,,ii #aacth ,,congress #b;d ,session ,s4 #bjjj ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #f1 #bjad ,mr4 ,baucus 7for himself and ,mr4 ,hatch7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to repeal the ,medicare sustainable growth rate and improve ,medicare payments for physicians and other professionals1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,,sgr ,repeal and ,medicare ,provider ,payment ,modernization ,act of #bjad4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,repealing the sustainable growth rate 7,,sgr7 and improving ,medicare payment for physicians' services4 ,sec4 #c4 ,priorities and funding for measure development4 ,sec4 #d4 ,encouraging care management for individuals with chronic care needs4 ,sec4 #e4 ,ensuring accurate valuation of services under the physician fee schedule4 ,sec4 #f4 ,promoting evidence-based care4 ,sec4 #g4 ,empowering beneficiary choices through access to information on physicians' services4 ,sec4 #h4 ,expanding availability of ,medicare data4 ,sec4 #i4 ,reducing administrative burden and other provisions4 #b4 ,repealing the sustainable growth rate 7,,sgr7 and improving ,medicare payment for physicians' services 7a7 ,stabilizing fee updates 7#a7 ,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-- 7i7 in paragraph 7#a77;,a71 by inserting or a subsequent paragraph after paragraph 7#d72 and 7ii7 in paragraph 7#d7-- 7,i7 in the heading1 by inserting and ending with #bjac after years beginning with #bjja2 and 7,,ii7 in subparagraph 7,a71 by inserting and ending with #bjac after a year beginning with #bjja2 and 7,b7 in subsection 7f7-- 7i7 in paragraph 7#a77;,b71 by inserting through #bjac after of each succeeding year2 and 7ii7 in paragraph 7#b71 in the matter preceding subparagraph 7,a71 by inserting and ending with #bjac after beginning with #bjjj4 7#b7 ,update of rates for ,april through ,december of #bjad1 #bjae1 and subsequent years ,subsection 7d7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended by striking paragraph 7#ae7 and inserting the following new paragraphs3 7#ae7 ,update for #bjad through #bjah ,the update to the single conversion factor established in paragraph 7#a77;,c7 for #bjad and each subsequent year through #bjah shall be #j4e percent4 7#af7 ,update for #bjai through #bjbc ,the update to the single conversion factor established in paragraph 7#a77;,c7 for #bjai and each subsequent year through #bjbc shall be zero percent4 7#ag7 ,update for #bjbd and subsequent years ,the update to the single conversion factor established in paragraph 7#a77;,c7 for #bjbd and each subsequent year shall be-- 7,a7 for items and services furnished by a qualifying ,,apm participant 7as defined in section #ahcc7z77#b77 for such year1 #a4j percent2 and 7,b7 for other items and services1 #j4e percent4 4 7#c7 ,med,p,a,c reports 7,a7 ,initial report ,not later than ,july #a1 #bjaf1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on the relationship between-- 7i7 physician and other health professional utilization and expenditures 7and the rate of increase of such utilization and expenditures7 of items and services for which payment is made under section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d72 and 7ii7 total utilization and expenditures 7and the rate of increase of such utilization and expenditures7 under parts ,a1 ,b1 and ,d of title ,,xviii of such ,act4 ,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 ,a1 ,b1 and ,d of such title4 7,b7 ,final report ,not later than ,july #a1 #bjbj1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on the relationship described in subparagraph 7,a71 including the results determined from applying the methodology included in the report submitted under such subparagraph4 7,c7 ,report on update to physicians' services under ,medicare ,not later than ,july #a1 #bjah1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on-- 7i7 the payment update for professional services applied under the ,medicare program under title ,,xviii of the ,social ,security ,act for the period of years #bjad through #bjah2 7ii7 the effect of such update on the efficiency1 economy1 and quality of care provided under such program2 7iii7 the effect of such update on ensuring a sufficient number of providers to maintain access to care by ,medicare beneficiaries2 and 7iv7 recommendations for any future payment updates for professional services under such program to ensure adequate access to care is maintained for ,medicare beneficiaries4 7b7 ,consolidation of certain current law performance programs with new merit-,based ,incentive ,payment ,system 7#a7 ,,ehr meaningful use incentive program 7,a7 ,sunsetting separate meaningful use payment adjustments ,section #ahdh7;a77#g77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#g77;,a77 is amended-- 7i7 in clause 7i71 by striking or any subsequent payment year and inserting or #bjag2 7ii7 in clause 7ii7-- 7,i7 in the matter preceding subclause 7,i71 by striking ,subject to clause 7iii71 for and inserting ,for2 7,,ii7 in subclause 7,i71 by adding at the end and2 7,,iii7 in subclause 7,,ii71 by striking 2 and and inserting a period2 and 7,,iv7 by striking subclause 7,,iii72 and 7iii7 by striking clause 7iii74 7,b7 ,continuation of meaningful use determinations for ,,mips ,section #ahdh7o77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77 is amended-- 7i7 in subparagraph 7,a71 in the matter preceding clause 7i7-- 7,i7 by striking ,for purposes of paragraph 7#a71 an and inserting ,an2 and 7,,ii7 by inserting 1 or pursuant to subparagraph 7,d7 for purposes of subsection 7q71 for a performance period under such subsection for a year after under such subsection for a year2 and 7ii7 by adding at the end the following new subparagraph3 7,d7 ,continued application for purposes of ,,mips ,with respect to #bjah and each subsequent payment year1 the ,secretary shall1 for purposes of subsection 7q7 and in accordance with paragraph 7#a77;,f7 of such subsection1 determine whether an eligible professional who is a ,,mips eligible professional 7as defined in subsection 7q77#a77;,c77 for such year is a meaningful ,,ehr user under this paragraph for the performance period under subsection 7q7 for such year4 4 7#b7 ,quality reporting 7,a7 ,sunsetting separate quality reporting incentives ,section #ahdh7;a77#h77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;a77#h77;,a77 is amended-- 7i7 in clause 7i71 by striking or any subsequent year and inserting or #bjag2 and 7ii7 in clause 7ii77,,ii71 by striking and each subsequent year4 7,b7 ,continuation of quality measures and processes for ,,mips ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended-- 7i7 in subsection 7k71 by adding at the end the following new paragraph3 7#i7 ,continued application for purposes of ,,mips and for certain professionals volunteering to report ,the ,secretary shall1 in accordance with subsection 7q77#a77;,f71 carry out the provisions of this subsection-- 7,a7 for purposes of subsection 7q72 and 7,b7 for eligible professionals who are not ,,mips eligible professionals 7as defined in subsection 7q77#a77;,c77 for the year involved4 2 and 7ii7 in subsection 7m7-- 7,i7 by redesignating paragraph 7#g7 added by section #ajcbg7;a7 of ,public ,law #aaa-adh as paragraph 7#h72 and 7,,ii7 by adding at the end the following new paragraph3 7#i7 ,continued application for purposes of ,,mips and for certain professionals volunteering to report ,the ,secretary shall1 in accordance with subsection 7q77#a77;,f71 carry out the processes under this subsection-- 7,a7 for purposes of subsection 7q72 and 7,b7 for eligible professionals who are not ,,mips eligible professionals 7as defined in subsection 7q77#a77;,c77 for the year involved4 4 7#c7 ,value-based payments 7,a7 ,sunsetting separate value-based payments ,clause 7iii7 of section #ahdh7p77#d77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#d77;,b77 is amended to read as follows3 7iii7 ,application ,the ,secretary shall apply the payment modifier established under this subsection for items and services furnished on or after ,january #a1 #bjae1 but before ,january #a1 #bjah1 with respect to specific physicians and groups of physicians the ,secretary determines appropriate4 ,such payment modifier shall not be applied for items and services furnished on or after ,january #a1 #bjah4 4 7,b7 ,continuation of value-based payment modifier measures for ,,mips ,section #ahdh7p7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77 is amended-- 7i7 in paragraph 7#b71 by adding at the end the following new subparagraph3 7,c7 ,continued application for purposes of ,,mips ,the ,secretary shall1 in accordance with subsection 7q77#a77;,f71 carry out subparagraph 7,b7 for purposes of subsection 7q74 2 and 7ii7 in paragraph 7#c71 by adding at the end the following3 ,with respect to #bjah and each subsequent year1 the ,secretary shall1 in accordance with subsection 7q77#a77;,f71 carry out this paragraph for purposes of subsection 7q744 7c7 ,merit-,based ,incentive ,payment ,system 7#a7 ,in general ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 is amended by adding at the end the following new subsection3 7q7 ,merit-,based ,incentive ,payment ,system 7#a7 ,establishment 7,a7 ,in general ,subject to the succeeding provisions of this subsection1 the ,secretary shall establish an eligible professional ,merit-based ,incentive ,payment ,system 7in this subsection referred to as the ,,mips7 under which the ,secretary shall-- 7i7 develop a methodology for assessing the total performance of each ,,mips eligible professional according to performance standards under paragraph 7#c7 for a performance period 7as established under paragraph 7#d77 for a year2 7ii7 using such methodology1 provide for a composite performance score in accordance with paragraph 7#e7 for each such professional for each performance period2 and 7iii7 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 7and1 as applicable1 an additional ,,mips adjustment factor7 under paragraph 7#f7 to the professional for the year4 7,b7 ,program implementation ,the ,,mips shall apply to payments for items and services furnished on or after ,january #a1 #bjah4 7,c7 ,,mips eligible professional defined 7i7 ,in general ,for purposes of this subsection1 subject to clauses 7ii7 and 7iv71 the term ,,mips eligible professional means-- 7,i7 for the first and second years for which the ,,mips applies to payments 7and for the performance period for such first and second year71 a physician 7as defined in section #ahfa7r771 a physician assistant1 nurse practitioner1 and clinical nurse specialist 7as such terms are defined in section #ahfa7;aa77#e771 and a certified registered nurse anesthetist 7as defined in section #ahfa7;bb77#b77 and a group that includes such professionals2 and 7,,ii7 for the third year for which the ,,mips applies to payments 7and for the performance period for such third year7 and for each succeeding year 7and for the performance period for each such year71 the professionals described in subclause 7,i7 and such other eligible professionals 7as defined in subsection 7k77#c77;,b77 as specified by the ,secretary and a group that includes such professionals4 7ii7 ,exclusions ,for purposes of clause 7i71 the term ,,mips eligible professional does not include1 with respect to a year1 an eligible professional 7as defined in subsection 7k77#c77;,b77 who-- 7,i7 is a qualifying ,,apm participant 7as defined in section #ahcc7z77#b772 7,,ii7 subject to clause 7vii71 is a partial qualifying ,,apm participant 7as defined in clause 7iii77 for the most recent period for which data are available and who1 for the performance period with respect to such year1 does not report on applicable measures and activities described in paragraph 7#b77;,b7 that are required to be reported by such a professional under the ,,mips2 or 7,,iii7 for the performance period with respect to such year1 does not exceed the low-volume threshold measurement selected under clause 7iv74 7iii7 ,partial qualifying ,,apm participant ,for purposes of this subparagraph1 the term partial qualifying ,,apm participant means1 with respect to a year1 an eligible professional for whom the ,secretary determines the minimum payment percentage 7or percentages71 as applicable1 described in paragraph 7#b7 of section #ahcc7z7 for such year have not been satisfied1 but who would be considered a qualifying ,,apm participant 7as defined in such paragraph7 for such year if-- 7,i7 with respect to #bjah and #bjai1 the reference in subparagraph 7,a7 of such paragraph to #be percent was instead a reference to #bj percent2 7,,ii7 with respect to #bjbj and #bjba-- 7aa7 the reference in subparagraph 7,b77i7 of such paragraph to #ej percent was instead a reference to #dj percent2 and 7bb7 the references in subparagraph 7,b77ii7 of such paragraph to #ej percent and #be percent of such paragraph were instead references to #dj percent and #bj percent1 respectively2 and 7,,iii7 with respect to #bjbb and subsequent years-- 7aa7 the reference in subparagraph 7,c77i7 of such paragraph to #ge percent was instead a reference to #ej percent2 and 7bb7 the references in subparagraph 7,c77ii7 of such paragraph to #ge percent and #be percent of such paragraph were instead references to #ej percent and #bj percent1 respectively4 7iv7 ,selection of low-volume threshold measurement ,the ,secretary shall select a low-volume threshold to apply for purposes of clause 7ii77,,iii71 which may include one or more or a combination of the following3 7,i7 ,the minimum number 7as determined by the ,secretary7 of individuals enrolled under this part who are treated by the eligible professional for the performance period involved4 7,,ii7 ,the minimum number 7as determined by the ,secretary7 of items and services furnished to individuals enrolled under this part by such professional for such performance period4 7,,iii7 ,the minimum amount 7as determined by the ,secretary7 of allowed charges billed by such professional under this part for such performance period4 7v7 ,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 7and had not previously submitted claims under this title such as a person1 an entity1 or a part of a physician group or under a different billing number or tax identifier71 such professional shall not be treated under this subsection as a ,,mips eligible professional until the subsequent year and performance period for such subsequent year4 7vi7 ,clarification ,in the case of items and services furnished during a year by an individual who is not a ,,mips eligible professional 7including pursuant to clauses 7ii7 and 7v77 with respect to a year1 in no case shall a ,,mips adjustment factor 7or additional ,,mips adjustment factor7 under paragraph 7#f7 apply to such individual for such year4 7vii7 ,partial qualifying ,,apm participant clarifications 7,i7 ,treatment as ,,mips eligible professional ,in the case of an eligible professional who is a partial qualifying ,,apm participant1 with respect to a year1 and who for the performance period for such year reports on applicable measures and activities described in paragraph 7#b77;,b7 that are required to be reported by such a professional under the ,,mips1 such eligible professional is considered to be a ,,mips eligible professional with respect to such year4 7,,ii7 ,not eligible for qualifying ,,apm participant payments ,in no case shall an eligible professional who is a partial qualifying ,,apm participant1 with respect to a year1 be considered a qualifying ,,apm participant 7as defined in paragraph 7#b7 of section #ahcc7z77 for such year or be eligible for the additional payment under paragraph 7#a7 of such section for such year4 7,d7 ,application to group practices 7i7 ,in general ,under the ,,mips3 7,i7 ,quality performance category ,the ,secretary shall establish and apply a process that includes features of the provisions of subsection 7m77#c77;,c7 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 7i7 of paragraph 7#b77;,a74 7,,ii7 ,other performance categories ,the ,secretary may establish and apply a process that includes features of the provisions of subsection 7m77#c77;,c7 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 7ii7 through 7iv7 of such paragraph4 7ii7 ,ensuring comprehensiveness of group practice assessment ,the process established under clause 7i7 shall to the extent practicable reflect the range of items and services furnished by the ,,mips eligible professionals in the group practice involved4 7iii7 ,clarification ,,mips eligible professionals electing to be a virtual group under paragraph 7#e77;,i7 shall not be considered ,,mips eligible professionals in a group practice for purposes of applying this subparagraph4 7,e7 ,use of registries ,under the ,,mips1 the ,secretary shall encourage the use of qualified clinical data registries pursuant to subsection 7m77#c77;,e7 in carrying out this subsection4 7,f7 ,application of certain provisions ,in applying a provision of subsection 7k71 7m71 7o71 or 7p7 for purposes of this subsection1 the ,secretary shall-- 7i7 adjust the application of such provision to ensure the provision is consistent with the provisions of this subsection2 and 7ii7 not apply such provision to the extent that the provision is duplicative with a provision of this subsection4 7,g7 ,accounting for risk factors 7i7 ,risk factors ,taking into account the relevant studies conducted and recommendations made in reports under section #b7;f77#a7 of the ,,sgr ,repeal and ,medicare ,provider ,payment ,modernization ,act of #bjad1 the ,secretary1 on an ongoing basis1 shall estimate how an individual's health status and other risk factors affect quality and resource use outcome measures and1 as feasible1 shall incorporate information from quality and resource use outcome measurement 7including care episode and patient condition groups7 into the ,,mips4 7ii7 ,accounting for other factors in payment adjustments ,taking into account the studies conducted and recommendations made in reports under section #b7;f77#a7 of the ,,sgr ,repeal and ,medicare ,provider ,payment ,modernization ,act of #bjad and other information as appropriate1 the ,secretary shall account for identified factors with an effect on quality and resource use outcome measures when determining payment adjustments1 composite performance scores1 scores for performance categories1 or scores for measures or activities under the ,,mips4 7#b7 ,measures and activities under performance categories 7,a7 ,performance categories ,under the ,,mips1 the ,secretary shall use the following performance categories 7each of which is referred to in this subsection as a performance category7 in determining the composite performance score under paragraph 7#e73 7i7 ,quality4 7ii7 ,resource use4 7iii7 ,clinical practice improvement activities4 7iv7 ,meaningful use of certified ,,ehr technology4 7,b7 ,measures and activities specified for each category ,for purposes of paragraph 7#c77;,a7 and subject to subparagraph 7,c71 measures and activities specified for a performance period 7as established under paragraph 7#d77 for a year are as follows3 7i7 ,quality ,for the performance category described in subparagraph 7,a77i71 the quality measures included in the final measures list published under subparagraph 7,d77i7 for such year and the list of quality measures described in subparagraph 7,d77vi7 used by qualified clinical data registries under subsection 7m77#c77;,e74 7ii7 ,resource use ,for the performance category described in subparagraph 7,a77ii71 the measurement of resource use for such period under subsection 7p77#c71 using the methodology under subsection 7r7 as appropriate1 and1 as feasible and applicable1 accounting for the cost of drugs under part ,d4 7iii7 ,clinical practice improvement activities ,for the performance category described in subparagraph 7,a77iii71 clinical practice improvement activities 7as defined in subparagraph 7,c77v77,,iii77 under subcategories specified by the ,secretary for such period1 which shall include at least the following3 7,i7 ,the subcategory of expanded practice access1 which shall include activities such as same day appointments for urgent needs and after hours access to clinician advice4 7,,ii7 ,the subcategory of population management1 which shall include activities such as monitoring health conditions of individuals to provide timely health care interventions or participation in a qualified clinical data registry4 7,,iii7 ,the subcategory of care coordination1 which shall include activities such as timely communication of test results1 timely exchange of clinical information to patients and other providers1 and use of remote monitoring or telehealth4 7,,iv7 ,the subcategory of beneficiary engagement1 which shall include activities such as the establishment of care plans for individuals with complex care needs1 beneficiary self-management assessment and training1 and using shared decision-making mechanisms4 7,v7 ,the subcategory of patient safety and practice assessment1 such as through use of clinical or surgical checklists and practice assessments related to maintaining certification4 7,,vi7 ,the subcategory of participation in an alternative payment model 7as defined in section #ahcc7z77#c77;,c774 ,in establishing activities under this clause1 the ,secretary shall give consideration to the circumstances of small practices 7consisting of #ae or fewer professionals7 and practices located in rural areas and in health professional shortage areas 7as designated under section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act74 7iv7 ,meaningful ,,ehr use ,for the performance category described in subparagraph 7,a77iv71 the requirements established for such period under subsection 7o77#b7 for determining whether an eligible professional is a meaningful ,,ehr user4 7,c7 ,additional provisions 7i7 ,emphasizing outcome measures under the quality performance category ,in applying subparagraph 7,b77i71 the ,secretary shall1 as feasible1 emphasize the application of outcome measures4 7ii7 ,application of additional system measures ,the ,secretary may use measures used for a payment system other than for physicians1 such as measures for inpatient hospitals1 for purposes of the performance categories described in clauses 7i7 and 7ii7 of subparagraph 7,a74 ,for purposes of the previous sentence1 the ,secretary may not use measures for hospital outpatient departments1 except in the case of emergency physicians4 7iii7 ,global and population-based measures ,the ,secretary may use global measures1 such as global outcome measures1 and population-based measures for purposes of the performance category described in subparagraph 7,a77i74 7iv7 ,application of measures and activities to non-patient-facing professionals ,in carrying out this paragraph1 with respect to measures and activities specified in subparagraph 7,b7 for performance categories described in subparagraph 7,a71 the ,secretary-- 7,i7 shall give consideration to the circumstances of professional types 7or subcategories of those types determined by practice characteristics7 who typically furnish services that do not involve face-to-face interaction with a patient2 and 7,,ii7 may1 to the extent feasible and appropriate1 take into account such circumstances and apply under this subsection with respect to ,,mips eligible professionals of such professional types or subcategories1 alternative measures or activities that fulfill the goals of the applicable performance category4 ,in carrying out the previous sentence1 the ,secretary shall consult with professionals of such professional types or subcategories4 7v7 ,clinical practice improvement activities 7,i7 ,request for information ,in initially applying subparagraph 7,b77iii71 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 activities4 7,,ii7 ,contract authority for clinical practice improvement activities performance category ,in applying subparagraph 7,b77iii71 the ,secretary may contract with entities to assist the ,secretary in-- 7aa7 identifying activities described in subparagraph 7,b77iii72 7bb7 specifying criteria for such activities2 and 7cc7 determining whether a ,,mips eligible professional meets such criteria4 7,,iii7 ,clinical practice improvement activities defined ,for purposes of this subsection1 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 determines1 when effectively executed1 is likely to result in improved outcomes4 7,d7 ,annual list of quality measures available for ,,mips assessment 7i7 ,in general ,under the ,,mips1 the ,secretary1 through notice and comment rulemaking and subject to the succeeding clauses of this subparagraph1 shall1 with respect to the performance period for a year1 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 period4 ,pursuant to the previous sentence1 the ,secretary shall-- 7,i7 not later than ,november #a of the year prior to the first day of the first performance period under the ,,mips1 establish and publish in the ,federal ,register a final list of quality measures2 and 7,,ii7 not later than ,november #a of the year prior to the first day of each subsequent performance period1 update the final list of quality measures from the previous year 7and publish such updated final list in the ,federal ,register71 by-- 7aa7 removing from such list1 as appropriate1 quality measures1 which may include the removal of measures that are no longer meaningful 7such as measures that are topped out72 7bb7 adding to such list1 as appropriate1 new quality measures2 and 7cc7 determining whether or not quality measures on such list that have undergone substantive changes should be included in the updated list4 7ii7 ,call for quality measures 7,i7 ,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 7i7 and to identify and submit updates to the measures on such list4 ,for purposes of the previous sentence1 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 #ahij7;a74 7,,ii7 ,eligible professional organization defined ,in this subparagraph1 the term eligible professional organization means a professional organization as defined by nationally recognized multispecialty boards of certification or equivalent certification boards4 7iii7 ,requirements ,in selecting quality measures for inclusion in the annual final list under clause 7i71 the ,secretary shall-- 7,i7 provide that1 to the extent practicable1 all quality domains 7as defined in subsection 7s77#a77;,b77 are addressed by such measures2 and 7,,ii7 ensure that such selection is consistent with the process for selection of measures under subsections 7k71 7m71 and 7p77#b74 7iv7 ,peer review ,before including a new measure or a measure described in clause 7i77,,ii77cc7 in the final list of measures published under clause 7i7 for a year1 the ,secretary shall submit for publication in applicable specialty-appropriate peer-reviewed journals such measure and the method for developing and selecting such measure1 including clinical and other data supporting such measure4 7v7 ,measures for inclusion ,the final list of quality measures published under clause 7i7 shall include1 as applicable1 measures under subsections 7k71 7m71 and 7p77#b71 including quality measures from among-- 7,i7 measures endorsed by a consensus-based entity2 7,,ii7 measures developed under subsection 7s72 and 7,,iii7 measures submitted under clause 7ii77,i74 ,any measure selected for inclusion in such list that is not endorsed by a consensus-based entity shall have a focus that is evidence-based4 7vi7 ,exception for qualified clinical data registry measures ,measures used by a qualified clinical data registry under subsection 7m77#c77;,e7 shall not be subject to the requirements under clauses 7i71 7iv71 and 7v74 ,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 ,services4 7vii7 ,exception for existing quality measures ,any quality measure specified by the ,secretary under subsection 7k7 or 7m71 including under subsection 7m77#c77;,e71 and any measure of quality of care established under subsection 7p77#b7 for the reporting period under the respective subsection beginning before the first performance period under the ,,mips-- 7,i7 shall not be subject to the requirements under clause 7i7 7except under items 7aa7 and 7cc7 of subclause 7,,ii7 of such clause7 or to the requirement under clause 7iv72 and 7,,ii7 shall be included in the final list of quality measures published under clause 7i7 unless removed under clause 7i77,,ii77aa74 7viii7 ,consultation with relevant eligible professional organizations and other relevant stakeholders ,relevant eligible professional organizations and other relevant stakeholders1 including ,state and national medical societies1 shall be consulted in carrying out this subparagraph4 7ix7 ,optional application ,the process under section #ahij;,a is not required to apply to the selection of measures under this subparagraph4 7#c7 ,performance standards 7,a7 ,establishment ,under the ,,mips1 the ,secretary shall establish performance standards with respect to measures and activities specified under paragraph 7#b77;,b7 for a performance period 7as established under paragraph 7#d77 for a year4 7,b7 ,considerations in establishing standards ,in establishing such performance standards with respect to measures and activities specified under paragraph 7#b77;,b71 the ,secretary shall consider the following3 7i7 ,historical performance standards4 7ii7 ,improvement4 7iii7 ,the opportunity for continued improvement4 7#d7 ,performance period ,the ,secretary shall establish a performance period 7or periods7 for a year 7beginning with the year described in paragraph 7#a77;,b774 ,such performance period 7or periods7 shall begin and end prior to the beginning of such year and be as close as possible to such year4 ,in this subsection1 such performance period 7or periods7 for a year shall be referred to as the performance period for the year4 7#e7 ,composite performance score 7,a7 ,in general ,subject to the succeeding provisions of this paragraph and taking into account1 as available and applicable1 paragraph 7#a77;,g71 the ,secretary shall develop a methodology for assessing the total performance of each ,,mips eligible professional according to performance standards under paragraph 7#c7 with respect to applicable measures and activities specified in paragraph 7#b77;,b7 with respect to each performance category applicable to such professional for a performance period 7as established under paragraph 7#d77 for a year4 ,using such methodology1 the ,secretary shall provide for a composite assessment 7using a scoring scale of #j to #ajj7 for each such professional for the performance period for such year4 ,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 period4 7,b7 ,incentive to report2 encouraging use of certified ,,ehr technology for reporting quality measures 7i7 ,incentive to report ,under the methodology established under subparagraph 7,a71 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 professional1 the professional shall be treated as achieving the lowest potential score applicable to such measure or activity4 7ii7 ,encouraging use of certified ,,ehr technology and qualified clinical data registries for reporting quality measures ,under the methodology established under subparagraph 7,a71 the ,secretary shall-- 7,i7 encourage ,,mips eligible professionals to report on applicable measures with respect to the performance category described in paragraph 7#b77;,a77i7 through the use of certified ,,ehr technology and qualified clinical data registries2 and 7,,ii7 with respect to a performance period1 with respect to a year1 for which a ,,mips eligible professional reports such measures through the use of such ,,ehr technology1 treat such professional as satisfying the clinical quality measures reporting requirement described in subsection 7o77#b77;,a77iii7 for such year4 7,c7 ,clinical practice improvement activities performance score 7i7 ,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 7b77#h77;,b77i7 with respect to a performance period shall be given the highest potential score for the performance category described in paragraph 7#b77;,a77iii7 for such period4 7ii7 ,,apm participation ,participation by a ,,mips eligible professional in an alternative payment model 7as defined in section #ahcc7z77#c77;,c77 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 7#b77;,a77iii7 for such performance period4 7iii7 ,subcategories ,a ,,mips eligible professional shall not be required to perform activities in each subcategory under paragraph 7#b77;,b77iii7 or participate in an alternative payment model in order to achieve the highest potential score for the performance category described in paragraph 7#b77;,a77iii74 7,d7 ,achievement and improvement 7i7 ,taking into account improvement ,beginning with the second year to which the ,,mips applies1 in addition to the achievement of a ,,mips eligible professional1 if data sufficient to measure improvement is available1 the methodology developed under subparagraph 7,a7-- 7,i7 in the case of the performance score for the performance category described in clauses 7i7 and 7ii7 of paragraph 7#b77;,a71 shall take into account the improvement of the professional2 and 7,,ii7 in the case of performance scores for other performance categories1 may take into account the improvement of the professional4 7ii7 ,assigning higher weight for achievement ,beginning with the fourth year to which the ,,mips applies1 under the methodology developed under subparagraph 7,a71 the ,secretary may assign a higher scoring weight under subparagraph 7,f7 with respect to the achievement of a ,,mips eligible professional than with respect to any improvement of such professional applied under clause 7i7 with respect to a measure1 activity1 or category described in paragraph 7#b74 7,e7 ,weights for the performance categories 7i7 ,in general ,under the methodology developed under subparagraph 7,a71 subject to subparagraph 7,f77i7 and clauses 7ii7 and 7iii71 the composite performance score shall be determined as follows3 7,i7 ,quality 7aa7 ,in general ,subject to item 7bb71 thirty percent of such score shall be based on performance with respect to the category described in clause 7i7 of paragraph 7#b77;,a74 ,in applying the previous sentence1 the ,secretary shall1 as feasible1 encourage the application of outcome measures within such category4 7bb7 ,first #b years ,for the first and second years for which the ,,mips applies to payments1 the percentage applicable under item 7aa7 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 7,,ii77bb7 for the respective year is less than #cj percent4 7,,ii7 ,resource use 7aa7 ,in general ,subject to item 7bb71 thirty percent of such score shall be based on performance with respect to the category described in clause 7ii7 of paragraph 7#b77;,a74 7bb7 ,first #b years ,for the first year for which the ,,mips applies to payments1 not more than #aj percent of such score shall be based on performance with respect to the category described in clause 7ii7 of paragraph 7#b77;,a74 ,for the second year for which the ,,mips applies to payments1 not more than #ae percent of such score shall be based on performance with respect to the category described in clause 7ii7 of paragraph 7#b77;,a74 7,,iii7 ,clinical practice improvement activities ,fifteen percent of such score shall be based on performance with respect to the category described in clause 7iii7 of paragraph 7#b77;,a74 7,,iv7 ,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 7iv7 of paragraph 7#b77;,a74 7ii7 ,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 7as defined in subsection 7o77#e77 who are meaningful ,,ehr users 7as determined under subsection 7o77#b77 is #ge percent or greater1 the ,secretary may reduce the percent applicable under clause 7i77,,iv71 but not below #ae percent4 ,if the ,secretary makes such reduction for a year1 subject to subclauses 7,i77bb7 and 7,,ii77bb7 of clause 7i71 the percentages applicable under one or more of subclauses 7,i71 7,,ii71 and 7,,iii7 of clause 7i7 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 year4 7,f7 ,certain flexibility for weighting performance categories1 measures1 and activities ,under the methodology under subparagraph 7,a71 if there are not sufficient measures and clinical practice improvement activities applicable and available to each type of eligible professional involved1 the ,secretary shall assign different scoring weights 7including a weight of #j7-- 7i7 which may vary from the scoring weights specified in subparagraph 7,e71 for each performance category based on the extent to which the category is applicable to the type of eligible professional involved2 and 7ii7 for each measure and activity specified under paragraph 7#b77;,b7 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 involved4 7,g7 ,resource use ,analysis of the performance category described in paragraph 7#b77;,a77ii7 shall include results from the methodology described in subsection 7r77#e71 as appropriate4 7,h7 ,inclusion of quality measure data from other payers ,in applying subsections 7k71 7m71 and 7p7 with respect to measures described in paragraph 7#b77;,b77i71 analysis of the performance category described in paragraph 7#b77;,a77i7 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 ,b4 7,i7 ,use of voluntary virtual groups for certain assessment purposes 7i7 ,in general ,in the case of ,,mips eligible professionals electing to be a virtual group under clause 7ii7 with respect to a performance period for a year1 for purposes of applying the methodology under subparagraph 7,a7-- 7,i7 the assessment of performance provided under such methodology with respect to the performance categories described in clauses 7i7 and 7ii7 of paragraph 7#b77;,a7 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 period2 and 7,,ii7 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 7,i7 for the performance category and performance period4 7ii7 ,election of practices to be a virtual group ,the ,secretary shall1 in accordance with clause 7iii71 establish and have in place a process to allow an individual ,,mips eligible professional or a group practice consisting of not more than #aj ,,mips eligible professionals to elect1 with respect to a performance period for a year1 for such individual ,,mips eligible professional or all such ,,mips eligible professionals in such group practice1 respectively1 to be a virtual group under this subparagraph with at least one other such individual ,,mips eligible professional or group practice making such an election4 ,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 categories4 7iii7 ,requirements ,the process under clause 7ii7-- 7,i7 shall provide that an election under such clause1 with respect to a performance period1 shall be made before or during the beginning of such performance period and may not be changed during such performance period2 7,,ii7 shall provide that a practice described in such clause1 and each ,,mips eligible professional in such practice1 may elect to be in no more than one virtual group for a performance period2 and 7,,iii7 may provide that a virtual group may be combined at the tax identification number level4 7#f7 ,,mips payments 7,a7 ,,mips adjustment factor ,taking into account paragraph 7#a77;,g71 the ,secretary shall specify a ,,mips adjustment factor for each ,,mips eligible professional for a year4 ,such ,,mips adjustment factor for a ,,mips eligible professional for a year shall be in the form of a percent and shall be determined-- 7i7 by comparing the composite performance score of the eligible professional for such year to the performance threshold established under subparagraph 7,d77i7 for such year2 7ii7 in a manner such that the adjustment factors specified under this subparagraph for a year result in differential payments under this paragraph reflecting that-- 7,i7 ,,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 7iii71 with such professionals having higher composite performance scores receiving higher adjustment factors2 and 7,,ii7 ,,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 7iv71 with such professionals having lower composite performance scores receiving lower adjustment factors2 7iii7 in a manner such that ,,mips eligible professionals with composite scores described in clause 7ii77,i7 for such year1 subject to clauses 7i7 and 7ii7 of subparagraph 7,f71 receive a zero or positive adjustment factor on a linear sliding scale such that an adjustment factor of #j percent is assigned for a score at the performance threshold and an adjustment factor of the applicable percent specified in subparagraph 7,b7 is assigned for a score of #ajj2 and 7iv7 in a manner such that-- 7,i7 subject to subclause 7,,ii71 ,,mips eligible professionals with composite performance scores described in clause 7ii77,,ii7 for such year receive a negative payment adjustment factor on a linear sliding scale such that an adjustment factor of #j percent is assigned for a score at the performance threshold and an adjustment factor of the negative of the applicable percent specified in subparagraph 7,b7 is assigned for a score of #j2 and 7,,ii7 ,,mips eligible professionals with composite performance scores that are equal to or greater than #j1 but not greater than #a_/d of the performance threshold specified under subparagraph 7,d77i7 for such year1 receive a negative payment adjustment factor that is equal to the negative of the applicable percent specified in subparagraph 7,b7 for such year4 7,b7 ,applicable percent defined ,for purposes of this paragraph1 the term applicable percent means-- 7i7 for #bjah1 #d percent2 7ii7 for #bjai1 #e percent2 7iii7 for #bjbj1 #g percent2 and 7iv7 for #bjba and subsequent years1 #i percent4 7,c7 ,additional ,,mips adjustment factors for exceptional performance 7i7 ,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 7,d77ii7 for such year1 in addition to the ,,mips adjustment factor under subparagraph 7,a7 for the eligible professional for such year1 subject to the availability of funds under clause 7ii71 the ,secretary shall specify an additional positive ,,mips adjustment factor for such professional and year4 ,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 factors4 7ii7 ,additional funding pool ,for #bjah and each subsequent year through #bjbc1 there is appropriated from the ,federal ,supplementary ,medical ,insurance ,trust ,fund #ejj1jjj1jjj for ,,mips payments under this paragraph resulting from the application of the additional ,,mips adjustment factors under clause 7i74 7,d7 ,establishment of performance thresholds 7i7 ,performance threshold ,for each year of the ,,mips1 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 7,a7 that are positive1 negative1 and zero4 ,such performance threshold for a year shall be the mean or median 7as selected by the ,secretary7 of the composite performance scores for all ,,mips eligible professionals with respect to a prior period specified by the ,secretary4 ,the ,secretary may reassess the selection under the previous sentence every #c years4 7ii7 ,additional performance threshold for exceptional performance ,in addition to the performance threshold under clause 7i71 for each year of the ,,mips1 the ,secretary shall compute an additional performance threshold for purposes of determining the additional ,,mips adjustment factors under subparagraph 7,c77i74 ,for each such year1 the ,secretary shall apply either of the following methods for computing such additional performance threshold for such a year3 7,i7 ,the threshold shall be the score that is equal to the #beth percentile of the range of possible composite performance scores above the performance threshold with respect to the prior period described in clause 7i74 7,,ii7 ,the threshold shall be the score that is equal to the #beth 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 7i74 7iii7 ,special rule for initial #b years ,with respect to each of the first two years to which the ,,mips applies1 the ,secretary shall1 prior to the performance period for such years1 establish a performance threshold for purposes of determining ,,mips adjustment factors under subparagraph 7,a7 and a threshold for purposes of determining additional ,,mips adjustment factors under subparagraph 7,c77i74 ,each such performance threshold shall-- 7,i7 be based on a period prior to such performance periods2 and 7,,ii7 take into account-- 7aa7 data available with respect to performance on measures and activities that may be used under the performance categories under subparagraph 7#b77;,b72 and 7bb7 other factors determined appropriate by the ,secretary4 7,e7 ,application of ,,mips adjustment factors ,in the case of items and services furnished by a ,,mips eligible professional during a year 7beginning with #bjah71 the amount otherwise paid under this part with respect to such items and services and ,,mips eligible professional for such year1 shall be multiplied by-- 7i7 #a1 plus 7ii7 the sum of-- 7,i7 the ,,mips adjustment factor determined under subparagraph 7,a7 divided by #ajj1 and 7,,ii7 as applicable1 the additional ,,mips adjustment factor determined under subparagraph 7,c77i7 divided by #ajj4 7,f7 ,aggregate application of ,,mips adjustment factors 7i7 ,application of scaling factor 7,i7 ,in general ,with respect to positive ,,mips adjustment factors under subparagraph 7,a77ii77,i7 for eligible professionals whose composite performance score is above the performance threshold under subparagraph 7,d77i7 for such year1 subject to subclause 7,,ii71 the ,secretary shall increase or decrease such adjustment factors by a scaling factor in order to ensure that the budget neutrality requirement of clause 7ii7 is met4 7,,ii7 ,scaling factor limit ,in no case may be the scaling factor applied under this clause exceed #c4j4 7ii7 ,budget neutrality requirement 7,i7 ,in general ,subject to clause 7iii71 the ,secretary shall ensure that the estimated amount described in subclause 7,,ii7 for a year is equal to the estimated amount described in subclause 7,,iii7 for such year4 7,,ii7 ,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 7,a7 7after application of the scaling factor described in clause 7i77 to ,,mips eligible professionals whose composite performance score for a year is above the performance threshold under subparagraph 7,d77i7 for such year4 7,,iii7 ,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 7,a7 to ,,mips eligible professionals whose composite performance score for a year is below the performance threshold under subparagraph 7,d77i7 for such year4 7iii7 ,exceptions 7,i7 ,in the case that all ,,mips eligible professionals receive composite performance scores for a year that are below the performance threshold under subparagraph 7,d77i7 for such year1 the negative ,,mips adjustment factors under subparagraph 7,a7 shall apply with respect to such ,,mips eligible professionals and the budget neutrality requirement of clause 7ii7 shall not apply for such year4 7,,ii7 ,in the case that1 with respect to a year1 the application of clause 7i7 results in a scaling factor equal to the maximum scaling factor specified in clause 7i77,,ii71 such scaling factor shall apply and the budget neutrality requirement of clause 7ii7 shall not apply for such year4 7iv7 ,additional incentive payment adjustments ,in specifying the ,,mips additional adjustment factors under subparagraph 7,c77i7 for each applicable ,,mips eligible professional for a year1 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 7as estimated by the ,secretary7 to the additional funding pool amount for such year under subparagraph 7,c77ii74 7#g7 ,announcement of result of adjustments ,under the ,,mips1 the ,secretary shall1 not later than #cj days prior to ,january #a of the year involved1 make available to ,,mips eligible professionals the ,,mips adjustment factor 7and1 as applicable1 the additional ,,mips adjustment factor7 under paragraph 7#f7 applicable to the eligible professional for items and services furnished by the professional for such year4 ,the ,secretary may include such information in the confidential feedback under paragraph 7#ab74 7#h7 ,no effect in subsequent years ,the ,,mips adjustment factors and additional ,,mips adjustment factors under paragraph 7#f7 shall apply only with respect to the year involved1 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 year4 7#i7 ,public reporting 7,a7 ,in general ,the ,secretary shall1 in an easily understandable format1 make available on the ,physician ,compare ,internet website of the ,centers for ,medicare ,medicaid ,services the following3 7i7 ,information regarding the performance of ,,mips eligible professionals under the ,,mips1 which-- 7,i7 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 category2 and 7,,ii7 may include the performance of each such ,,mips eligible professional with respect to each measure or activity specified in paragraph 7#b77;,b74 7ii7 ,the names of eligible professionals in eligible alternative payment models 7as defined in section #ahcc7z77#c77;,d77 and1 to the extent feasible1 the names of such eligible alternative payment models and performance of such models4 7,b7 ,disclosure ,the information made available under this paragraph shall indicate1 where appropriate1 that publicized information may not be representative of the eligible professional's entire patient population1 the variety of services furnished by the eligible professional1 or the health conditions of individuals treated4 7,c7 ,opportunity to review and submit corrections ,the ,secretary shall provide for an opportunity for a professional described in subparagraph 7,a7 to review1 and submit corrections for1 the information to be made public with respect to the professional under such subparagraph prior to such information being made public4 7,d7 ,aggregate information ,the ,secretary shall periodically post on the ,physician ,compare ,internet website aggregate information on the ,,mips1 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 category4 7#aj7 ,consultation ,the ,secretary shall consult with stakeholders in carrying out the ,,mips1 including for the identification of measures and activities under paragraph 7#b77;,b7 and the methodologies developed under paragraphs 7#e77;,a7 and 7#f7 and regarding the use of qualified clinical data registries4 ,such consultation shall include the use of a request for information or other mechanisms determined appropriate4 7#aa7 ,technical assistance to small practices and practices in health professional shortage areas 7,a7 ,in general ,the ,secretary shall enter into contracts or agreements with appropriate entities 7such as quality improvement organizations1 regional extension centers 7as described in section #cjab7;c7 of the ,public ,health ,service ,act71 or regional health collaboratives7 to offer guidance and assistance to ,,mips eligible professionals in practices of #ae or fewer professionals 7with priority given to such practices located in rural areas1 health professional shortage areas 7as designated under in section #ccb7;a77#a77;,a7 of such ,act71 and medically underserved areas1 and practices with low composite scores7 with respect to-- 7i7 the performance categories described in clauses 7i7 through 7iv7 of paragraph 7#b77;,a72 or 7ii7 how to transition to the implementation of and participation in an alternative payment model as described in section #ahcc7z77#c77;,c74 7,b7 ,funding for implementation 7i7 ,in general ,for purposes of implementing subparagraph 7,a71 the ,secretary shall provide for the transfer from the ,federal ,supplementary ,medical ,insurance ,trust ,fund established under section #ahda to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account of #dj1jjj1jjj for each of fiscal years #bjae through #bjai4 ,amounts transferred under this subparagraph for a fiscal year shall be available until expended4 7ii7 ,technical assistance ,of the amounts transferred pursuant to clause 7i7 for each of fiscal years #bjae through #bjai1 not less than #aj1jjj1jjj shall be made available for each such year for technical assistance to small practices in health professional shortage areas 7as so designated7 and medically underserved areas4 7#ab7 ,feedback and information to improve performance 7,a7 ,performance feedback 7i7 ,in general ,beginning ,july #a1 #bjaf1 the ,secretary-- 7,i7 shall make available timely 7such as quarterly7 confidential feedback to ,,mips eligible professionals on the performance of such professionals with respect to the performance categories under clauses 7i7 and 7ii7 of paragraph 7#b77;,a72 and 7,,ii7 may make available confidential feedback to each such professional on the performance of such professional with respect to the performance categories under clauses 7iii7 and 7iv7 of such paragraph4 7ii7 ,mechanisms ,the ,secretary may use one or more mechanisms to make feedback available under clause 7i71 which may include use of a web-based portal or other mechanisms determined appropriate by the ,secretary4 ,with respect to the performance category described in paragraph 7#b77;,a77i71 feedback under this subparagraph shall1 to the extent an eligible professional chooses to participate in a data registry for purposes of this subsection 7including registries under subsections 7k7 and 7m771 be provided based on performance on quality measures reported through the use of such registries4 ,with respect to any other performance category described in paragraph 7#b77;,a71 the ,secretary shall encourage provision of feedback through qualified clinical data registries as described in subsection 7m77#c77;,e774 7iii7 ,use of data ,for purposes of clause 7i71 the ,secretary may use data1 with respect to a ,,mips eligible professional1 from periods prior to the current performance period and may use rolling periods in order to make illustrative calculations about the performance of such professional4 7iv7 ,disclosure exemption ,feedback made available under this subparagraph shall be exempt from disclosure under section #eeb of title #e1 ,united ,states ,code4 7v7 ,receipt of information ,the ,secretary may use the mechanisms established under clause 7ii7 to receive information from professionals1 such as information with respect to this subsection4 7,b7 ,additional information 7i7 ,in general ,beginning ,july #a1 #bjag1 the ,secretary shall make available to each ,,mips eligible professional information1 with respect to individuals who are patients of such ,,mips eligible professional1 about items and services for which payment is made under this title that are furnished to such individuals by other suppliers and providers of services1 which may include information described in clause 7ii74 ,such information may be made available under the previous sentence to such ,,mips eligible professionals by mechanisms determined appropriate by the ,secretary1 which may include use of a web-based portal4 ,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 #ahii1 including a beneficiary opt-out4 7ii7 ,type of information ,for purposes of clause 7i71 the information described in this clause1 is the following3 7,i7 ,with respect to selected items and services 7as determined appropriate by the ,secretary7 for which payment is made under this title and that are furnished to individuals1 who are patients of a ,,mips eligible professional1 by another supplier or provider of services during the most recent period for which data are available 7such as the most recent three-month period71 such as the name of such providers furnishing such items and services to such patients during such period1 the types of such items and services so furnished1 and the dates such items and services were so furnished4 7,,ii7 ,historical data1 such as averages and other measures of the distribution if appropriate1 of the total1 and components of1 allowed charges 7and other figures as determined appropriate by the ,secretary74 7#ac7 ,review 7,a7 ,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 year4 ,the results of a review conducted pursuant to the previous sentence shall not be taken into account for purposes of paragraph 7#f7 with respect to a year 7other than with respect to the calculation of such eligible professional's ,,mips adjustment factor for such year or additional ,,mips adjustment factor for such year7 after the factors determined in subparagraph 7,a7 and subparagraph 7,c7 of such paragraph have been determined for such year4 7,b7 ,limitation ,except as provided for in subparagraph 7,a71 there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise of the following3 7i7 ,the methodology used to determine the amount of the ,,mips adjustment factor under paragraph 7#f77;,a7 and the amount of the additional ,,mips adjustment factor under paragraph 7#f77;,c77i7 and the determination of such amounts4 7ii7 ,the establishment of the performance standards under paragraph 7#c7 and the performance period under paragraph 7#d74 7iii7 ,the identification of measures and activities specified under paragraph 7#b77;,b7 and information made public or posted on the ,physician ,compare ,internet website of the ,centers for ,medicare ,medicaid ,services under paragraph 7#i74 7iv7 ,the methodology developed under paragraph 7#e7 that is used to calculate performance scores and the calculation of such scores1 including the weighting of measures and activities under such methodology4 4 7#b7 ,,gao reports 7,a7 ,evaluation of eligible professional ,,mips ,not later than ,october #a1 #bjai1 and ,october #a1 #bjbb1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report evaluating the eligible professional ,merit-based ,incentive ,payment ,system under subsection 7q7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as added by paragraph 7#a74 ,such report shall-- 7i7 examine the distribution of the composite performance scores and ,,mips adjustment factors 7and additional ,,mips adjustment factors7 for ,,mips eligible professionals 7as defined in subsection 7q77#a77;c7 of such section7 under such program1 and patterns relating to such scores and adjustment factors1 including based on type of provider1 practice size1 geographic location1 and patient mix2 7ii7 provide recommendations for improving such program2 7iii7 evaluate the impact of technical assistance funding under section #ahdh7q77#aa7 of the ,social ,security ,act1 as added by paragraph 7#a71 on the ability of professionals to improve within such program or successfully transition to an alternative payment model 7as defined in section #ahcc7z77#c7 of the ,social ,security ,act1 as added by subsection 7e771 with priority for such evaluation given to practices located in rural areas1 health professional shortage areas 7as designated in section #ccb7;a77#a77;a7 of the ,public ,health ,service ,act71 and medically underserved areas2 and 7iv7 provide recommendations for optimizing the use of such technical assistance funds4 7,b7 ,study to examine alignment of quality measures used in public and private programs 7i7 ,in general ,not later than #ah months after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report that-- 7,i7 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 ,act1 the ,medicare ,advantage program under part ,c of such title1 selected ,state ,medicaid programs under title ,,xix of such ,act1 and private payer arrangements2 and 7,,ii7 makes recommendations on how to reduce the administrative burden involved in applying such quality measures4 7ii7 ,requirements ,the report under clause 7i7 shall-- 7,i7 consider those measures applicable to individuals entitled to1 or enrolled for1 benefits under such part ,a1 or enrolled under such part ,b and individuals under the age of #fe2 and 7,,ii7 focus on those measures that comprise the most significant component of the quality performance category of the eligible professional ,,mips incentive program under subsection 7q7 of section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as added by paragraph 7#a74 7,c7 ,study on role of independent risk managers ,not later than ,january #a1 #bjaf1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report examining whether entities that pool financial risk for physician practices1 such as independent risk managers1 can play a role in supporting physician practices1 particularly small physician practices1 in assuming financial risk for the treatment of patients4 ,such report shall examine barriers that small physician practices currently face in assuming financial risk for treating patients1 the types of risk management entities that could assist physician practices in participating in two-sided risk payment models1 and how such entities could assist with risk management and with quality improvement activities4 ,such report shall also include an analysis of any existing legal barriers to such arrangements4 7,d7 ,study to examine rural and health professional shortage area alternative payment models ,not later than ,october #a1 #bjbj1 and ,october #a1 #bjbb1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report that examines the transition of professionals in rural areas1 health professional shortage areas 7as designated in section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act71 or medically underserved areas to an alternative payment model 7as defined in section #ahcc7z77#c7 of the ,social ,security ,act1 as added by subsection 7e774 ,such report shall make recommendations for removing administrative barriers to practices1 including small practices consisting of #ae or fewer professionals1 in rural areas1 health professional shortage areas1 and medically underserved areas to participation in such models4 7#c7 ,funding for implementation ,for purposes of implementing the provisions of and the amendments made by this section1 the ,secretary of ,health and ,human ,services shall provide for the transfer of #hj1jjj1jjj from the ,supplementary ,medical ,insurance ,trust ,fund established under section #ahda of the ,social ,security ,act 7#db ,u4,s4,c4 #aciet7 to the ,centers for ,medicare ,medicaid ,program ,management ,account for each of the fiscal years #bjad through #bjah4 ,amounts transferred under this paragraph shall be available until expended4 7d7 ,improving quality reporting for composite scores 7#a7 ,changes for group reporting option 7,a7 ,in general ,section #ahdh7m77#c77;,c77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,c77ii77 is amended by inserting and1 for #bjae and subsequent years1 may provide after shall provide4 7,b7 ,clarification of qualified clinical data registry reporting to group practices ,section #ahdh7m77#c77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,d77 is amended by inserting and1 for #bjae and subsequent years1 subparagraph 7,a7 or 7,c7 after subparagraph 7,a74 7#b7 ,changes for multiple reporting periods and alternative criteria for satisfactory reporting ,section #ahdh7m77#e77;,f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#e77;,f77 is amended-- 7,a7 by striking and subsequent years and inserting through reporting periods occurring in #bjad2 and 7,b7 by inserting and1 for reporting periods occurring in #bjae and subsequent years1 the ,secretary may establish following shall establish4 7#c7 ,physician feedback program reports succeeded by reports under ,,mips ,section #ahdh7n7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7n77 is amended by adding at the end the following new paragraph3 7#aa7 ,reports ending with #bjaf ,reports under the ,program shall not be provided after ,december #ca1 #bjaf4 ,see subsection 7q77#ab7 for reports under the eligible professionals ,merit-based ,incentive ,payment ,system4 4 7#d7 ,coordination with satisfying meaningful ,,ehr use clinical quality measure reporting requirement ,section #ahdh7o77#b77;,a77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77;,a77iii77 is amended by inserting and subsection 7q77#e77;,b77ii77,,ii7 after ,subject to subparagraph 7,b77ii74 7e7 ,promoting alternative payment models 7#a7 ,increasing transparency of physician focused payment models ,section #ahfh of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ee7 is amended by adding at the end the following new subsection3 7c7 ,physician focused payment models 7#a7 ,technical advisory committee 7,a7 ,establishment ,there is established an ad hoc committee to be known as the ,payment ,model ,technical ,advisory ,committee 7referred to in this subsection as the ,committee74 7,b7 ,membership 7i7 ,number and appointment ,the ,committee shall be composed of #aa members appointed by the ,comptroller ,general of the ,united ,states4 7ii7 ,qualifications ,the membership of the ,committee shall include individuals with national recognition for their expertise in payment models and related delivery of care4 ,no more than #e members of the ,committee shall be providers of services or suppliers1 or representatives of providers of services or suppliers4 7iii7 ,prohibition on federal employment ,a member of the ,committee shall not be an employee of the ,federal ,government4 7iv7 ,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 members4 ,members of the ,committee shall be treated as employees of ,congress for purposes of applying title ,i of the ,ethics in ,government ,act of #aigh 7,public ,law #ie-eba74 7v7 ,date of initial appointments ,the initial appointments of members of the ,committee shall be made by not later than #ahj days after the date of enactment of this subsection4 7,c7 ,term2 vacancies 7i7 ,term ,the terms of members of the ,committee shall be for #c years except that the ,comptroller ,general shall designate staggered terms for the members first appointed4 7ii7 ,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 term4 ,a member may serve after the expiration of that member's term until a successor has taken office4 ,a vacancy in the ,committee shall be filled in the manner in which the original appointment was made4 7,d7 ,duties ,the ,committee shall meet1 as needed1 to provide comments and recommendations to the ,secretary1 as described in paragraph 7#b77;,c71 on physician-focused payment models4 7,e7 ,compensation of members 7i7 ,in general ,except as provided in clause 7ii71 a member of the ,committee shall serve without compensation4 7ii7 ,travel expenses ,a member of the ,committee shall be allowed travel expenses1 including per diem in lieu of subsistence1 at rates authorized for an employee of an agency under subchapter ,i of chapter #eg of title #e1 ,united ,states ,code1 while away from the home or regular place of business of the member in the performance of the duties of the ,committee4 7,f7 ,operational and technical support 7i7 ,in general ,the ,assistant ,secretary for ,planning and ,evaluation shall provide technical and operational support for the ,committee1 which may be by use of a contractor4 ,the ,office of the ,actuary of the ,centers for ,medicare ,medicaid ,services shall provide to the ,committee actuarial assistance as needed4 7ii7 ,funding ,the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 such amounts as are necessary to carry out clause 7i7 7not to exceed #e1jjj1jjj7 for fiscal year #bjad and each subsequent fiscal year4 ,any amounts transferred under the preceding sentence for a fiscal year shall remain available until expended4 7,g7 ,application ,section #ad of the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 ,app47 shall not apply to the ,committee4 7#b7 ,criteria and process for submission and review of physician-focused payment models 7,a7 ,criteria for assessing physician-focused payment models 7i7 ,rulemaking ,not later than ,november #a1 #bjae1 the ,secretary shall1 through notice and comment rulemaking1 following a request for information1 establish criteria for physician-focused payment models1 including models for specialist physicians1 that could be used by the ,committee for making comments and recommendations pursuant to paragraph 7#a77;,d74 7ii7 ,med,p,a,c submission of comments ,during the comment period for the proposed rule described in clause 7i71 the ,medicare ,payment ,advisory ,commission may submit comments to the ,secretary on the proposed criteria under such clause4 7iii7 ,updating ,the ,secretary may update the criteria established under this subparagraph through rulemaking4 7,b7 ,stakeholder submission of physician focused payment models ,on an ongoing basis1 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 7,a74 7,c7 ,,tac review of models submitted ,the ,committee shall1 on a periodic basis1 review models submitted under subparagraph 7,b71 prepare comments and recommendations regarding whether such models meet the criteria described in subparagraph 7,a71 and submit such comments and recommendations to the ,secretary4 7,d7 ,secretary review and response ,the ,secretary shall review the comments and recommendations submitted by the ,committee under subparagraph 7,c7 and post a detailed response to such comments and recommendations on the ,internet ,website of the ,centers for ,medicare ,medicaid ,services4 7#c7 ,rule of construction ,nothing in this subsection shall be construed to impact the development or testing of models under this title or titles ,,xi1 ,,xix1 or ,,xxi4 4 7#b7 ,incentive payments for participation in eligible alternative payment models ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended by adding at the end the following new subsection3 7z7 ,incentive payments for participation in eligible alternative payment models 7#a7 ,payment incentive 7,a7 ,in general ,in the case of covered professional services furnished by an eligible professional during a year that is in the period beginning with #bjah and ending with #bjbc and for which the professional is a qualifying ,,apm participant1 in addition to the amount of payment that would otherwise be made for such covered professional services under this part for such year1 there also shall be paid to such professional an amount equal to #e percent of the payment amount for the covered professional services under this part for the preceding year4 ,for purposes of the previous sentence1 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 year4 ,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 participant4 7,b7 ,form of payment ,payments under this subsection shall be made in a lump sum1 on an annual basis1 as soon as practicable4 7,c7 ,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 model4 7,d7 ,coordination ,the amount of the additional payment for an item or service under this subsection or subsection 7m7 shall be determined without regard to any additional payment for the item or service under subsection 7m7 and this subsection1 respectively4 ,the amount of the additional payment for an item or service under this subsection or subsection 7x7 shall be determined without regard to any additional payment for the item or service under subsection 7x7 and this subsection1 respectively4 ,the amount of the additional payment for an item or service under this subsection or subsection 7y7 shall be determined without regard to any additional payment for the item or service under subsection 7y7 and this subsection1 respectively4 7#b7 ,qualifying ,,apm participant ,for purposes of this subsection1 the term qualifying ,,apm participant means the following3 7,a7 #bjah and #bjai ,with respect to #bjah and #bjai1 an eligible professional for whom the ,secretary determines that at least #be percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available 7which may be less than a year7 were attributable to such services furnished under this part through an entity that participates in an eligible alternative payment model with respect to such services4 7,b7 #bjbj and #bjba ,with respect to #bjbj and #bjba1 an eligible professional described in either of the following clauses3 7i7 ,medicare revenue threshold option ,an eligible professional for whom the ,secretary determines that at least #ej percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available 7which may be less than a year7 were attributable to such services furnished under this part through an entity that participates in an eligible alternative payment model with respect to such services4 7ii7 ,combination all-payer and ,medicare revenue threshold option ,an eligible professional-- 7,i7 for whom the ,secretary determines1 with respect to items and services furnished by such professional during the most recent period for which data are available 7which may be less than a year71 that at least #ej percent of the sum of-- 7aa7 payments described in clause 7i72 and 7bb7 all other payments1 regardless of payer 7other than payments made by the ,secretary of ,defense or the ,secretary of ,veterans ,affairs under chapter #ee of title #aj1 ,united ,states ,code1 or title #ch1 ,united ,states ,code1 or any other provision of law1 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 title71 meet the requirement described in clause 7iii77,i7 with respect to payments described in item 7aa7 and meet the requirement described in clause 7iii77,,ii7 with respect to payments described in item 7bb72 7,,ii7 for whom the ,secretary determines at least #be percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available 7which may be less than a year7 were attributable to such services furnished under this part through an entity that participates in an eligible alternative payment model with respect to such services2 and 7,,iii7 who provides to the ,secretary such information as is necessary for the ,secretary to make a determination under subclause 7,i71 with respect to such professional4 7iii7 ,requirement ,for purposes of clause 7ii77,i7-- 7,i7 the requirement described in this subclause1 with respect to payments described in item 7aa7 of such clause1 is that such payments are made under an eligible alternative payment model2 and 7,,ii7 the requirement described in this subclause1 with respect to payments described in item 7bb7 of such clause1 is that such payments are made under an arrangement in which-- 7aa7 quality measures comparable to measures under the performance category described in section #ahdh7q77#b77;,b77i7 apply2 7bb7 certified ,,ehr technology is used2 and 7cc7 the eligible professional 7,,aa7 bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures2 or 7,,bb7 is a medical home 7with respect to beneficiaries under title ,,xix7 that meets criteria comparable to medical homes expanded under section #aaae;,a7c74 7,c7 ,beginning in #bjbb ,with respect to #bjbb and each subsequent year1 an eligible professional described in either of the following clauses3 7i7 ,medicare revenue threshold option ,an eligible professional for whom the ,secretary determines that at least #ge percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available 7which may be less than a year7 were attributable to such services furnished under this part through an entity that participates in an eligible alternative payment model with respect to such services4 7ii7 ,combination all-payer and ,medicare revenue threshold option ,an eligible professional-- 7,i7 for whom the ,secretary determines1 with respect to items and services furnished by such professional during the most recent period for which data are available 7which may be less than a year71 that at least #ge percent of the sum of-- 7aa7 payments described in clause 7i72 and 7bb7 all other payments1 regardless of payer 7other than payments made by the ,secretary of ,defense or the ,secretary of ,veterans ,affairs under chapter #ee of title #aj1 ,united ,states ,code1 or title #ch1 ,united ,states ,code1 or any other provision of law1 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 title71 meet the requirement described in clause 7iii77,i7 with respect to payments described in item 7aa7 and meet the requirement described in clause 7iii77,,ii7 with respect to payments described in item 7bb72 7,,ii7 for whom the ,secretary determines at least #be percent of payments under this part for covered professional services furnished by such professional during the most recent period for which data are available 7which may be less than a year7 were attributable to such services furnished under this part through an entity that participates in an eligible alternative payment model with respect to such services2 and 7,,iii7 who provides to the ,secretary such information as is necessary for the ,secretary to make a determination under subclause 7,i71 with respect to such professional4 7iii7 ,requirement ,for purposes of clause 7ii77,i7-- 7,i7 the requirement described in this subclause1 with respect to payments described in item 7aa7 of such clause1 is that such payments are made under an eligible alternative payment model2 and 7,,ii7 the requirement described in this subclause1 with respect to payments described in item 7bb7 of such clause1 is that such payments are made under an arrangement in which-- 7aa7 quality measures comparable to measures under the performance category described in section #ahdh7q77#b77;,b77i7 apply2 7bb7 certified ,,ehr technology is used2 and 7cc7 the eligible professional 7,,aa7 bears more than nominal financial risk if actual aggregate expenditures exceeds expected aggregate expenditures2 or 7,,bb7 is a medical home 7with respect to beneficiaries under title ,,xix7 that meets criteria comparable to medical homes expanded under section #aaae;,a7c74 7#c7 ,additional definitions ,in this subsection3 7,a7 ,covered professional services ,the term covered professional services has the meaning given that term in section #ahdh7k77#c77;,a74 7,b7 ,eligible professional ,the term eligible professional has the meaning given that term in section #ahdh7k77#c77;,b74 7,c7 ,alternative payment model 7,,apm7 ,the term alternative payment model means any of the following3 7i7 ,a model under section #aaae;,a 7other than a health care innovation award74 7ii7 ,the shared savings program under section #ahii4 7iii7 ,a demonstration under section #ahff;,c4 7iv7 ,a demonstration required by ,federal law4 7,d7 ,eligible alternative payment model 7,,apm7 7i7 ,in general ,the term eligible alternative payment model means1 with respect to a year1 an alternative payment model-- 7,i7 that requires use of certified ,,ehr technology 7as defined in subsection 7o77#d772 7,,ii7 that provides for payment for covered professional services based on quality measures comparable to measures under the performance category described in section #ahdh7q77#b77;,b77i72 and 7,,iii7 that satisfies the requirement described in clause 7ii74 7ii7 ,additional requirement ,for purposes of clause 7i77,,iii71 the requirement described in this clause1 with respect to a year and an alternative payment model1 is that the alternative payment model-- 7,i7 is one in which one or more entities bear financial risk for monetary losses under such model that are in excess of a nominal amount2 or 7,,ii7 is a medical home expanded under section #aaae;,a7c74 7#d7 ,limitation ,there shall be no administrative or judicial review under section #ahfi1 #ahgh1 or otherwise1 of the following3 7,a7 ,the determination that an eligible professional is a qualifying ,,apm participant under paragraph 7#b7 and the determination that an alternative payment model is an eligible alternative payment model under paragraph 7#c77;,d74 7,b7 ,the determination of the amount of the #e percent payment incentive under paragraph 7#a77;,a71 including any estimation as part of such determination4 4 7#c7 ,coordination conforming amendments ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is further amended-- 7,a7 in subsection 7x77#c71 by adding at the end the following new sentence3 ,the amount of the additional payment for a service under this subsection and subsection 7z7 shall be determined without regard to any additional payment for the service under subsection 7z7 and this subsection1 respectively42 and 7,b7 in subsection 7y77#c71 by adding at the end the following new sentence3 ,the amount of the additional payment for a service under this subsection and subsection 7z7 shall be determined without regard to any additional payment for the service under subsection 7z7 and this subsection1 respectively44 7#d7 ,encouraging development and testing of certain models ,section #aaae;,a7b77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is amended-- 7,a7 in subparagraph 7,b71 by adding at the end the following new clauses3 7xxi7 ,focusing primarily on physicians' services 7as defined in section #ahdh7;j77#c77 furnished by physicians who are not primary care practitioners4 7xxii7 ,focusing on practices of #ae or fewer professionals4 7xxiii7 ,focusing on risk-based models for small physician practices which may involve two-sided risk and prospective patient assignment1 and which examine risk-adjusted decreases in mortality rates1 hospital readmissions rates1 and other relevant and appropriate clinical measures4 7xxiv7 ,focusing primarily on title ,,xix1 working in conjunction with the ,center for ,medicaid and ,,chip ,services4 2 and 7,b7 in subparagraph 7,c77viii71 by striking other public sector or private sector payers and inserting other public sector payers1 private sector payers1 or ,statewide payment models4 7#e7 ,construction regarding telehealth services ,nothing in the provisions of1 or amendments made by1 this ,act shall be construed as precluding an alternative payment model or a qualifying ,,apm participant 7as those terms are defined in section #ahcc7z7 of the ,social ,security ,act1 as added by paragraph 7#a77 from furnishing a telehealth service for which payment is not made under section #ahcd7m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m774 7#f7 ,integrating ,medicare ,advantage alternative payment models ,not later than ,july #a1 #bjae1 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 system4 ,the study shall include the feasibility of including a value-based modifier and whether such modifier should be budget neutral4 7#g7 ,study and report on fraud related to alternative payment models under the ,medicare program 7,a7 ,study ,the ,secretary of ,health and ,human ,services1 in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 shall conduct a study that-- 7i7 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 7as defined in section #ahcc7z77#c77;,c7 of such ,act 7#db ,u4,s4,c4 #aciel7z77#c77;,c7772 7ii7 identifies aspects of such alternative payment models that are vulnerable to fraudulent activity2 and 7iii7 examines the implications of waivers to such laws granted in support of such alternative payment models1 including under any potential expansion of such models4 7,b7 ,report ,not later than #b years after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report containing the results of the study conducted under subparagraph 7,a74 ,such report shall include recommendations for actions to be taken to reduce the vulnerability of such alternative payment models to fraudulent activity4 ,such report also shall include1 as appropriate1 recommendations of the ,inspector ,general for changes in ,federal fraud prevention laws to reduce such vulnerability4 7f7 ,improving payment accuracy 7#a7 ,studies and reports of effect of certain information on quality and resource use 7,a7 ,study using existing ,medicare data 7i7 ,study ,the ,secretary of ,health and ,human ,services 7in this subsection referred to as the ,secretary7 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 7such as to recognize that less healthy individuals may require more intensive interventions74 ,the study shall use information collected on such individuals in carrying out such program1 such as urban and rural location1 eligibility for ,medicaid 7recognizing and accounting for varying ,medicaid eligibility across ,states71 and eligibility for benefits under the supplemental security income 7,,ssi7 program4 ,the ,secretary shall carry out this paragraph acting through the ,assistant ,secretary for ,planning and ,evaluation4 7ii7 ,report ,not later than #b years after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report on the study conducted under clause 7i74 7,b7 ,study using other data 7i7 ,study ,the ,secretary shall conduct a study that examines the impact of risk factors1 such as those described in section #ahdh7p77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7p77#c771 race1 health literacy1 limited ,english proficiency 7,,lep71 and patient activation1 on quality and resource use outcome measures under the ,medicare program 7such as to recognize that less healthy individuals may require more intensive interventions74 ,in conducting such study the ,secretary may use existing ,federal data and collect such additional data as may be necessary to complete the study4 7ii7 ,report ,not later than #e years after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report on the study conducted under clause 7i74 7,c7 ,examination of data in conducting studies ,in conducting the studies under subparagraphs 7,a7 and 7,b71 the ,secretary shall examine what non-,medicare data sets1 such as data from the ,american ,community ,survey 7,,acs71 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 program4 7,d7 ,recommendations to account for information in payment adjustment mechanisms ,if the studies conducted under subparagraphs 7,a7 and 7,b7 find a relationship between the factors examined in the studies and quality and resource use outcome measures1 then the ,secretary shall also provide recommendations for how the ,centers for ,medicare ,medicaid ,services should-- 7i7 obtain access to the necessary data 7if such data is not already being collected7 on such factors1 including recommendations on how to address barriers to the ,centers in accessing such data2 and 7ii7 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 #ahdh7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77 and1 as the ,secretary determines appropriate1 other similar provisions of title ,,xviii of such ,act4 7,e7 ,funding ,there are hereby appropriated from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda of the ,social ,security ,act to the ,secretary to carry out this paragraph #f1jjj1jjj1 to remain available until expended4 7#b7 ,,cms activities 7,a7 ,hierarchal ,condition ,category 7,,hcc7 improvement ,taking into account the relevant studies conducted and recommendations made in reports under paragraph 7#a71 the ,secretary1 on an ongoing basis1 shall1 as the ,secretary determines appropriate1 estimate how an individual's health status and other risk factors affect quality and resource use outcome measures and1 as feasible1 shall incorporate information from quality and resource use outcome measurement 7including care episode and patient condition groups7 into provisions of title ,,xviii of the ,social ,security ,act that are similar to the eligible professional ,merit-based ,incentive ,payment ,system under section #ahdh7q7 of such ,act4 7,b7 ,accounting for other factors in payment adjustment mechanisms 7i7 ,in general ,taking into account the studies conducted and recommendations made in reports under paragraph 7#a7 and other information as appropriate1 the ,secretary shall1 as the ,secretary determines appropriate1 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 #ahdh7q7 of such ,act4 7ii7 ,accessing data ,the ,secretary shall collect or otherwise obtain access to the data necessary to carry out this paragraph through existing and new data sources4 7iii7 ,periodic analyses ,the ,secretary shall carry out periodic analyses1 at least every #c years1 based on the factors referred to in clause 7i7 so as to monitor changes in possible relationships4 7,c7 ,funding ,there are hereby appropriated from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda 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 #ahdh7q7 of such ,act #aj1jjj1jjj1 to remain available until expended4 7#c7 ,strategic plan for accessing race and ethnicity data ,not later than #ah months after the date of the enactment of this ,act1 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 #ahdh7q7 of the ,social ,security ,act and1 as the ,secretary determines appropriate1 other similar provisions of title ,,xviii of such ,act4 7g7 ,collaborating with the physician1 practitioner1 and other stakeholder communities ,to improve resource use measurement ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as amended by subsection 7c71 is further amended by adding at the end the following new subsection3 7r7 ,collaborating with the physician1 practitioner1 and other stakeholder communities ,to improve resource use measurement 7#a7 ,in general ,in order to involve the physician1 practitioner1 and other stakeholder communities in enhancing the infrastructure for resource use measurement1 including for purposes of the value-based performance incentive program under subsection 7q7 and alternative payment models under section #ahcc7z71 the ,secretary shall undertake the steps described in the succeeding provisions of this subsection4 7#b7 ,development of care episode and patient condition groups and classification codes 7,a7 ,in general ,in order to classify similar patients into care episode groups and patient condition groups1 the ,secretary shall undertake the steps described in the succeeding provisions of this paragraph4 7,b7 ,public availability of existing efforts to design an episode grouper ,not later than #abj days after the date of the enactment of this subsection1 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 7n77#i77;,a7 and related descriptive information4 7,c7 ,stakeholder input ,the ,secretary shall accept1 through the date that is #fj days after the day the ,secretary posts the list pursuant to subparagraph 7,b71 suggestions from physician specialty societies1 applicable practitioner organizations1 and other stakeholders for episode groups in addition to those posted pursuant to such subparagraph1 and specific clinical criteria and patient characteristics to classify patients into-- 7i7 care episode groups2 and 7ii7 patient condition groups4 7,d7 ,development of proposed classification codes 7i7 ,in general ,taking into account the information described in subparagraph 7,b7 and the information received under subparagraph 7,c71 the ,secretary shall-- 7,i7 establish care episode groups and patient condition groups1 which account for a target of an estimated #b_/c of expenditures under parts ,a and ,b2 and 7,,ii7 assign codes to such groups4 7ii7 ,care episode groups ,in establishing the care episode groups under clause 7i71 the ,secretary shall take into account-- 7,i7 the patient's clinical problems at the time items and services are furnished during an episode of care1 such as the clinical conditions or diagnoses1 whether or not inpatient hospitalization is anticipated or occurs1 and the principal procedures or services planned or furnished2 and 7,,ii7 other factors determined appropriate by the ,secretary4 7iii7 ,patient condition groups ,in establishing the patient condition groups under clause 7i71 the ,secretary shall take into account-- 7,i7 the patient's clinical history at the time of each medical visit1 such as the patient's combination of chronic conditions1 current health status1 and recent significant history 7such as hospitalization and major surgery during a previous period1 such as #c months72 and 7,,ii7 other factors determined appropriate by the ,secretary1 such as eligibility status under this title 7including eligibility under section #bbf7;a71 #bbf7;b71 or #bbf;,a1 and dual eligibility under this title and title ,,xix74 7,e7 ,draft care episode and patient condition groups and classification codes ,not later than #ahj days after the end of the comment period described in subparagraph 7,c71 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 7,d7 7and the criteria and characteristics assigned to such code74 7,f7 ,solicitation of input ,the ,secretary shall seek1 through the date that is #fj days after the ,secretary posts the list pursuant to subparagraph 7,e71 comments from physician specialty societies1 applicable practitioner organizations1 and other stakeholders1 including representatives of individuals entitled to benefits under part ,a or enrolled under this part1 regarding the care episode and patient condition groups 7and codes7 posted under subparagraph 7,e74 ,in seeking such comments1 the ,secretary shall use one or more mechanisms 7other than notice and comment rulemaking7 that may include use of open door forums1 town hall meetings1 or other appropriate mechanisms4 7,g7 ,operational list of care episode and patient condition groups and codes ,not later than #ahj days after the end of the comment period described in subparagraph 7,f71 taking into account the comments received under such subparagraph1 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 7and the criteria and characteristics assigned to such code74 7,h7 ,subsequent revisions ,not later than ,november #a of each year 7beginning with #bjag71 the ,secretary shall1 through rulemaking1 make revisions to the operational lists of care episode and patient condition codes as the ,secretary determines may be appropriate4 ,such revisions may be based on experience1 new information developed pursuant to subsection 7n77#i77;,a71 and input from the physician specialty societies1 applicable practitioner organizations1 and other stakeholders1 including representatives of individuals entitled to benefits under part ,a or enrolled under this part4 7#c7 ,attribution of patients to physicians or practitioners 7,a7 ,in general ,in order to facilitate the attribution of patients and episodes 7in whole or in part7 to one or more physicians or applicable practitioners furnishing items and services1 the ,secretary shall undertake the steps described in the succeeding provisions of this paragraph4 7,b7 ,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 service4 ,such patient relationship categories shall include different relationships of the physician or applicable practitioner to the patient 7and the codes may reflect combinations of such categories71 such as a physician or applicable practitioner who-- 7i7 considers themself to have the primary responsibility for the general and ongoing care for the patient over extended periods of time2 7ii7 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 episode2 7iii7 furnishes items and services to the patient on a continuing basis during an acute episode of care1 but in a supportive rather than a lead role2 7iv7 furnishes items and services to the patient on an occasional basis1 usually at the request of another physician or practitioner2 or 7v7 furnishes items and services only as ordered by another physician or practitioner4 7,c7 ,draft list of patient relationship categories and codes ,not later than #bgj days after the date of the enactment of this subsection1 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 7,b74 7,d7 ,stakeholder ,input ,the ,secretary shall seek1 through the date that is #fj days after the ,secretary posts the list pursuant to subparagraph 7,c71 comments from physician specialty societies1 applicable practitioner organizations1 and other stakeholders1 including representatives of individuals entitled to benefits under part ,a or enrolled under this part1 regarding the patient relationship categories and codes posted under subparagraph 7,c74 ,in seeking such comments1 the ,secretary shall use one or more mechanisms 7other than notice and comment rulemaking7 that may include open door forums1 town hall meetings1 or other appropriate mechanisms4 7,e7 ,operational list of patient relationship categories and codes ,not later than #ahj days after the end of the comment period described in subparagraph 7,d71 taking into account the comments received under such subparagraph1 the ,secretary shall post on the ,internet website of the ,centers for ,medicare ,medicaid ,services an operational list of patient relationship categories and codes4 7,f7 ,subsequent revisions ,not later than ,november #a of each year 7beginning with #bjag71 the ,secretary shall1 through rulemaking1 make revisions to the operational list of patient relationship categories and codes as the ,secretary determines appropriate4 ,such revisions may be based on experience1 new information developed pursuant to subsection 7n77#i77;,a71 and input from the physician specialty societies1 applicable practitioner organizations1 and other stakeholders1 including representatives of individuals entitled to benefits under part ,a or enrolled under this part4 7#d7 ,reporting of information for resource use measurement ,claims submitted for items and services furnished by a physician or applicable practitioner on or after ,january #a1 #bjag1 shall1 as determined appropriate by the ,secretary1 include-- 7,a7 applicable codes established under paragraphs 7#b7 and 7#c72 and 7,b7 the national provider identifier of the ordering physician or applicable practitioner 7if different from the billing physician or applicable practitioner74 7#e7 ,methodology for resource use analysis 7,a7 ,in general ,in order to evaluate the resources used to treat patients 7with respect to care episode and patient condition groups71 the ,secretary shall-- 7i7 use the patient relationship codes reported on claims pursuant to paragraph 7#d7 to attribute patients 7in whole or in part7 to one or more physicians and applicable practitioners2 7ii7 use the care episode and patient condition codes reported on claims pursuant to paragraph 7#d7 as a basis to compare similar patients and care episodes and patient condition groups2 and 7iii7 conduct an analysis of resource use 7with respect to care episodes and patient condition groups of such patients71 as the ,secretary determines appropriate4 7,b7 ,analysis of patients of physicians and practitioners ,in conducting the analysis described in subparagraph 7,a77iii7 with respect to patients attributed to physicians and applicable practitioners1 the ,secretary shall1 as feasible-- 7i7 use the claims data experience of such patients by patient condition codes during a common period1 such as #ab months2 and 7ii7 use the claims data experience of such patients by care episode codes-- 7,i7 in the case of episodes without a hospitalization1 during periods of time 7such as the number of days7 determined appropriate by the ,secretary2 and 7,,ii7 in the case of episodes with a hospitalization1 during periods of time 7such as the number of days7 before1 during1 and after the hospitalization4 7,c7 ,measurement of resource use ,in measuring such resource use1 the ,secretary-- 7i7 shall use per patient total allowed charges for all services under part ,a and this part 7and1 if the ,secretary determines appropriate1 part ,d7 for the analysis of patient resource use1 by care episode codes and by patient condition codes2 and 7ii7 may1 as determined appropriate1 use other measures of allowed charges 7such as subtotals for categories of items and services7 and measures of utilization of items and services 7such as frequency of specific items and services and the ratio of specific items and services among attributed patients or episodes74 7,d7 ,stakeholder ,input ,the ,secretary shall seek comments from the physician specialty societies1 applicable practitioner organizations1 and other stakeholders1 including representatives of individuals entitled to benefits under part ,a or enrolled under this part1 regarding the resource use methodology established pursuant to this paragraph4 ,in seeking comments the ,secretary shall use one or more mechanisms 7other than notice and comment rulemaking7 that may include open door forums1 town hall meetings1 or other appropriate mechanisms4 7#f7 ,implementation ,to the extent that the ,secretary contracts with an entity to carry out any part of the provisions of this subsection1 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 section4 7#g7 ,limitation ,there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise of-- 7,a7 care episode and patient condition groups and codes established under paragraph 7#b72 7,b7 patient relationship categories and codes established under paragraph 7#c72 and 7,c7 measurement of1 and analyses of resource use with respect to1 care episode and patient condition codes and patient relationship codes pursuant to paragraph 7#e74 7#h7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to this section4 7#i7 ,definitions ,in this section3 7,a7 ,physician ,the term physician has the meaning given such term in section #ahfa7r77#a74 7,b7 ,applicable practitioner ,the term applicable practitioner means-- 7i7 a physician assistant1 nurse practitioner1 and clinical nurse specialist 7as such terms are defined in section #ahfa7;aa77#e771 and a certified registered nurse anesthetist 7as defined in section #ahfa7;bb77#b772 and 7ii7 beginning ,january #a1 #bjah1 such other eligible professionals 7as defined in subsection 7k77#c77;,b77 as specified by the ,secretary4 7#aj7 ,clarification ,the provisions of sections #ahij7;b77#g7 and #ahij;,a shall not apply to this subsection4 4 #c4 ,priorities and funding for measure development ,section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d71 as amended by subsections 7c7 and 7g7 of section #b1 is further amended by inserting at the end the following new subsection3 7s7 ,priorities and funding for measure development 7#a7 ,plan identifying measure development priorities and timelines 7,a7 ,draft measure development plan ,not later than ,january #a1 #bjae1 the ,secretary shall develop1 and post on the ,internet website of the ,centers for ,medicare ,medicaid ,services1 a draft plan for the development of quality measures for application under the applicable provisions 7as defined in paragraph 7#e774 ,under such plan the ,secretary shall-- 7i7 address how measures used by private payers and integrated delivery systems could be incorporated under title ,,xviii2 7ii7 describe how coordination1 to the extent possible1 will occur across organizations developing such measures2 and 7iii7 take into account how clinical best practices and clinical practice guidelines should be used in the development of quality measures4 7,b7 ,quality domains ,for purposes of this subsection1 the term quality domains means at least the following domains3 7i7 ,clinical care4 7ii7 ,safety4 7iii7 ,care coordination4 7iv7 ,patient and caregiver experience4 7v7 ,population health and prevention4 7,c7 ,consideration ,in developing the draft plan under this paragraph1 the ,secretary shall consider-- 7i7 gap analyses conducted by the entity with a contract under section #ahij7;a7 or other contractors or entities2 7ii7 whether measures are applicable across health care settings2 7iii7 clinical practice improvement activities submitted under subsection 7q77#b77;,c77iv7 for identifying possible areas for future measure development and identifying existing gaps with respect to such measures2 and 7iv7 the quality domains applied under this subsection4 7,d7 ,priorities ,in developing the draft plan under this paragraph1 the ,secretary shall give priority to the following types of measures3 7i7 ,outcome measures1 including patient reported outcome and functional status measures4 7ii7 ,patient experience measures4 7iii7 ,care coordination measures4 7iv7 ,measures of appropriate use of services1 including measures of over use4 7,e7 ,stakeholder input ,the ,secretary shall accept through ,march #a1 #bjae1 comments on the draft plan posted under paragraph 7#a77;,a7 from the public1 including health care providers1 payers1 consumers1 and other stakeholders4 7,f7 ,final measure development plan ,not later than ,may #a1 #bjae1 taking into account the comments received under this subparagraph1 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 provisions4 ,such plan shall be updated as appropriate4 7#b7 ,contracts and other arrangements for quality measure development 7,a7 ,in general ,the ,secretary shall enter into contracts or other arrangements with entities for the purpose of developing1 improving1 updating1 or expanding in accordance with the plan under paragraph 7#a7 quality measures for application under the applicable provisions4 ,such entities shall include organizations with quality measure development expertise4 7,b7 ,prioritization 7i7 ,in general ,in entering into contracts or other arrangements under subparagraph 7,a71 the ,secretary shall give priority to the development of the types of measures described in paragraph 7#a77;,d74 7ii7 ,consideration ,in selecting measures for development under this subsection1 the ,secretary shall consider-- 7,i7 whether such measures would be electronically specified2 and 7,,ii7 clinical practice guidelines to the extent that such guidelines exist4 7#c7 ,annual report by the ,secretary 7,a7 ,in general ,not later than ,may #a1 #bjaf1 and annually thereafter1 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 provisions4 7,b7 ,requirements ,each report submitted pursuant to subparagraph 7,a7 shall include the following3 7i7 ,a description of the ,secretary's efforts to implement this paragraph4 7ii7 ,with respect to the measures developed during the previous year-- 7,i7 a description of the total number of quality measures developed and the types of such measures1 such as an outcome or patient experience measure2 7,,ii7 the name of each measure developed2 7,,iii7 the name of the developer and steward of each measure2 7,,iv7 with respect to each type of measure1 an estimate of the total amount expended under this title to develop all measures of such type2 and 7,v7 whether the measure would be electronically specified4 7iii7 ,with respect to measures in development at the time of the report-- 7,i7 the information described in clause 7ii71 if available2 and 7,,ii7 a timeline for completion of the development of such measures4 7iv7 ,a description of any updates to the plan under paragraph 7#a7 7including newly identified gaps and the status of previously identified gaps7 and the inventory of measures applicable under the applicable provisions4 7v7 ,other information the ,secretary determines to be appropriate4 7#d7 ,stakeholder input ,with respect to paragraph 7#a71 the ,secretary shall seek stakeholder input with respect to-- 7,a7 the identification of gaps where no quality measures exist1 particularly with respect to the types of measures described in paragraph 7#a77;,d72 7,b7 prioritizing quality measure development to address such gaps2 and 7,c7 other areas related to quality measure development determined appropriate by the ,secretary4 7#e7 ,definition of applicable provisions ,in this subsection1 the term applicable provisions means the following provisions3 7,a7 ,subsection 7q77#b77;,b77i74 7,b7 ,section #ahcc7z77#b77;,c74 7#f7 ,funding ,for purposes of carrying out this subsection1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #ae1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for each of fiscal years #bjad through #bjah4 ,amounts transferred under this paragraph shall remain available through the end of fiscal year #bjba4 4 #d4 ,encouraging care management for individuals with chronic care needs 7a7 ,in general ,section #ahdh7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;b77 is amended by adding at the end the following new paragraph3 7#h7 ,encouraging care management for individuals with chronic care needs 7,a7 ,in general ,in order to encourage the management of care by an applicable provider 7as defined in subparagraph 7,b77 for individuals with chronic care needs the ,secretary shall-- 7i7 establish one or more ,,hcpcs codes for chronic care management services for such individuals2 and 7ii7 subject to subparagraph 7,d71 make payment 7as the ,secretary determines to be appropriate7 under this section for such management services furnished on or after ,january #a1 #bjae1 by an applicable provider4 7,b7 ,applicable provider defined ,for purposes of this paragraph1 the term applicable provider means a physician 7as defined in section #ahfa7r77#a771 physician assistant or nurse practitioner 7as defined in section #ahfa7;aa77#e77;,a771 or clinical nurse specialist 7as defined in section #ahfa7;aa77#e77;,b77 who furnishes services as part of a patient-centered medical home or a comparable specialty practice that-- 7i7 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 practice2 or 7ii7 meets such other comparable qualifications as the ,secretary determines to be appropriate4 7,c7 ,budget neutrality ,the budget neutrality provision under subsection 7c77#b77;,b77ii77,,ii7 shall apply in establishing the payment under subparagraph 7,a77ii74 7,d7 ,policies relating to payment ,in carrying out this paragraph1 with respect to chronic care management services1 the ,secretary shall-- 7i7 make payment to only one applicable provider for such services furnished to an individual during a period2 7ii7 not make payment under subparagraph 7,a7 if such payment would be duplicative of payment that is otherwise made under this title for such services 7such as in the case of hospice care or home health services72 and 7iii7 not require that an annual wellness visit 7as defined in section #ahfa7;hhh77 or an initial preventive physical examination 7as defined in section #ahfa7ww77 be furnished as a condition of payment for such management services4 4 7b7 ,education and outreach 7#a7 ,campaign 7,a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this subsection referred to as the ,secretary7 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 #ahdh7;b77#h7 of the ,social ,security ,act1 as added by subsection 7a71 and encourage such individuals with chronic care needs to receive such services4 7,b7 ,requirements ,such campaign shall-- 7i7 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 ,services2 and 7ii7 focus on encouraging participation by underserved rural populations and racial and ethnic minority populations4 7#b7 ,report 7,a7 ,in general ,not later than ,december #ca1 #bjag1 the ,secretary shall submit to ,congress a report on the use of chronic care management services described in such section #ahdh7;b77#h7 by individuals living in rural areas and by racial and ethnic minority populations4 ,such report shall-- 7i7 identify barriers to receiving chronic care management services2 and 7ii7 make recommendations for increasing the appropriate use of chronic care management services4 #e4 ,ensuring accurate valuation of services under the physician fee schedule 7a7 ,authority ,to collect and use information on physicians' services in the determination of relative values 7#a7 ,in general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended by adding at the end the following new subparagraph3 7,m7 ,authority to collect and use information on physicians' services in the determination of relative values 7i7 ,collection of information ,notwithstanding any other provision of law1 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 7b74 ,such information may be collected or obtained from any eligible professional or any other source4 7ii7 ,use of information ,notwithstanding any other provision of law1 subject to clause 7v71 the ,secretary may 7as the ,secretary determines appropriate7 use information collected or obtained pursuant to clause 7i7 in the determination of relative values for services under this section4 7iii7 ,types of information ,the types of information described in clauses 7i7 and 7ii7 may1 at the ,secretary's discretion1 include any or all of the following3 7,i7 ,time involved in furnishing services4 7,,ii7 ,amounts and types of practice expense inputs involved with furnishing services4 7,,iii7 ,prices 7net of any discounts7 for practice expense inputs1 which may include paid invoice prices or other documentation or records4 7,,iv7 ,overhead and accounting information for practices of physicians and other suppliers4 7,v7 ,any other element that would improve the valuation of services under this section4 7iv7 ,information collection mechanisms ,information may be collected or obtained pursuant to this subparagraph from any or all of the following3 7,i7 ,surveys of physicians1 other suppliers1 providers of services1 manufacturers1 and vendors4 7,,ii7 ,surgical logs1 billing systems1 or other practice or facility records4 7,,iii7 ,electronic health records4 7,,iv7 ,any other mechanism determined appropriate by the ,secretary4 7v7 ,transparency of use of information 7,i7 ,in general ,subject to subclauses 7,,ii7 and 7,,iii71 if the ,secretary uses information collected or obtained under this subparagraph in the determination of relative values under this subsection1 the ,secretary shall disclose the information source and discuss the use of such information in such determination of relative values through notice and comment rulemaking4 7,,ii7 ,thresholds for use ,the ,secretary may establish thresholds in order to use such information1 including the exclusion of information collected or obtained from eligible professionals who use very high resources 7as determined by the ,secretary7 in furnishing a service4 7,,iii7 ,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 practice1 or information collected or obtained pursuant to a nondisclosure agreement4 7vi7 ,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 submission4 ,such payments shall be provided in a form and manner specified by the ,secretary4 7vii7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to information collected or obtained under this subparagraph4 7viii7 ,definition of eligible professional ,in this subparagraph1 the term eligible professional has the meaning given such term in subsection 7k77#c77;,b74 7ix7 ,funding ,for purposes of carrying out this subparagraph1 in addition to funds otherwise appropriated1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #b1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for each fiscal year beginning with fiscal year #bjad4 ,amounts transferred under the preceding sentence for a fiscal year shall be available until expended4 4 7#b7 ,limitation on review ,section #ahdh7;i77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;i77#a77 is amended-- 7,a7 in subparagraph 7,d71 by striking and at the end2 7,b7 in subparagraph 7,e71 by striking the period at the end and inserting 1 and2 and 7,c7 by adding at the end the following new subparagraph3 7,f7 the collection and use of information in the determination of relative values under subsection 7c77#b77,m74 4 7b7 ,authority for alternative approaches ,to establishing practice expense relative values ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by subsection 7a71 is amended by adding at the end the following new subparagraph3 7,n7 ,authority for alternative approaches to establishing practice expense relative values ,the ,secretary may establish or adjust practice expense relative values under this subsection using cost1 charge1 or other data from suppliers or providers of services1 including information collected or obtained under subparagraph 7,m74 4 7c7 ,revised and expanded identification of potentially misvalued codes ,section #ahdh7;c77#b77,k77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77,k77ii77 is amended to read as follows3 7ii7 ,identification of potentially misvalued codes ,for purposes of identifying potentially misvalued codes pursuant to clause 7i77,i71 the ,secretary shall examine codes 7and families of codes as appropriate7 based on any or all of the following criteria3 7,i7 ,codes that have experienced the fastest growth4 7,,ii7 ,codes that have experienced substantial changes in practice expenses4 7,,iii7 ,codes that describe new technologies or services within an appropriate time period 7such as #c years7 after the relative values are initially established for such codes4 7,,iv7 ,codes which are multiple codes that are frequently billed in conjunction with furnishing a single service4 7,v7 ,codes with low relative values1 particularly those that are often billed multiple times for a single treatment4 7,,vi7 ,codes that have not been subject to review since implementation of the fee schedule4 7,,vii7 ,codes that account for the majority of spending under the physician fee schedule4 7,,viii7 ,codes for services that have experienced a substantial change in the hospital length of stay or procedure time4 7,,ix7 ,codes for which there may be a change in the typical site of service since the code was last valued4 7,x7 ,codes for which there is a significant difference in payment for the same service between different sites of service4 7,,xi7 ,codes for which there may be anomalies in relative values within a family of codes4 7,,xii7 ,codes for services where there may be efficiencies when a service is furnished at the same time as other services4 7,,xiii7 ,codes with high intra-service work per unit of time4 7,,xiv7 ,codes with high practice expense relative value units4 7,,xv7 ,codes with high cost supplies4 7,,xvi7 ,codes as determined appropriate by the ,secretary4 4 7d7 ,target for relative value adjustments for misvalued services 7#a7 ,in general ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b771 as amended by subsections 7a7 and 7b71 is amended by adding at the end the following new subparagraph3 7,o7 ,target for relative value adjustments for misvalued services ,with respect to fee schedules established for each of #bjae through #bjah1 the following shall apply3 7i7 ,determination of net reduction in expenditures ,for each year1 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 codes4 7ii7 ,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 7i7 for the year is equal to or greater than the target for the year-- 7,i7 reduced expenditures attributable to such adjustments shall be redistributed for the year in a budget neutral manner in accordance with subparagraph 7,b77ii77,,ii72 and 7,,ii7 the amount by which such reduced expenditures exceeds the target for the year shall be treated as a reduction in expenditures described in clause 7i7 for the succeeding year1 for purposes of determining whether the target has or has not been met under this subparagraph with respect to that year4 7iii7 ,exemption from budget neutrality if target not met ,if the estimated net reduction in expenditures determined under clause 7i7 for the year is less than the target for the year1 reduced expenditures in an amount equal to the target recapture amount shall not be taken into account in applying subparagraph 7,b77ii77,,ii7 with respect to fee schedules beginning with #bjae4 7iv7 ,target recapture amount ,for purposes of clause 7iii71 the target recapture amount is1 with respect to a year1 an amount equal to the difference between-- 7,i7 the target for the year2 and 7,,ii7 the estimated net reduction in expenditures determined under clause 7i7 for the year4 7v7 ,target ,for purposes of this subparagraph1 with respect to a year1 the target is calculated as #j4e percent of the estimated amount of expenditures under the fee schedule under this section for the year4 4 7#b7 ,conforming amendment ,section #ahdh7;c77#b77;,b77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77v77 is amended by adding at the end the following new subclause3 7,,viii7 ,reductions for misvalued services if target not met ,effective for fee schedules beginning with #bjae1 reduced expenditures attributable to the application of the target recapture amount described in subparagraph 7,o77iii74 4 7e7 ,phase-,in of significant relative value unit 7,,rvu7 reductions 7#a7 ,in general ,section #ahdh7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77 is amended by adding at the end the following new paragraph3 7#g7 ,phase-in of significant relative value unit 7,,rvu7 reductions ,effective for fee schedules established beginning with #bjae1 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 #bj percent as compared to the total relative value units for the previous year1 the applicable adjustments in work1 practice expense1 and malpractice relative value units shall be phased-in over a #b-year period4 4 7#b7 ,conforming amendments ,section #ahdh7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77 is amended-- 7,a7 in subparagraph 7,b77ii77,i71 by striking subclause 7,,ii7 and inserting subclause 7,,ii7 and paragraph 7#g72 and 7,b7 in subparagraph 7,k77iii77,,vi7-- 7i7 by striking provisions of subparagraph 7,b77ii77,,ii7 and inserting provisions of subparagraph 7,b77ii77,,ii7 and paragraph 7#g72 and 7ii7 by striking under subparagraph 7,b77ii77,,ii7 and inserting under subparagraph 7,b77ii77,i74 7f7 ,authority ,to smooth relative values within groups of services ,section #ahdh7;c77#b77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,c77 is amended-- 7#a7 in each of clauses 7i7 and 7iii71 by striking the service and inserting the service or group of services each place it appears2 and 7#b7 in the first sentence of clause 7ii71 by inserting or group of services before the period4 7g7 ,,gao study and report on ,relative ,value ,scale ,update ,committee 7#a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this subsection referred to as the ,comptroller ,general7 shall conduct a study of the processes used by the ,relative ,value ,scale ,update ,committee 7,,ruc7 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 #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 7#b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report containing the results of the study conducted under paragraph 7#a74 7h7 ,adjustment to ,medicare payment localities 7#a7 ,in general ,section #ahdh7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77 is amended by adding at the end the following new paragraph3 7#f7 ,use of ,m,s,as as fee schedule areas in ,california 7,a7 ,in general ,subject to the succeeding provisions of this paragraph and notwithstanding the previous provisions of this subsection1 for services furnished on or after ,january #a1 #bjag1 the fee schedule areas used for payment under this section applicable to ,california shall be the following3 7i7 ,each ,metropolitan ,statistical ,area 7each in this paragraph referred to as an ,,msa71 as defined by the ,director of the ,office of ,management and ,budget as of ,december #ca of the previous year1 shall be a fee schedule area4 7ii7 ,all areas not included in an ,,msa shall be treated as a single rest-of-,state fee schedule area4 7,b7 ,transition for ,m,s,as previously in rest-of-,state payment locality or in locality #c 7i7 ,in general ,for services furnished in ,california during a year beginning with #bjag and ending with #bjba in an ,,msa in a transition area 7as defined in subparagraph 7,d771 subject to subparagraph 7,c71 the geographic index values to be applied under this subsection for such year shall be equal to the sum of the following3 7,i7 ,current law component ,the old weighting factor 7described in clause 7ii77 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 7as estimated by the ,secretary7 if this paragraph did not apply4 7,,ii7 ,,msa-based component ,the ,,msa-based weighting factor 7described in clause 7iii77 for such year multiplied by the geographic index values computed for the fee schedule area under subparagraph 7,a7 for the year 7determined without regard to this subparagraph74 7ii7 ,old weighting factor ,the old weighting factor described in this clause-- 7,i7 for #bjag1 is #e_/f2 and 7,,ii7 for each succeeding year1 is the old weighting factor described in this clause for the previous year minus #a_/f4 7iii7 ,,msa-based weighting factor ,the ,,msa-based weighting factor described in this clause for a year is #a minus the old weighting factor under clause 7ii7 for that year4 7,c7 ,hold harmless ,for services furnished in a transition area in ,california during a year beginning with #bjag1 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 7as estimated by the ,secretary7 if this paragraph did not apply4 7,d7 ,transition area defined ,in this paragraph1 the term transition area means each of the following fee schedule areas for #bjac3 7i7 ,the rest-of-,state payment locality4 7ii7 ,payment locality #c4 7,e7 ,references to fee schedule areas ,effective for services furnished on or after ,january #a1 #bjag1 for ,california1 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 paragraph4 4 7#b7 ,conforming amendment to definition of fee schedule area ,section #ahdh7;j77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#b77 is amended by striking ,the term and inserting ,except as provided in subsection 7e77#f77;,d71 the term4 7i7 ,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 ,register1 v4 #gg1 n4 #bbb1 ,november #af1 #bjab1 pages #fhhia-fichj under the physician fee schedule under section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d74 #f4 ,promoting evidence-based care 7a7 ,in general ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following new subsection3 7p7 ,recognizing appropriate use criteria for certain imaging services 7#a7 ,program established 7,a7 ,in general ,the ,secretary shall establish a program to promote the use of appropriate use criteria 7as defined in subparagraph 7,b77 for applicable imaging services 7as defined in subparagraph 7,c77 furnished in an applicable setting 7as defined in subparagraph 7,d77 by ordering professionals and furnishing professionals 7as defined in subparagraphs 7,e7 and 7,f71 respectively74 7,b7 ,appropriate use criteria defined ,in this subsection1 the term appropriate use criteria means criteria1 only developed or endorsed by national professional medical specialty societies or other provider-led entities1 to assist ordering professionals and furnishing professionals in making the most appropriate treatment decision for a specific clinical condition4 ,to the extent feasible1 such criteria shall be evidence-based4 7,c7 ,applicable imaging service defined ,in this subsection1 the term applicable imaging service means an advanced diagnostic imaging service 7as defined in subsection 7e77#a77;,b77 for which the ,secretary determines-- 7i7 one or more applicable appropriate use criteria specified under paragraph 7#b7 apply2 7ii7 there are one or more qualified clinical decision support mechanisms listed under paragraph 7#c77;,c72 and 7iii7 one or more of such mechanisms is available free of charge4 7,d7 ,applicable setting defined ,in this subsection1 the term applicable setting means a physician's office1 a hospital outpatient department 7including an emergency department71 an ambulatory surgical center1 and any other provider-led outpatient setting determined appropriate by the ,secretary4 7,e7 ,ordering professional defined ,in this subsection1 the term ordering professional means a physician 7as defined in section #ahfa7r77 or a practitioner described in section #ahdb7;b77#ah77;,c7 who orders an applicable imaging service for an individual4 7,f7 ,furnishing professional defined ,in this subsection1 the term furnishing professional means a physician 7as defined in section #ahfa7r77 or a practitioner described in section #ahdb7;b77#ah77;,c7 who furnishes an applicable imaging service for an individual4 7#b7 ,establishment of applicable appropriate use criteria 7,a7 ,in general ,not later than ,november #ae1 #bjae1 the ,secretary shall through rulemaking1 and in consultation with physicians1 practitioners1 and other stakeholders1 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 entities4 7,b7 ,considerations ,in specifying applicable appropriate use criteria under subparagraph 7,a71 the ,secretary shall take into account whether the criteria-- 7i7 have stakeholder consensus2 7ii7 are scientifically valid and evidence based2 and 7iii7 are based on studies that are published and reviewable by stakeholders4 7,c7 ,revisions ,the ,secretary shall review1 on an annual basis1 the specified applicable appropriate use criteria to determine if there is a need to update or revise 7as appropriate7 such specification of applicable appropriate use criteria and make such updates or revisions through rulemaking4 7,d7 ,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 service1 the ,secretary shall permit one or more applicable appropriate use criteria under this paragraph for the service4 7#c7 ,mechanisms for consultation with applicable appropriate use criteria 7,a7 ,identification of mechanisms to consult with applicable appropriate use criteria 7i7 ,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 services4 7ii7 ,consultation ,the ,secretary shall consult with physicians1 practitioners1 health care technology experts1 and other stakeholders in specifying mechanisms under this paragraph4 7iii7 ,inclusion of certain mechanisms ,mechanisms specified under this paragraph may include any or all of the following that meet the requirements described in subparagraph 7,b77ii73 7,i7 ,use of clinical decision support modules in certified ,,ehr technology 7as defined in section #ahdh7o77#d774 7,,ii7 ,use of private sector clinical decision support mechanisms that are independent from certified ,,ehr technology1 which may include use of clinical decision support mechanisms available from medical specialty organizations4 7,,iii7 ,use of a clinical decision support mechanism established by the ,secretary4 7,b7 ,qualified clinical decision support mechanisms 7i7 ,in general ,for purposes of this subsection1 a qualified clinical decision support mechanism is a mechanism that the ,secretary determines meets the requirements described in clause 7ii74 7ii7 ,requirements ,the requirements described in this clause are the following3 7,i7 ,the mechanism makes available to the ordering professional applicable appropriate use criteria specified under paragraph 7#b7 and the supporting documentation for the applicable imaging service ordered4 7,,ii7 ,in the case where there are more than one applicable appropriate use criteria specified under such paragraph for an applicable imaging service1 the mechanism indicates the criteria that it uses for the service4 7,,iii7 ,the mechanism determines the extent to which an applicable imaging service ordered is consistent with the applicable appropriate use criteria so specified4 7,,iv7 ,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 professional4 7,v7 ,the mechanism is updated on a timely basis to reflect revisions to the specification of applicable appropriate use criteria under such paragraph4 7,,vi7 ,the mechanism meets privacy and security standards under applicable provisions of law4 7,,vii7 ,the mechanism performs such other functions as specified by the ,secretary1 which may include a requirement to provide aggregate feedback to the ordering professional4 7,c7 ,list of mechanisms for consultation with applicable appropriate use criteria 7i7 ,initial list ,not later than ,april #a1 #bjaf1 the ,secretary shall publish a list of mechanisms specified under this paragraph4 7ii7 ,periodic updating of list ,the ,secretary shall identify on an annual basis the list of qualified clinical decision support mechanisms specified under this paragraph4 7#d7 ,consultation with applicable appropriate use criteria 7,a7 ,consultation by ordering professional ,beginning with ,january #a1 #bjag1 subject to subparagraph 7,c71 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 7as defined in subparagraph 7,d771 an ordering professional shall-- 7i7 consult with a qualified decision support mechanism listed under paragraph 7#c77;,c72 and 7ii7 provide to the furnishing professional the information described in clauses 7i7 through 7iii7 of subparagraph 7,b74 7,b7 ,reporting by furnishing professional ,beginning with ,january #a1 #bjag1 subject to subparagraph 7,c71 with respect to an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system 7as defined in subparagraph 7,d771 payment for such service may only be made if the claim for the service includes the following3 7i7 ,information about which qualified clinical decision support mechanism was consulted by the ordering professional for the service4 7ii7 ,information regarding-- 7,i7 whether the service ordered would adhere to the applicable appropriate use criteria specified under paragraph 7#b72 7,,ii7 whether the service ordered would not adhere to such criteria2 or 7,,iii7 whether such criteria was not applicable to the service ordered4 7iii7 ,the national provider identifier of the ordering professional 7if different from the furnishing professional74 7,c7 ,exceptions ,the provisions of subparagraphs 7,a7 and 7,b7 and paragraph 7#f77;,a7 shall not apply to the following3 7i7 ,emergency services ,an applicable imaging service ordered for an individual with an emergency medical condition 7as defined in section #ahfg7;e77#a774 7ii7 ,inpatient services ,an applicable imaging service ordered for an inpatient and for which payment is made under part ,a4 7iii7 ,alternative payment models ,an applicable imaging service ordered by an ordering professional with respect to an individual attributed to an alternative payment model 7as defined in section #ahcc7z77#c77;,c774 7iv7 ,significant hardship ,an applicable imaging service ordered by an ordering professional who the ,secretary may1 on a case-by-case basis1 exempt from the application of such provisions if the ,secretary determines1 subject to annual renewal1 that consultation with applicable appropriate use criteria would result in a significant hardship1 such as in the case of a professional who practices in a rural area without sufficient ,internet access4 7,d7 ,applicable payment system defined ,in this subsection1 the term applicable payment system means the following3 7i7 ,the physician fee schedule established under section #ahdh7;b74 7ii7 ,the prospective payment system for hospital outpatient department services under section #ahcc7t74 7iii7 ,the ambulatory surgical center payment systems under section #ahcc7;i74 7#e7 ,identification of outlier ordering professionals 7,a7 ,in general ,with respect to applicable imaging services furnished beginning with #bjag1 the ,secretary shall determine1 on an annual basis1 no more than five percent of the total number of ordering professionals who are outlier ordering professionals4 7,b7 ,outlier ordering professionals ,the determination of an outlier ordering professional shall-- 7i7 be based on low adherence to applicable appropriate use criteria specified under paragraph 7#b71 which may be based on comparison to other ordering professionals2 and 7ii7 include data for ordering professionals for whom prior authorization under paragraph 7#f77;,a7 applies4 7,c7 ,use of two years of data ,the ,secretary shall use two years of data to identify outlier ordering professionals under this paragraph4 7,d7 ,process ,the ,secretary shall establish a process for determining when an outlier ordering professional is no longer an outlier ordering professional4 7,e7 ,consultation with stakeholders ,the ,secretary shall consult with physicians1 practitioners and other stakeholders in developing methods to identify outlier ordering professionals under this paragraph4 7#f7 ,prior authorization for ordering professionals who are outliers 7,a7 ,in general ,beginning ,january #a1 #bjbj1 subject to paragraph 7#d77;,c71 with respect to services furnished during a year1 the ,secretary shall1 for a period determined appropriate by the ,secretary1 apply prior authorization for applicable imaging services that are ordered by an outlier ordering professional identified under paragraph 7#e74 7,b7 ,appropriate use criteria in prior authorization ,in applying prior authorization under subparagraph 7,a71 the ,secretary shall utilize only the applicable appropriate use criteria specified under this subsection4 7,c7 ,funding ,for purposes of carrying out this paragraph1 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #e1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for each of fiscal years #bjai through #bjba4 ,amounts transferred under the preceding sentence shall remain available until expended4 7#g7 ,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 criteria4 4 7b7 ,conforming amendment ,section #ahcc7t77#af7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is amended by adding at the end the following new subparagraph3 7,e7 ,application of appropriate use criteria for certain imaging services ,for provisions relating to the application of appropriate use criteria for certain imaging services1 see section #ahcd7p74 4 7c7 ,report on experience of imaging appropriate use criteria program ,not later than #ah months after the date of the enactment of this ,act1 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 7#db ,u4,s4,c4 #acie;j et seq471 such as radiation therapy and clinical diagnostic laboratory services4 #g4 ,empowering beneficiary choices through access to information on physicians' services 7a7 ,in general ,the ,secretary shall make publicly available on ,physician ,compare the information described in subsection 7b7 with respect to eligible professionals4 7b7 ,information described ,the following information1 with respect to an eligible professional1 is described in this subsection3 7#a7 ,information on the number of services furnished by the eligible professional under part ,b of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;j et seq471 which may include information on the most frequent services furnished or groupings of services4 7#b7 ,information on submitted charges and payments for services under such part4 7#c7 ,a unique identifier for the eligible professional that is available to the public1 such as a national provider identifier4 7c7 ,searchability ,the information made available under this section shall be searchable by at least the following3 7#a7 ,the specialty or type of the eligible professional4 7#b7 ,characteristics of the services furnished1 such as volume or groupings of services4 7#c7 ,the location of the eligible professional4 7d7 ,disclosure ,the information made available under this section shall indicate1 where appropriate1 that publicized information may not be representative of the eligible professional's entire patient population1 the variety of services furnished by the eligible professional1 or the health conditions of individuals treated4 7e7 ,implementation 7#a7 ,initial implementation ,physician ,compare shall include the information described in subsection 7b7-- 7,a7 with respect to physicians1 by not later than ,july #a1 #bjae2 and 7,b7 with respect to other eligible professionals1 by not later than ,july #a1 #bjaf4 7#b7 ,annual updating ,the information made available under this section shall be updated on ,physician ,compare not less frequently than on an annual basis4 7f7 ,opportunity ,to review and submit corrections ,the ,secretary shall provide for an opportunity for an eligible professional to review1 and submit corrections for1 the information to be made public with respect to the eligible professional under this section prior to such information being made public4 7g7 ,definitions ,in this section3 7#a7 ,eligible professional2 physician2 secretary ,the terms eligible professional1 physician1 and ,secretary have the meaning given such terms in section #ajcca7;i7 of ,public ,law #aaa-adh4 7#b7 ,physician ,compare ,the term ,physician ,compare means the ,physician ,compare ,internet website of the ,centers for ,medicare ,medicaid ,services 7or a successor website74 #h4 ,expanding availability of ,medicare data 7a7 ,expanding uses of ,medicare data by qualified entities 7#a7 ,additional analyses 7,a7 ,in general ,subject to subparagraph 7,b71 to the extent consistent with applicable information1 privacy1 security1 and disclosure laws 7including paragraph 7#c771 notwithstanding paragraph 7#d77;,b7 of section #ahgd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 and the second sentence of paragraph 7#d77;,d7 of such section1 beginning ,july #a1 #bjae1 a qualified entity may use the combined data described in paragraph 7#d77;,b77iii7 of such section received by such entity under such section1 and information derived from the evaluation described in such paragraph 7#d77;,d71 to conduct additional non-public analyses 7as determined appropriate by the ,secretary7 and provide or sell such analyses to authorized users for non-public use 7including for the purposes of assisting providers of services and suppliers to develop and participate in quality and patient care improvement activities1 including developing new models of care74 7,b7 ,limitations with respect to analyses 7i7 ,employers ,any analyses provided or sold under subparagraph 7,a7 to an employer described in paragraph 7#i77;,a77iii7 may only be used by such employer for purposes of providing health insurance to employees and retirees of the employer4 7ii7 ,health insurance issuers ,a qualified entity may not provide or sell an analysis to a health insurance issuer described in paragraph 7#i77;,a77iv7 unless the issuer is providing the qualified entity with data under section #ahgd7;e77#d77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,b77iii774 7#b7 ,access to certain data 7,a7 ,access ,to the extent consistent with applicable information1 privacy1 security1 and disclosure laws 7including paragraph 7#c771 notwithstanding paragraph 7#d77;,b7 of section #ahgd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 and the second sentence of paragraph 7#d77;,d7 of such section1 beginning ,july #a1 #bjae1 a qualified entity may-- 7i7 provide or sell the combined data described in paragraph 7#d77;,b77iii7 of such section to authorized users described in clauses 7i71 7ii71 and 7v7 of paragraph 7#i77;,a7 for non-public use1 including for the purposes described in subparagraph 7,b72 or 7ii7 subject to subparagraph 7,c71 provide ,medicare claims data to authorized users described in clauses 7i71 7ii71 and 7v71 of paragraph 7#i77;,a7 for non-public use1 including for the purposes described in subparagraph 7,b74 7,b7 ,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 activities1 including developing new models of care4 7,c7 ,medicare claims data must be provided at no cost ,a qualified entity may not charge a fee for providing the data under subparagraph 7,a77ii74 7#c7 ,protection of information 7,a7 ,in general ,except as provided in subparagraph 7,b71 an analysis or data that is provided or sold under paragraph 7#a7 or 7#b7 shall not contain information that individually identifies a patient4 7,b7 ,information on patients of the provider of services or supplier ,to the extent consistent with applicable information1 privacy1 security1 and disclosure laws1 an analysis or data that is provided or sold to a provider of services or supplier under paragraph 7#a7 or 7#b7 may contain information that individually identifies a patient of such provider or supplier1 including with respect to items and services furnished to the patient by other providers of services or suppliers4 7,c7 ,prohibition on using analyses or data for marketing purposes ,an authorized user shall not use an analysis or data provided or sold under paragraph 7#a7 or 7#b7 for marketing purposes4 7#d7 ,data use agreement ,a qualified entity and an authorized user described in clauses 7i71 7ii71 and 7v7 of paragraph 7#i77;,a7 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 7#b74 ,such agreement shall describe the requirements for privacy and security of the data and1 as determined appropriate by the ,secretary1 any prohibitions on using such data to link to other individually identifiable sources of information4 ,if the authorized user is not a covered entity under the rules promulgated pursuant to the ,health ,insurance ,portability and ,accountability ,act of #aiif1 the agreement shall identify the relevant regulations1 as determined by the ,secretary1 that the user shall comply with as if it were acting in the capacity of such a covered entity4 7#e7 ,no redisclosure of analyses or data 7,a7 ,in general ,except as provided in subparagraph 7,b71 an authorized user that is provided or sold an analysis or data under paragraph 7#a7 or 7#b7 shall not redisclose or make public such analysis or data or any analysis using such data4 7,b7 ,permitted redisclosure ,a provider of services or supplier that is provided or sold an analysis or data under paragraph 7#a7 or 7#b7 may1 as determined by the ,secretary1 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 data4 7#f7 ,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 7#a71 to the extent that such analysis would individually identify a provider of services or supplier who is not being provided or sold such analysis1 such qualified entity shall provide such provider or supplier with the opportunity to appeal and correct errors in the manner described in section #ahgd7;e77#d77;,c77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,c77ii774 7#g7 ,assessment for a breach 7,a7 ,in general ,in the case of a breach of a data use agreement under this section or section #ahgd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e771 the ,secretary shall impose an assessment on the qualified entity both in the case of-- 7i7 an agreement between the ,secretary and a qualified entity2 and 7ii7 an agreement between a qualified entity and an authorized user4 7,b7 ,assessment ,the assessment under subparagraph 7,a7 shall be an amount up to #ajj for each individual entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii of the ,social ,security ,act or enrolled for benefits under part ,b of such title-- 7i7 in the case of an agreement described in subparagraph 7,a77i71 for whom the ,secretary provided data on to the qualified entity under paragraph 7#b72 and 7ii7 in the case of an agreement described in subparagraph 7,a77ii71 for whom the qualified entity provided data on to the authorized user under paragraph 7#b74 7,c7 ,deposit of amounts collected ,any amounts collected pursuant to this paragraph shall be deposited in ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda of the ,social ,security ,act 7#db ,u4,s4,c4 #aciet74 7#h7 ,annual reports ,any qualified entity that provides or sells an analysis or data under paragraph 7#a7 or 7#b7 shall annually submit to the ,secretary a report that includes-- 7,a7 a summary of the analyses provided or sold1 including the number of such analyses1 the number of purchasers of such analyses1 and the total amount of fees received for such analyses2 7,b7 a description of the topics and purposes of such analyses2 7,c7 information on the entities who received the data under paragraph 7#b71 the uses of the data1 and the total amount of fees received for providing1 selling1 or sharing the data2 and 7,d7 other information determined appropriate by the ,secretary4 7#i7 ,definitions ,in this subsection and subsection 7b73 7,a7 ,authorized user ,the term authorized user means the following3 7i7 ,a provider of services4 7ii7 ,a supplier4 7iii7 ,an employer 7as defined in section #c7e7 of the ,employee ,retirement ,insurance ,security ,act of #aigd74 7iv7 ,a health insurance issuer 7as defined in section #bgia of the ,public ,health ,service ,act74 7v7 ,a medical society or hospital association4 7vi7 ,any entity not described in clauses 7i7 through 7v7 that is approved by the ,secretary 7other than an employer or health insurance issuer not described in clauses 7iii7 and 7iv71 respectively1 as determined by the ,secretary74 7,b7 ,provider of services ,the term provider of services has the meaning given such term in section #ahfa7u7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7u774 7,c7 ,qualified entity ,the term qualified entity has the meaning given such term in section #ahgd7;e77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e774 7,d7 ,secretary ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7,e7 ,supplier ,the term supplier has the meaning given such term in section #ahfa7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7d774 7b7 ,access to ,medicare data by qualified clinical data registries ,to facilitate quality improvement 7#a7 ,access 7,a7 ,in general ,to the extent consistent with applicable information1 privacy1 security1 and disclosure laws1 beginning ,july #a1 #bjae1 the ,secretary shall1 at the request of a qualified clinical data registry under section #ahdh7m77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e771 provide the data described in subparagraph 7,b7 7in a form and manner determined to be appropriate7 to such qualified clinical data registry for purposes of linking such data with clinical outcomes data and performing risk-adjusted1 scientifically valid analyses and research to support quality improvement or patient safety1 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 7a77#f74 7,b7 ,data described ,the data described in this subparagraph is-- 7i7 claims data under the ,medicare program under title ,,xviii of the ,social ,security ,act2 and 7ii7 if the ,secretary determines appropriate1 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 ,act4 7#b7 ,fee ,data described in paragraph 7#a77;,b7 shall be provided to a qualified clinical data registry under paragraph 7#a7 at a fee equal to the cost of providing such data4 ,any fee collected pursuant to the preceding sentence shall be deposited in the ,centers for ,medicare ,medicaid ,services ,program ,management ,account4 7c7 ,expansion of data available to qualified entities ,section #ahgd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77 is amended-- 7#a7 in the subsection heading1 by striking ,medicare2 and 7#b7 in paragraph 7#c7-- 7,a7 by inserting after the first sentence the following new sentence3 ,beginning ,july #a1 #bjae1 if the ,secretary determines appropriate1 the data described in this paragraph may also include standardized extracts 7as determined by the ,secretary7 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 entity42 and 7,b7 in the last sentence1 by inserting or under titles ,,xix or ,,xxi before the period at the end4 7d7 ,revision of placement of fees ,section #ahgd7;e77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#d77;,a77 is amended1 in the second sentence-- 7#a7 by inserting 1 for periods prior to ,july #a1 #bjae1 after deposited2 and 7#b7 by inserting the following before the period at the end3 1 and1 beginning ,july #a1 #bjae1 into the ,centers for ,medicare ,medicaid ,services ,program ,management ,account4 #i4 ,reducing administrative burden and other provisions 7a7 ,medicare physician and practitioner opt-,out to private contract 7#a7 ,indefinite1 continuing automatic extension of opt out election 7,a7 ,in general ,section #ahjb7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7b77#c77 is amended-- 7i7 in subparagraph 7,b77ii71 by striking during the #b-year period beginning on the date the affidavit is signed and inserting during the applicable #b-year period 7as defined in subparagraph 7,d772 7ii7 in subparagraph 7,c71 by striking during the #b-year period described in subparagraph 7,b77ii7 and inserting during the applicable #b-year period2 and 7iii7 by adding at the end the following new subparagraph3 7,d7 ,applicable #b-year periods for effectiveness of affidavits ,in this subsection1 the term applicable #b-year period means1 with respect to an affidavit of a physician or practitioner under subparagraph 7,b71 the #b-year period beginning on the date the affidavit is signed and includes each subsequent #b-year period unless the physician or practitioner involved provides notice to the ,secretary 7in a form and manner specified by the ,secretary71 not later than #cj days before the end of the previous #b-year period1 that the physician or practitioner does not want to extend the application of the affidavit for such subsequent #b-year period4 4 7,b7 ,effective date ,the amendments made by subparagraph 7,a7 shall apply to affidavits entered into on or after the date that is #fj days after the date of the enactment of this ,act4 7#b7 ,public availability of information on opt-out physicians and practitioners ,section #ahjb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;a7b77 is amended-- 7,a7 in paragraph 7#e71 by adding at the end the following new subparagraph3 7,d7 ,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 7#c77;,b74 2 7,b7 by redesignating paragraph 7#e7 as paragraph 7#f72 and 7,c7 by inserting after paragraph 7#d7 the following new paragraph3 7#e7 ,posting of information on opt-out physicians and practitioners 7,a7 ,in general ,beginning not later than ,february #a1 #bjae1 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 annually4 7,b7 ,information to be included ,the information to be made available under subparagraph 7,a7 shall include at least the following with respect to opt-out physicians and practitioners3 7i7 ,their number4 7ii7 ,their physician or professional specialty or other designation4 7iii7 ,their geographic distribution4 7iv7 ,the timing of their becoming opt-out physicians and practitioners1 relative to when they first entered practice and with respect to applicable #b-year periods4 7v7 ,the proportion of such physicians and practitioners who billed for emergency or urgent care services4 4 7b7 ,gainsharing study and report ,not later than #f months after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services1 in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services1 shall submit to ,congress a report with legislative recommendations to amend existing fraud and abuse laws1 through exceptions1 safe harbors1 or other narrowly targeted provisions1 to permit gainsharing or similar arrangements between physicians and hospitals that improve care while reducing waste and increasing efficiency4 ,the report shall-- 7#a7 consider whether such provisions should apply to ownership interests1 compensation arrangements1 or other relationships2 7#b7 describe how the recommendations address accountability1 transparency1 and quality1 including how best to limit inducements to stint on care1 discharge patients prematurely1 or otherwise reduce or limit medically necessary care2 and 7#c7 consider whether a portion of any savings generated by such arrangements should accrue to the ,medicare program under title ,,xviii of the ,social ,security ,act4 7c7 ,promoting interoperability of electronic health record systems 7#a7 ,recommendations for achieving widespread ,,ehr interoperability 7,a7 ,objective ,as a consequence of a significant ,federal investment in the implementation of health information technology through the ,medicare and ,medicaid ,,ehr incentive programs1 ,congress declares it a national objective to achieve widespread exchange of health information through interoperable certified ,,ehr technology nationwide by ,december #ca1 #bjag4 7,b7 ,definitions ,in this paragraph3 7i7 ,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 basis4 7ii7 ,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 outcomes4 7,c7 ,establishment of metrics ,not later than ,july #a1 #bjae1 and in consultation with stakeholders1 the ,secretary shall establish metrics to be used to determine if and to the extent that the objective described in subparagraph 7,a7 has been achieved4 7,d7 ,recommendations if objective not achieved ,if the ,secretary of ,health and ,human ,services determines that the objective described in subparagraph 7,a7 has not been achieved by ,december #ca1 #bjag1 then the ,secretary shall submit to ,congress a report1 by not later than ,december #ca1 #bjah1 that identifies barriers to such objective and recommends actions that the ,federal ,government can take to achieve such objective4 ,such recommended actions may include recommendations-- 7i7 to adjust payments for not being meaningful ,,ehr users under the ,medicare ,,ehr incentive programs2 and 7ii7 for criteria for decertifying certified ,,ehr technology products4 7#b7 ,preventing blocking the sharing of information 7,a7 ,for meaningful ,,ehr professionals ,section #ahdh7o77#b77;,a77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#b77;,a77ii77 is amended by inserting before the period at the end the following3 1 and the professional demonstrates 7through a process specified by the ,secretary1 such as the use of an attestation7 that the professional has not knowingly and willfully taken any action to limit or restrict the compatibility or interoperability of the certified ,,ehr technology4 7,b7 ,for meaningful ,,ehr hospitals ,section #ahhf7n77#c77;,a77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7n77#c77;,a77ii77 is amended by inserting before the period at the end the following3 1 and the hospital demonstrates 7through a process specified by the ,secretary1 such as the use of an attestation7 that the hospital has not knowingly and willfully taken any action to limit or restrict the compatibility or interoperability of the certified ,,ehr technology4 7,c7 ,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 ,act4 7#c7 ,study and report on the feasibility of establishing a website to compare certified ,,ehr technology products 7,a7 ,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 products4 ,such information may be made available through contracts with physician1 hospital1 or other organizations that maintain such comparative information4 7,b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,secretary shall submit to ,congress a report on the website4 ,the report shall include information on the benefits of1 and resources needed to develop and maintain1 such a website4 7#d7 ,definitions ,in this subsection3 7,a7 ,the term certified ,,ehr technology has the meaning given such term in section #ahdh7o77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7o77#d774 7,b7 ,the term meaningful ,,ehr user has the meaning given such term under the ,medicare ,,ehr incentive programs4 7,c7 ,the term ,medicare and ,medicaid ,,ehr incentive programs means-- 7i7 in the case of the ,medicare program under title ,,xviii of the ,social ,security ,act1 the incentive programs under section #ahad7l77#c71 section #ahdh7o71 subsections 7l7 and 7m7 of section #ahec1 and section #ahhf7n7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7l77#c71 #aciew-#d7o71 #aciew-#bc1 #acieww7n772 and 7ii7 in the case of the ,medicaid program under title ,,xix of such ,act1 the incentive program under subsections 7a77#c77;,f7 and 7t7 of section #aijc of such ,act 7#db ,u4,s4,c4 #acif;b74 7,d7 ,the term ,secretary means the ,secretary of ,health and ,human ,services4 7d7 ,,gao studies and reports on the use of telehealth under ,federal programs and on remote patient monitoring services 7#a7 ,study on telehealth services ,the ,comptroller ,general of the ,united ,states shall conduct a study on the following3 7,a7 ,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 7#db ,u4,s4,c4 #acie et seq474 7,b7 ,issues that can facilitate or inhibit the use of telehealth under the ,medicare program under such title1 including oversight and professional licensure1 changing technology1 privacy and security1 infrastructure requirements1 and varying needs across urban and rural areas4 7,c7 ,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 7#db ,u4,s4,c4 #acif et seq474 7,d7 ,how the ,centers for ,medicare ,medicaid ,services conducts oversight of payments made under the ,medicare program under such title ,,xviii to providers for telehealth services4 7#b7 ,study on remote patient monitoring services 7,a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct a study-- 7i7 of the dissemination of remote patient monitoring technology in the private health insurance market2 7ii7 of the financial incentives in the private health insurance market relating to adoption of such technology2 7iii7 of the barriers to adoption of such services under the ,medicare program under title ,,xviii of the ,social ,security ,act2 7iv7 that evaluates the patients1 conditions1 and clinical circumstances that could most benefit from remote patient monitoring services2 and 7v7 that evaluates the challenges related to establishing appropriate valuation for remote patient monitoring services under the ,medicare physician fee schedule under section #ahdh of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7 in order to accurately reflect the resources involved in furnishing such services4 7,b7 ,definitions ,for purposes of this paragraph3 7i7 ,remote patient monitoring services ,the term remote patient monitoring services means services furnished through remote patient monitoring technology4 7ii7 ,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 7concerning the privacy of individually identifiable health information7 promulgated under section #bfd7;c7 of the ,health ,insurance ,portability and ,accountability ,act of #aiif1 as part of an established plan of care for that patient that includes the review and interpretation of that data by a health care professional4 7#c7 ,reports ,not later than #bd months after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress-- 7,a7 a report containing the results of the study conducted under paragraph 7#a72 and 7,b7 a report containing the results of the study conducted under paragraph 7#b74 ,a report required under this paragraph shall be submitted together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 ,the ,comptroller ,general may submit one report containing the results described in subparagraphs 7,a7 and 7,b7 and the recommendations described in the previous sentence4 7e7 ,rule of construction regarding healthcare provider standards of care 7#a7 ,maintenance of state standards ,the development1 recognition1 or implementation of any guideline or other standard under any ,federal health care provision shall not be construed-- 7,a7 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 claim2 or 7,b7 to preempt any standard of care or duty of care1 owed by a health care provider to a patient1 duly established under ,state or common law4 7#b7 ,definitions ,for purposes of this subsection3 7,a7 ,federal health care provision ,the term ,federal health care provision means any provision of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 title ,i or subtitle ,b of title ,,ii of the ,health ,care and ,education ,reconciliation ,act of #bjaj 7,public ,law #aaa-aeb71 or title ,,xviii or ,,xix of the ,social ,security ,act4 7,b7 ,health care provider ,the term health care provider means any individual or entity-- 7i7 licensed1 registered1 or certified under ,federal or ,state laws or regulations to provide health care services2 or 7ii7 required to be so licensed1 registered1 or certified but that is exempted by other statute or regulation4 7,c7 ,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 7as defined in section #dca7g7 of the ,health ,care ,quality ,improvement ,act of #aihf 7#db ,u4,s4,c4 #aaaea7g777 and includes a liability action or claim relating to a health care provider's prescription or provision of a drug1 device1 or biological product 7as such terms are defined in section #bja of the ,federal ,food1 ,drug1 and ,cosmetic ,act or section #cea of the ,public ,health ,service ,act74 7,d7 ,state ,the term ,state includes the ,district of ,columbia1 ,puerto ,rico1 and any other commonwealth1 possession1 or territory of the ,united ,states4 7#c7 ,preservation of ,state law ,no provision of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 title ,i or subtitle ,b of title ,,ii of the ,health ,care and ,education ,reconciliation ,act of #bjaj 7,public ,law #aaa-aeb71 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 claims4