Rothfus
Royce
Runyan
Ryan (WI)
Salmon
Sanford
Scalise
Schneider
Schock
Schweikert
Scott, Austin
Sensenbrenner
Sessions
Shimkus
Shuster
Simpson
Sinema
Smith (MO)
Smith (NE)
Smith (NJ)
Smith (TX)
Southerland
Stewart
Stivers
Stockman
Stutzman
Terry
Thompson (PA)
Thornberry
Tiberi
Tipton
Turner
Upton
Valadao
Wagner
Walberg
Walden
Walorski
Weber (TX)
Webster (FL)
Wenstrup
Westmoreland
Whitfield
Williams
Wilson (SC)
Wittman
Wolf
Womack
Woodall
Yoder
Yoho
Young (AK)
Young (IN)
NAYS--181
Beatty
Becerra
Bishop (GA)
Bishop (NY)
Blumenauer
Bonamici
Brady (PA)
Braley (IA)
Brown (FL)
Brownley (CA)
Bustos
Butterfield
Capps
Capuano
Cardenas
Carney
Carson (IN)
Cartwright
Castor (FL)
Castro (TX)
Chu
Cicilline
Clark (MA)
Clarke (NY)
Clay
Cleaver
Clyburn
Cohen
Connolly
Conyers
Cooper
Costa
Crowley
Cuellar
Cummings
Davis (CA)
DeFazio
DeGette
Delaney
DeLauro
DelBene
Deutch
Doggett
Doyle
Duckworth
Edwards
Ellison
Engel
Enyart
Eshoo
Esty
Farr
Fattah
Foster
Frankel (FL)
Fudge
Gabbard
Gallego
Garamendi
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hahn
Hanabusa
Hastings (FL)
Heck (WA)
Higgins
Himes
Hinojosa
Holt
Honda
Horsford
Hoyer
Huffman
Israel
Jackson Lee
Jeffries
Johnson (GA)
Johnson, E. B.
Kaptur
Keating
Kelly (IL)
Kennedy
Kildee
Kilmer
Kind
Kirkpatrick
Kuster
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis
Lipinski
Loebsack
Lofgren
Lowenthal
Lowey
Lujan Grisham (NM)
Lujan, Ben Ray (NM)
Lynch
Maffei
Maloney, Carolyn
Maloney, Sean
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McNerney
Meeks
Meng
Michaud
Miller, George
Moore
Moran
Nadler
Napolitano
Neal
Negrete McLeod
Nolan
O'Rourke
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Peters (MI)
Pingree (ME)
Pocan
Polis
Price (NC)
Quigley
Rangel
Richmond
Roybal-Allard
Ruiz
Ruppersberger
Ryan (OH)
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schiff
Schrader
Schwartz
Scott (VA)
Scott, David
Serrano
Sewell (AL)
Shea-Porter
Sherman
Sires
Slaughter
Speier
Swalwell (CA)
Takano
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Tsongas
Van Hollen
Vargas
Veasey
Vela
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Waxman
Welch
Wilson (FL)
Yarmuth
NOT VOTING--12
Amodei
Bachmann
Bass
Courtney
Culberson
Davis, Danny
Dingell
Franks (AZ)
Gosar
Gowdy
Rush
Smith (WA)
{time} 1115
So the bill was passed.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.
PERSONAL EXPLANATION
Mr. FRANKS of Arizona. Mr. Speaker, had I been present, I would have
voted ``yes'' on rollcall No. 132 on H.R. 3189, I would have voted
``yes'' on rollcall No. 129 on H.R. 3973, and I would have voted
``yes'' on rollcall No. 135 on H.R. 4015.
____________________