[Congressional Record (Bound Edition), Volume 160 (2014), Part 3]
[House]
[Pages 4516-4549]
[From the U.S. 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 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--

[[Page 4517]]

       (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 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).

[[Page 4518]]

       ``(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--

       ``(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--

[[Page 4519]]

       ``(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 4520]]

     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

[[Page 4521]]

     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.--
       ``(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

[[Page 4522]]

       ``(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. 
     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

[[Page 4523]]

     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 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.

[[Page 4524]]

     The Secretary shall establish policies to implement this 
     subparagraph in cases where payment for covered professional 
     services furnished by a qualifying APM participant in an 
     alternative payment model is made to an entity participating 
     in the alternative payment model rather than directly to the 
     qualifying APM participant.
       ``(B) Form of payment.--Payments under this subsection 
     shall be made in a lump sum, on an annual basis, as soon as 
     practicable.
       ``(C) Treatment of payment incentive.--Payments under this 
     subsection shall not be taken into account for purposes of 
     determining actual expenditures under an alternative payment 
     model and for purposes of determining or rebasing any 
     benchmarks used under the alternative payment model.
       ``(D) Coordination.--The amount of the additional payment 
     for an item or service under this subsection or subsection 
     (m) shall be determined without regard to any additional 
     payment for the item or service under subsection (m) and this 
     subsection, respectively. The amount of the additional 
     payment for an item or service under this subsection or 
     subsection (x) shall be determined without regard to any 
     additional payment for the item or service under subsection 
     (x) and this subsection, respectively. The amount of the 
     additional payment for an item or service under this 
     subsection or subsection (y) shall be determined without 
     regard to any additional payment for the item or service 
     under subsection (y) and this subsection, respectively.
       ``(2) Qualifying apm participant.--For purposes of this 
     subsection, the term `qualifying APM participant' means the 
     following:
       ``(A) 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).

[[Page 4525]]

       ``(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:
       ``(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.

[[Page 4526]]

       (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 
     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

[[Page 4527]]

     (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).
       ``(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

[[Page 4528]]

     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 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;

[[Page 4529]]

       (B) in subparagraph (E), by striking the period at the end 
     and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(F) the collection and use of information in the 
     determination of relative values under subsection 
     (c)(2)(M).''.
       (b) Authority for Alternative Approaches To Establishing 
     Practice Expense Relative Values.--Section 1848(c)(2) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)), as amended by 
     subsection (a), is amended by adding at the end the following 
     new subparagraph:
       ``(N) Authority for alternative approaches to establishing 
     practice expense relative values.--The Secretary may 
     establish or adjust practice expense relative values under 
     this subsection using cost, charge, or other data from 
     suppliers or providers of services, including information 
     collected or obtained under subparagraph (M).''.
       (c) Revised and Expanded Identification of Potentially 
     Misvalued Codes.--Section 1848(c)(2)(K)(ii) of the Social 
     Security Act (42 U.S.C. 1395w-4(c)(2)(K)(ii)) is amended to 
     read as follows:
       ``(ii) Identification of potentially misvalued codes.--For 
     purposes of identifying potentially misvalued codes pursuant 
     to clause (i)(I), the Secretary shall examine codes (and 
     families of codes as appropriate) based on any or all of the 
     following criteria:

       ``(I) Codes that have experienced the fastest growth.
       ``(II) Codes that have experienced substantial changes in 
     practice expenses.
       ``(III) Codes that describe new technologies or services 
     within an appropriate time period (such as 3 years) after the 
     relative values are initially established for such codes.
       ``(IV) Codes which are multiple codes that are frequently 
     billed in conjunction with furnishing a single service.
       ``(V) Codes with low relative values, particularly those 
     that are often billed multiple times for a single treatment.
       ``(VI) Codes that have not been subject to review since 
     implementation of the fee schedule.
       ``(VII) Codes that account for the majority of spending 
     under the physician fee schedule.
       ``(VIII) Codes for services that have experienced a 
     substantial change in the hospital length of stay or 
     procedure time.
       ``(IX) Codes for which there may be a change in the typical 
     site of service since the code was last valued.
       ``(X) Codes for which there is a significant difference in 
     payment for the same service between different sites of 
     service.
       ``(XI) Codes for which there may be anomalies in relative 
     values within a family of codes.
       ``(XII) Codes for services where there may be efficiencies 
     when a service is furnished at the same time as other 
     services.
       ``(XIII) Codes with high intra-service work per unit of 
     time.
       ``(XIV) Codes with high practice expense relative value 
     units.
       ``(XV) Codes with high cost supplies.
       ``(XVI) Codes as determined appropriate by the 
     Secretary.''.

       (d) Target for Relative Value Adjustments for Misvalued 
     Services.--
       (1) In general.--Section 1848(c)(2) of the Social Security 
     Act (42 U.S.C. 1395w-4(c)(2)), as amended by subsections (a) 
     and (b), is amended by adding at the end the following new 
     subparagraph:
       ``(O) Target for relative value adjustments for misvalued 
     services.--With respect to fee schedules established for each 
     of 2015 through 2018, the following shall apply:
       ``(i) Determination of net reduction in expenditures.--For 
     each year, the Secretary shall determine the estimated net 
     reduction in expenditures under the fee schedule under this 
     section with respect to the year as a result of adjustments 
     to the relative values established under this paragraph for 
     misvalued codes.
       ``(ii) Budget neutral redistribution of funds if target met 
     and counting overages towards the target for the succeeding 
     year.--If the estimated net reduction in expenditures 
     determined under clause (i) for the year is equal to or 
     greater than the target for the year--

       ``(I) reduced expenditures attributable to such adjustments 
     shall be redistributed for the year in a budget neutral 
     manner in accordance with subparagraph (B)(ii)(II); and
       ``(II) the amount by which such reduced expenditures 
     exceeds the target for the year shall be treated as a 
     reduction in expenditures described in clause (i) for the 
     succeeding year, for purposes of determining whether the 
     target has or has not been met under this subparagraph with 
     respect to that year.

       ``(iii) Exemption from budget neutrality if target not 
     met.--If the estimated net reduction in expenditures 
     determined under clause (i) for the year is less than the 
     target for the year, reduced expenditures in an amount equal 
     to the target recapture amount shall not be taken into 
     account in applying subparagraph (B)(ii)(II) with respect to 
     fee schedules beginning with 2015.
       ``(iv) Target recapture amount.--For purposes of clause 
     (iii), the target recapture amount is, with respect to a 
     year, an amount equal to the difference between--

       ``(I) the target for the year; and
       ``(II) the estimated net reduction in expenditures 
     determined under clause (i) for the year.

       ``(v) Target.--For purposes of this subparagraph, with 
     respect to a year, the target is calculated as 0.5 percent of 
     the estimated amount of expenditures under the fee schedule 
     under this section for the year.''.
       (2) Conforming amendment.--Section 1848(c)(2)(B)(v) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)(v)) is 
     amended by adding at the end the following new subclause:

       ``(VIII) Reductions for misvalued services if target not 
     met.--Effective for fee schedules beginning with 2015, 
     reduced expenditures attributable to the application of the 
     target recapture amount described in subparagraph 
     (O)(iii).''.

       (e) Phase-In of Significant Relative Value Unit (RVU) 
     Reductions.--
       (1) In general.--Section 1848(c) of the Social Security Act 
     (42 U.S.C. 1395w-4(c)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Phase-in of significant relative value unit (rvu) 
     reductions.--Effective for fee schedules established 
     beginning with 2015, if the total relative value units for a 
     service for a year would otherwise be decreased by an 
     estimated amount equal to or greater than 20 percent as 
     compared to the total relative value units for the previous 
     year, the applicable adjustments in work, practice expense, 
     and malpractice relative value units shall be phased-in over 
     a 2-year period.''.
       (2) Conforming amendments.--Section 1848(c)(2) of the 
     Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended--
       (A) in subparagraph (B)(ii)(I), by striking ``subclause 
     (II)'' and inserting ``subclause (II) and paragraph (7)''; 
     and
       (B) in subparagraph (K)(iii)(VI)--
       (i) by striking ``provisions of subparagraph (B)(ii)(II)'' 
     and inserting ``provisions of subparagraph (B)(ii)(II) and 
     paragraph (7)''; and
       (ii) by striking ``under subparagraph (B)(ii)(II)'' and 
     inserting ``under subparagraph (B)(ii)(I)''.
       (f) Authority To Smooth Relative Values Within Groups of 
     Services.--Section 1848(c)(2)(C) of the Social Security Act 
     (42 U.S.C. 1395w-4(c)(2)(C)) is amended--
       (1) in each of clauses (i) and (iii), by striking ``the 
     service'' and inserting ``the service or group of services'' 
     each place it appears; and
       (2) in the first sentence of clause (ii), by inserting ``or 
     group of services'' before the period.
       (g) GAO Study and Report on Relative Value Scale Update 
     Committee.--
       (1) Study.--The Comptroller General of the United States 
     (in this subsection referred to as the ``Comptroller 
     General'') shall conduct a study of the processes used by the 
     Relative Value Scale Update Committee (RUC) to provide 
     recommendations to the Secretary of Health and Human Services 
     regarding relative values for specific services under the 
     Medicare physician fee schedule under section 1848 of the 
     Social Security Act (42 U.S.C. 1395w-4).
       (2) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report containing the results of the study 
     conducted under paragraph (1).
       (h) Adjustment to Medicare Payment Localities.--
       (1) In general.--Section 1848(e) of the Social Security Act 
     (42 U.S.C. 1395w-4(e)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Use of msas as fee schedule areas in california.--
       ``(A) In general.--Subject to the succeeding provisions of 
     this paragraph and notwithstanding the previous provisions of 
     this subsection, for services furnished on or after January 
     1, 2017, the fee schedule areas used for payment under this 
     section applicable to California shall be the following:
       ``(i) Each Metropolitan Statistical Area (each in this 
     paragraph referred to as an `MSA'), as defined by the 
     Director of the Office of Management and Budget as of 
     December 31 of the previous year, shall be a fee schedule 
     area.
       ``(ii) All areas not included in an MSA shall be treated as 
     a single rest-of-State fee schedule area.
       ``(B) Transition for msas previously in rest-of-state 
     payment locality or in locality 3.--
       ``(i) In general.--For services furnished in California 
     during a year beginning with 2017 and ending with 2021 in an 
     MSA in a transition area (as defined in subparagraph (D)), 
     subject to subparagraph (C), the geographic index values to 
     be applied under this subsection for such year shall be equal 
     to the sum of the following:

       ``(I) Current law component.--The old weighting factor 
     (described in clause (ii)) for such year multiplied by the 
     geographic index values under this subsection for the fee 
     schedule area that included such MSA that would have applied 
     in such area (as estimated by the Secretary) if this 
     paragraph did not apply.
       ``(II) MSA-based component.--The MSA-based weighting factor 
     (described in clause (iii)) for such year multiplied by the 
     geographic index values computed for the fee schedule area 
     under subparagraph (A) for the year (determined without 
     regard to this subparagraph).

[[Page 4530]]

       ``(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--
       ``(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

[[Page 4531]]

     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 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,

[[Page 4532]]

     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 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,

[[Page 4533]]

     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.--
       (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.).

[[Page 4534]]

       (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 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

[[Page 4535]]

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.
  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.

[[Page 4536]]

  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. 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

[[Page 4537]]

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 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

[[Page 4538]]

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 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.

[[Page 4539]]


  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 Michigan?
  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,

[[Page 4540]]

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. 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 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. 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.

[[Page 4541]]

  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.
  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. The gentleman from Texas (Mr. Brady) has 5 
minutes remaining, and the gentleman from Michigan (Mr. Levin) 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

[[Page 4542]]

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.
  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. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. LEVIN. Mr. Speaker, I yield 1 minute to the gentleman from 
Minnesota (Mr. Nolan).
  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.
  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.''

[[Page 4543]]

  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 remaining, 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 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.

[[Page 4544]]

       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 
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

[[Page 4545]]

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.
  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.

[[Page 4546]]

  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, and Wisconsin 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 Web site 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.

  Ms. CLARKE of New York. Mr. Speaker, today, I rise to oppose H.R. 
4015, the SGR Repeal and Medicare Provider Payment Modernization Act.
  For years, I have worked with my colleagues, hospitals, and doctors 
to temporarily repair a permanent problem. We have continued placing a 
Band-Aid on a gunshot wound. The Band-Aid doesn't work anymore. We need 
some serious treatment for this SGR wound. However, the suture we need 
is not H.R. 4015.
  This bill is just another attempt by Republicans to undermine the law 
that is the Affordable Care Act. Their weak attempt at yet another 
delay of ACA's individual mandate will not be accepted by the American 
people. Millions of Americans are benefiting from ACA. They now have 
access to free preventative care; they are now no longer denied 
coverage due to preexisting conditions; and parents can now keep their 
children on their healthcare plan until age 26.
  It is important to recognize that the bill, in its original form, 
stood as a bipartisan agreement. It was a permanent fix to the SGR 
problem. To have physicians paid based on merit, using a metric system 
to access doctors on the quality of care given not the quantity of 
patients seen, served to benefit the medical community and the patients 
in their care.
  However, the Republicans have poisoned this bipartisan agreement 
making it impossible for me to vote ``yes'' on H.R. 4015. Specifically, 
they are delaying ACA's individual mandate for five years by changing 
the penalty for failing to purchase health insurance to zero (0) until 
2019.
  There is no argument that a SGR permanent fix is necessary. However, 
it should not, and will not, be at the expense of hard-working 
Americans who now have access to health care that they may not have had 
before the Affordable Care Act.
  It is imperative that we continue to work in a bipartisan way to seek 
a solution to the SGR problem, because H.R. 4015--in its current form--
is not the solution.
  I ask my colleagues to join me in voting ``no'' on this bill.

  Mr. VAN HOLLEN. Mr. Speaker, using Medicare as a political pawn in 
their 51st attempt to undermine the Affordable Care Act is a new low, 
even for House Republicans.
  Americans are waiting for Congress to stop wasting time and start 
passing constructive solutions to the real challenges this country 
faces. The broken Medicare physician payment system is one such 
challenge. And there is a bipartisan, bicameral plan to reform Medicare 
physician payments to promote quality and efficiency.
  Unfortunately, today's vote isn't about that plan at all. We know 
this because the bill includes a poison pill that guarantees it will 
never become law. This is nothing more than one more tired exercise in 
Republicans indulging their obsessive hatred of the Affordable Care 
Act. Rather than working with Democrats to reach agreement on how to 
advance Medicare payment reform in a fiscally responsible way, 
Republicans instead attached a five-year delay of the Affordable Care 
Act's requirement that everyone take responsibility for having health 
insurance. The White House has indicated the President would veto this 
bill if it were to reach his desk.
  Private health insurers object to today's anti-Obamacare exercise. 
America's Health Insurance Plans and Blue Cross BlueShield Association 
wrote:

       ``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.''


[[Page 4547]]


  The American Academy of Family Physicians had this to say:

       ``It is disturbing that work designed to expand access to 
     quality health care would be advanced alongside a policy that 
     deliberately removes access to quality health care coverage. 
     Providing access to health care coverage for millions of 
     Medicare beneficiaries while eliminating access to health 
     care coverage for millions more is simply poor public policy 
     and we urge that such approach be abandoned.''

  This vote today is further evidence--as if any more were needed--that 
Republicans in Congress simply are not serious about addressing our 
real challenges. We need to fix Medicare physician payments. We need to 
improve opportunity in this country. We need to raise the minimum wage. 
We need to renew extended unemployment benefits. Currently over two 
million Americans out of work through no fault of their own have been 
left in the lurch by Republicans' refusal to renew these benefits. We 
were elected to this body to solve problems, not to posture endlessly.
  If Congressional Republicans were serious about fixing Medicare 
physician payments, they would not pull stunts like this. If they cared 
more about solving problems than they do about fulfilling their anti-
Obamacare fetish, they would not pull stunts like this. Americans 
deserve better. Medicare beneficiaries deserve better, as do the 
doctors who treat them. To the majority, I say, stop wasting everyone's 
time.
  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.
  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.

[[Page 4548]]

  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
     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

[[Page 4549]]


     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.

                          ____________________