,i #aacth ,,congress #ast ,session ,h4 ,r4 #egd ,,in ,,the ,,house ,,of ,,representatives ,february #f1 #bjac ,ms4 ,schwartz 7for herself1 ,mr4 ,heck of ,nevada1 ,mr4 ,blumenauer1 ,mrs4 ,christensen1 ,mr4 ,carney1 ,mr4 ,courtney1 ,mr4 ,polis1 ,mr4 ,fattah1 and ,ms4 ,castor of ,florida7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend part ,b of title ,,xviii of the ,social ,security ,act to reform ,medicare payment for physicians' services by eliminating the sustainable growth rate system and providing incentives for the adoption of innovative payment and delivery models to improve quality and efficiency4 #a4 ,short title2 purpose 7a7 ,short title ,this ,act may be cited as the ,medicare ,physician ,payment ,innovation ,act of #bjac4 7b7 ,purpose ,the purpose of this ,act is to reform the system of ,medicare payment for physicians' services-- 7#a7 by ending the application of the sustainable growth rate 7,,sgr7 system2 7#b7 to stabilize payments for #bjad2 7#c7 to promote the rapid development and implementation of alternative improved payment and delivery models that incentivize high quality1 high-value care2 and 7#d7 to provide continuing incentives for adoption of such alternative payment and delivery models by physicians and other providers4 #b4 ,medicare physician payment reform 7a7 ,repeal of ,,sgr payment methodology ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended-- 7#a7 in subsection 7d7-- 7,a7 in paragraph 7#a77;,a71 by inserting or a subsequent paragraph after paragraph 7#d72 and 7,b7 in paragraph 7#d7-- 7i7 in the heading1 by striking years beginning with #bjja and inserting #bjja1 #bjjb1 and #bjjc2 and 7ii7 in subparagraph 7,a71 by striking a year beginning with #bjja and inserting #bjja1 #bjjb1 and #bjjc2 and 7#b7 in subsection 7f7-- 7,a7 in paragraph 7#a77;,b71 by inserting through #bjac after of such succeeding year2 and 7,b7 in paragraph 7#b71 by inserting and ending with #bjac after beginning with #bjjj4 7b7 ,stabilizing #bjad payment rates at current level 7#a7 ,in general ,subsection 7d7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as amended by section #fja of the ,american ,taxpayer ,relief ,act of #bjab 7,public ,law #aab-bdj71 is amended by adding at the end the following new paragraph3 7#ae7 ,update for #bjad ,in lieu of the update to the single conversion factor established in paragraph 7#a77;,c7 that would otherwise apply for #bjad1 the update to the single conversion factor shall be #j percent for #bjad4 4 7#b7 ,technical amendment ,effective for years beginning with #bjad1 subparagraph 7,c77i7 of paragraph 7#g7 of section #ahdh7m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#g77;,c77i72 relating to additional incentive payment7 is amended by inserting 1 the program of ,osteopathic ,continuous ,certification of the ,american ,osteopathic ,association1 after ,specialties ,maintenance of ,certification program4 7c7 ,establishment of differential updates beginning with #bjae ,to promote access to primary care services 7#a7 ,establishment of service categories ,subsection 7j7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended by adding at the end the following new paragraphs3 7#e7 ,service categories 7,a7 ,in general ,for services furnished on or after ,january #a1 #bjae1 each of the following categories of services shall be treated as a separate service category3 7i7 ,primary care ,primary care services 7as defined in subparagraph 7,b77 furnished by a qualifying practitioner4 7ii7 ,other services ,other physicians' services4 7,b7 ,primary care services ,in this subsection1 the term primary care services means services identified1 as of ,april #a1 #bjac1 with the following ,,hcpcs codes 7and as subsequently modified by the ,secretary73 7i7 ,office and outpatient visits #iibja through #iibae4 7ii7 ,hospital observational services #iibag through #iibbj4 7iii7 ,hospital inpatient visits services #iibba through #iibci4 7iv7 ,nursing home1 domiciliary1 rest home or custodial care visits #iicjd through #iicdj4 7v7 ,home service visits #iicda through #iicej4 7vi7 ,welcome to ,medicare visit ,g#jdjb4 7vii7 ,annual wellness visits ,g#jdch and ,g#jdci4 7,c7 ,inclusion of preventive services ,such term also includes preventive services described in section #ahfa7;ddd77#c7 and additional preventive services described in section #ahfa7;ddd77#a74 7,d7 ,inclusion of additional services ,such term also includes services1 such as care coordination services1 telemedicine services1 non-face-to-face care management services1 preparation and supervision of long-term care plans1 home care plan oversight services1 and similar services that the ,secretary identifies1 by regulation1 as being similar to the services described in subparagraph 7,b7 or 7,c74 7#f7 ,qualifying practitioner ,the term qualifying practitioner means1 with respect to the furnishing of primary care services1 an individual-- 7,a7 for whom primary care services has accounted for at least #fj percent of the allowed charges under this part 7not counting any such charges attributable to in-office clinical laboratory services7 in a prior period as determined by the ,secretary2 or 7,b7 who does not have claims under this part during such a prior period and whom the ,secretary determines is likely to meet the requirement of subparagraph 7,a7 for the subsequent period4 4 7#b7 ,establishment of separate conversion factors for each service category ,section #ahdh7;d77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d77#a771 as amended by subsection 7a77#a77;,a71 is further amended-- 7,a7 in subparagraph 7,a7-- 7i7 by designating the sentence beginning ,the conversion factor as clause 7i7 with the heading ,application of single conversion factor4-- and with appropriate indentation2 7ii7 by striking ,the conversion factor and inserting ,subject to clause 7ii71 the conversion factor2 and 7iii7 by adding at the end the following new clause3 7ii7 ,application of multiple conversion factors beginning with #bjae 7,i7 ,in general ,in applying clause 7i7 for each year beginning with #bjae1 separate conversion factors shall be established for each service category of physicians' services 7as defined in subsection 7j77#e77;,a77 and any reference in this section to a conversion factor for such years shall be deemed a reference to the conversion factor for each of such categories4 7,,ii7 ,initial conversion factors ,such factors for #bjae shall be based upon the single conversion factor for the previous year multiplied by the update established under paragraph 7#af7 for such category for #bjae4 7,,iii7 ,updating of conversion factors ,such factor for a service category for a subsequent year shall be based upon the conversion factor for such category for the previous year and adjusted by the update established for such category under paragraph 7#af7 or a subsequent paragraph for the year involved4 2 and 7,b7 in subparagraph 7,d71 by striking other physicians' services and inserting for physicians' services in the service category described in subsection 7j77#e77;,a77ii774 7#c7 ,establishment of separate updates for conversion factors for each service category ,section #ahdh7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d771 as amended by subsection 7b71 is amended by adding at the end the following new paragraph3 7#af7 ,updates by service category beginning with #bjae2 updates for #bjae through #bjah ,in applying paragraph 7#d7 for each year beginning with #bjae1 the following rules apply3 7,a7 ,application of separate update adjustments for each service category ,pursuant to paragraph 7#a77;,a77ii77,i71 for each year beginning with #bjad1 the update shall be made to the conversion factor for each service category 7as defined in subsection 7j77#e77;,a774 7,b7 ,updates for #bjae through #bjah ,the updates for #bjae1 #bjaf1 #bjag1 and #bjah for the conversion factor for the services category described in-- 7i7 subsection 7j77#e77;,a77i7 shall be #b4e percent2 and 7ii7 subsection 7j77#e77;,a77ii7 shall be #j4e percent4 4 7d7 ,promoting testing and evaluation of new payment and delivery models 7,phase ,i7 7#a7 ,expansion of testing in multiple geographic regions ,section #aaae;,a7a77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7a77#e77 is amended by inserting before the period at the end the following3 1 but shall 7to the maximum extent feasible7 including testing of each such model in geographic areas in at least #c regions4 7#b7 ,inclusion of physician implementation costs in evaluations ,section #aaae;,a7b77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#d77;,a77 is amended-- 7,a7 by striking and at the end of clause 7i72 7,b7 by striking the period at the end of clause 7ii7 and inserting 2 and2 and 7,c7 by adding at the end the following new clause3 7iii7 the average cost1 per physician1 of implementation of the model with respect to physicians' services4 4 7#c7 ,accelerating testing and evaluation process ,section #aaae;,a7b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77 is amended by adding at the end the following new paragraph3 7#e7 ,timing ,the ,secretary1 acting through the ,,cmi1 shall conduct activities under this subsection in such a timely manner so that evaluations of initial models can be initially completed so that physicians and other providers can begin to transition to implementation of such models with respect to services for which payment is made under section #ahdh beginning not later than ,january #a1 #bjah4 4 7#d7 ,involvement of provider groups in selection of models ,section #aaae;,a7b77#d7 of such ,act is amended by adding at the end the following subparagraph3 7,d7 ,involvement of provider groups in model selection ,the ,secretary shall consult and work closely with physician and other provider groups in the selection of models under this subsection and subsection 7c74 4 7#e7 ,use of other models ,section #aaae;,a of such ,act is further amended-- 7,a7 by adding at the end of subsection 7b77#b77;,b7 the following new clause3 7xxi7 ,providing payment for outpatient therapy services and speech language pathology services on the basis of a treatment session1 an episode of care1 or other bundled payment methodology that takes into account varying levels of severity and complexity of patient diagnoses1 conditions1 and comorbidities and the varying intensity of services needed for effective treatment of patients4 2 and 7,b7 in subsection 7c71 in the matter preceding paragraph 7#a71 by-- 7i7 striking or after tested under subsection 7b7 and inserting a comma2 and 7ii7 by inserting 1 or other model 7including a model that was not tested under subsection 7b77 after section #ahff;,c4 7#f7 ,,gao review and study ,the ,comptroller ,general of the ,united ,states shall conduct a study of the evaluations made under subsection 7b7 of section #aaae;,a of the ,social ,security ,act1 as amended by this section4 ,such study shall include an analysis of the alternative payment and delivery models identified under such section for payment for physicians' services 7and other services7 under the ,medicare program4 ,not later than ,april #a1 #bjag1 the ,comptroller ,general shall submit a report to ,congress on such study and shall include in the report such recommendations as the ,comptroller ,general deems appropriate for-- 7,a7 changes in the development and implementation process under such section2 and 7,b7 alternative payment and delivery models identified under such section as being appropriate for expansion under subsection 7c7 of such section4 7#g7 ,publication of list of successful models ,beginning on ,october #a1 #bjag1 and each year thereafter1 the ,secretary of ,health and ,human ,services shall publicly release a comprehensive list of such health care delivery and payment models identified1 under section #aaae;,a of the ,social ,security ,act or otherwise1 as meeting 7or likely to meet7 the requirements of subsection 7c77#a7 of such section4 ,such list shall include at least #d health care delivery and payment models and may include models not tested under subsection 7b7 of such section4 7#h7 ,considerations ,the ,comptroller ,general in making recommendations under paragraph 7#f7 and the ,secretary in releasing the list of models under paragraph 7#g7 shall take into account variations among providers in size1 specialty mix1 case mix1 and patient demographics1 as well as regional health care infrastructure variations and variations in cost of living among areas1 and shall specifically consider appropriate variations that take into account the special circumstances of providers in rural and other underserved areas4 7e7 ,implementation of payment and delivery model options 7,phase ,,ii7 7#a7 ,in general ,based on the report of the ,comptroller ,general under subsection 7d77#d7 and not later than ,october #a1 #bjag1 the ,secretary of ,health and ,human ,services shall provide information to physicians 7and nurse practitioners and other providers for which payment is determined based on the fee schedule under section #ahdh of the ,social ,security ,act7 or group practices and institutions employing ,medicare part ,b providers on how best to transition to alternative health care delivery and payment models that are aimed at improving the coordination1 quality and efficiency of health care1 including those developed under section #aaae;,a or #ahff;,e of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a1 #acie;cc-#e74 7#b7 ,increasing flexibility in implementation ,section #aaae;,a7c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7c771 as amended by subsection 7c77#e71 is further amended1 in the matter preceding paragraph 7#a71 by inserting1 after through rulemaking1 the following3 7which may include the issuance of interim final rules7 or through publication of a directive or other guidance4 7#c7 ,timing ,section #aaae;,a of such ,act is further amended by adding at the end the following3 ,the ,secretary shall seek to effect such expansion to the maximum extent feasible so that physicians 7and other providers paid in amounts determined based on the fee schedule under section #ahdh7 may begin to transition to implementation of such models beginning not later than ,january #a1 #bjah44 7f7 ,transition during #bjai 7#a7 ,freeze in fee schedule for #bjai ,subsection 7d7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as amended by subsections 7b7 and 7c77#c71 is amended by adding at the end the following new paragraph3 7#ag7 ,update for #bjai ,the update to both of the conversion factors for #bjai shall be #j percent4 4 7#b7 ,expanded assistance through regional extension centers and other qualified entities ,section #aaae;,a7d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7d77 is amended by adding at the end the following new paragraph3 7#d7 ,assistance in implementation 7,a7 ,in general ,using funds available under subsection 7f77#a7 and consistent with this paragraph1 the ,secretary shall enter into contracts and agreements with regional extension centers1 in coordination with the ,national ,coordinator for ,health ,information ,technology1 and other appropriate entities to provide guidance and assistance on how physicians 7and other providers paid in amounts determined based on the fee schedule under section #ahdh7 may transition to implementation of alternative health care delivery models identified as representing best practices under this section4 7,b7 ,dedicated funding 7i7 ,in general ,of the amounts available under subsection 7f77#a77;,b71 the ,secretary shall make #gbj1jjj1jjj available to the ,office of the ,national ,coordinator for ,health ,information ,technology for the awarding of grants and incentive payments under a competitive process to regional extension centers 7receiving funding under section #cjab7;c7 of the ,public ,health ,service ,act7 and other qualified entities for activities described in subparagraph 7,a74 ,such grants and payments shall not be available for assistance after ,december #ca1 #bjai4 7ii7 ,process ,under clause 7i71 the ,office shall-- 7,i7 establish a competitive selection process for the selection of regional extension centers 7and other qualified entities7 in the third quarter of #bjae2 and 7,,ii7 provide for the initial distribution of funds to such centers and entities by ,january #a1 #bjaf4 7iii7 ,collaboration ,the ,center shall collaborate with the ,office in providing direction to such centers and entities in conducting activities under this paragraph1 including the development of performance benchmarks based on provider participation and progress toward integration4 7iv7 ,priority ,the grants and incentive payments under this subparagraph shall be directed to target assistance to solo and small specialty practices as well as community health centers and similar providers of primary care services4 4 7g7 ,continuing incentives for providing high-,quality1 high-,value care 7#a7 ,fee schedule adjustments ,subsection 7d7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as amended by subsections 7b71 7c77#c71 and 7f71 is amended by adding at the end the following3 7#ah7 ,updates for #bjbj through #bjbc 7,a7 ,in general ,except as provided in this paragraph1 the update to each of the conversion factors-- 7i7 for #bjbj shall be minus #b percent2 7ii7 for #bjba shall be minus #c percent2 7iii7 for #bjbb shall be minus #d percent2 and 7iv7 for #bjbc shall be minus #e percent4 7,b7 ,treatment of services paid using alternative payment and delivery models ,in the case of physicians' services for which payment is covered under an alternative payment and delivery model1 such as those implemented under section #aaae;,a1 subparagraph 7,a7 does not apply4 7,c7 ,general exemption ,the ,secretary shall1 by regulation1 exempt a provider from the application of the negative payment update specified in subparagraph 7,a7 for a year if the ,secretary determines that-- 7i7 the provider-- 7,i7 is a meaningful ,,ehr user 7as determined under subsection 7o77#b7 with respect to the year72 and 7,,ii7 meets the qualifications under subparagraph 7,b7 of subsection 7m77#g7 7relating to additional incentive payments7 for an additional incentive payment under subparagraph 7,a7 of such subsection 7which includes satisfactory participation in the quality reporting system and participation in an approved ,maintenance of ,certification program72 7ii7 the payment modifier for the provider under subsection 7p71 which is based upon the performance of the provider on measures of quality of care furnished compared to cost and which is expressed as a percentage of payment1 is within the top #be percent of such payment modifiers for providers within the same fee schedule area1 as determined by the ,secretary2 or 7iii7 in the case of outpatient therapy services1 the provider of such services adheres to a comprehensive list of cost1 quality1 and outcome measures as demonstrated by-- 7,i7 participation in a certified registry2 7,,ii7 if applicable1 participation in the physician quality reporting system under subsection 7k72 7,,iii7 use of an approved patient assessment tool2 7,,iv7 current certification as a physical therapist clinical specialist by the ,american ,physical ,therapy ,association 7,,apta71 an occupational therapist by the ,american ,occupational ,therapy ,association1 or as an audiologist or a speech-language pathologist by the ,american ,speech-,language-,hearing ,association2 or 7,v7 compliance with comparable functional measures reporting requirements as recognized by the ,secretary4 7,d7 ,case-by-case hardship exemption ,the ,secretary may1 on a case-by-case basis1 exempt a provider from the application of the negative payment update specified in subparagraph 7,a7 for a year if the ,secretary determines1 subject to annual renewal1 that because of limitations in the nature of a medical practice1 limitations in the number of ,medicare beneficiaries that may be served by the provider1 or other special circumstances1 imposing a financial disincentive under such subparagraph for failure to adopt an alternative payment and delivery model referred to in subparagraph 7,b7 would result in a significant hardship to the provider4 7#ai7 ,updates beginning with #bjbd 7,a7 ,in general ,the update to both of the conversion factors for each year beginning with #bjbd shall be #j percent4 7,b7 ,treatment of services paid using alternative payment and delivery models ,in the case of physicians' services for which payment is covered under an alternative payment and delivery model1 such as those implemented under section #aaae;,a1 subparagraph 7,a7 does not apply4 4 7#b7 ,considerations in promulgating growth rates for alternative payment and delivery models 7,a7 ,in general ,in determining the growth rates to be recognized beginning with #bjbj for alternative payment and delivery models under the ,medicare program that cover physicians' services1 such as those implemented under section #aaae;,a of the ,social ,security ,act1 the ,secretary of ,health and ,human ,services shall consider 7among other factors7 the following3 7i7 ,ensuring access to primary care and specialty services1 including participation of primary care practitioners and specialists and newly graduating practitioners4 7ii7 ,restraining spending growth4 7iii7 ,ensuring access to services for vulnerable populations4 7,b7 ,limitations ,in no case shall the growth factor determined under this paragraph for a year-- 7i7 be less than #a percent2 or 7ii7 be greater than the percentage increase in the ,,mei 7as defined in section #ahdb7;i77#c7 of the ,social ,security ,act1 #db ,u4,s4,c4 #acieu7i77#c77 for such year4 7,c7 ,application of ,congressional ,review ,act ,chapter #h of title #e1 ,united ,states ,code1 applies with respect to the promulgation of a growth factor under this paragraph for a year4 7h7 ,impact report ,not later than ,january #a1 #bjbc1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the impact on spending and on access to services under title ,,xviii of the ,social ,security ,act1 including under part ,a of such title1 resulting from changes to ,medicare delivery and payment systems1 including under the amendments made by this section4