,,ii #aaith ,,congress #b;d ,session ,s4 #efgb ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #cj1 #bjbf,mr4 ,marshall 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 modify certain physician payments under the ,medicare program4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,patients ,first ,act of #bjbf4 7b7 ,table of contents ,sec4 #a4 ,short title2 table of contents4,,title ,i--,strengthening reimbursement and patient access,sec4 #aja4 ,modifying the conversion factor updates applicable to physicians' services under the ,medicare program4,sec4 #ajb4 ,hybrid payment model for primary care services4,sec4 #ajc4 ,work geographic floor adjustment for high inflationary years4,,title ,,ii--,p,o,i,n,t,s,sec4 #bja4 ,implementation of the ,patient ,outcome ,improvement ,national ,tabulation ,system4,sec4 #bjb4 ,payment reform4,sec4 #bjc4 ,quality ,reform ,task ,force4,sec4 #bjd4 ,modification of ,,mips payment adjustments4,sec4 #bje4 ,modifying requirements and approval periods for qualified clinical data registries4,sec4 #bjf4 ,expanded access to claims data to facilitate research and quality improvement4,sec4 #bjg4 ,modification of appropriate use criteria data collection for applicable imaging services4,sec4 #bjh4 ,rules of construction4,,title ,,iii--,,apm improvement,sec4 #cja4 ,qualifying ,,apm participant threshold freeze4,sec4 #cjb4 ,,cmi model requirements4,sec4 #cjc4 ,report on barriers to participation in value-based payment models4,,title ,,iv--,physician payment improvements,sec4 #dja4 ,updating the budget neutrality threshold4,sec4 #djb4 ,budget neutrality corrections relating to estimated utilization4,sec4 #djc4 ,timely updates to direct costs used to calculate practice expense ,r,v,us4,sec4 #djd4 ,limitation on year-to-year conversion factor variance4 ,i ,strengthening reimbursement and patient access #aja4 ,modifying the conversion factor updates applicable to physicians' services under the ,medicare program 7a7 ,in general ,section #ahdh7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d77 is amended-- 7#a7 in paragraph 7#a77;,a71 in the second sentence1 by inserting or 7#ba7 after paragraph 7#bj72 7#b7 in paragraph 7#bj7-- 7,a7 in the header1 by striking and subsequent years2 and 7,b7 by striking and each subsequent year2 and 7#c7 by adding at the end the following new paragraph3 7#ba7 ,update for #bjbg and subsequent years 7,a7 ,in general ,for #bjbg and each subsequent year1 the update to the nonqualifying ,,apm conversion factor established under paragraph 7#a77;,a7 is1 subject to subparagraph 7,b71 the ,secretary's estimate of the percentage increase in the ,,mei 7as defined in section #ahdb7;i77#c77 for the year1 less #a percentage point1 and the update to the qualifying ,,apm conversion factor established under such paragraph is the update to the nonqualifying ,,apm conversion factor for the year1 increased by #j4e percentage point4 7,b7 ,floor and ceiling on nonqualifying ,,apm conversion factor update ,in the case that the update to the nonqualifying ,,apm conversion factor for a year as calculated under subparagraph 7,a7 is-- 7i7 less than #be percent of the ,secretary's estimate of the percentage increase in the ,,mei 7as defined in section #ahdb7;i77#c77 for the year1 such update shall be deemed to be equal to #be percent of such estimate2 or 7ii7 more than #ge percent of such estimate1 such update shall be deemed to be equal to #ge percent of such estimate4 4 7b7 ,reports ,the ,secretary of ,health and ,human ,services shall1 for #bjbg and each year thereafter1 submit to ,congress a report on the updates to the qualifying ,,apm conversion factor and nonqualifying ,,apm conversion factor under section #ahdh7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;d77 for such year4 ,such report shall include an analysis of the impact of such updates on ,medicare beneficiaries' access to services under the ,medicare program and on the consolidation of physician practices4 #ajb4 ,hybrid payment model for primary care services ,part ,e of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq47 is amended by inserting after section #ahff;,g the following new section3 #ahff;,h4 ,hybrid payment model for primary care services 7a7 ,in general ,the ,secretary shall1 for #bjbg and each subsequent year through #bjca1 carry out a hybrid payment model for primary care services 7in this section referred to as the model7 under which the ,secretary shall make a monthly payment to each qualifying supplier for each individual attributed to such practice for such year in lieu of payment for any designated primary care services furnished by such supplier to such individuals during such year that would otherwise be made under the payment schedule established under section #ahdh 7or on the basis of such schedule74 7b7 ,payment amount 7#a7 ,in general ,the monthly amount payable to a qualifying supplier for a year under the model is equal to #a_/ab of the national average amount that the ,secretary estimates will be payable under the payment basis established under section #ahdh for designated primary care services furnished during such year 7so estimated as if no cost sharing requirements applied to individuals enrolled under part ,b71 adjusted by a geographic index determined appropriate by the ,secretary and risk adjusted in a manner determined appropriate by the ,secretary4 7#b7 ,nonapplication of cost sharing ,no cost sharing requirement shall apply with respect to a monthly payment made under the model to a qualifying supplier for an individual attributed to such supplier4 7c7 ,attribution process 7#a7 ,in general ,the ,secretary shall establish a process under which1 for each year of the model1 individuals enrolled under part ,b who are not enrolled under an ,,ma plan under part ,c may designate a qualifying supplier as such individual's primary care provider for such year4 7#b7 ,attribution based on prior claims ,in the case of an individual described in paragraph 7#a7 who fails to make a designation for a year but for whom the ,secretary determines1 based on claims history of items and services furnished under this title1 that such individual has a primary care provider who is a qualifying supplier1 the ,secretary may designate such supplier as such individual's primary care provider for such year4 7#c7 ,treated as attributed ,for purposes of this section1 each individual who makes a designation under paragraph 7#a7 7or for whom such a designation is made under paragraph 7#b77 with respect to a qualifying supplier for a year shall be treated as attributed to such supplier for such year4 7d7 ,no effect on ,,pfs budget neutrality ,section #ahdh7;c77#b77;,b7 shall be applied for #bjbg and each subsequent year as if the model had never applied4 7e7 ,funding ,payments under the model shall be made from the ,federal ,supplementary ,medical ,insurance ,trust ,fund established under section #ahda4 7f7 ,definitions ,in this section3 7#a7 ,designated health care practitioner ,the term designated health care practitioner means a physician assistant1 a nurse practitioner1 a clinical nurse specialist1 a physical therapist1 an occupational therapist1 or such other health care practitioner as the ,secretary may specify4 7#b7 ,designated primary care services ,the term designated primary care services means-- 7,a7 care management services2 7,b7 behavioral health integration services2 7,c7 office-based evaluation and management services 7whether furnished in person or via telehealth72 and 7,d7 communications such as telephone calls1 emails and patient portals between patients and their care givers4 7#c7 ,excluded practice 7,a7 ,in general ,the term excluded practice means1 subject to subparagraph 7,b71 any practice-- 7i7 in which any entity that is not a physician or designated health care practitioner or a professional corporation1 professional association1 limited liability company1 or other professional body that is majority owned and controlled by physicians or designated health care practitioners has an ownership interest2 7ii7 in which any entity described in subparagraph 7,a7 exercises de facto control over employment decisions 7including rates of pay and terms of employment71 clinical staffing levels1 amount of time spent between a supplier and a patient1 diagnostic or procedural coding decisions1 clinical standards or policy1 billing and collection1 prices for items and services1 contracting with third party payors1 or controlling or restricting the practice's assets2 7iii7 in which physicians or designated health care practitioners hold #ej percent or less of voting shares or membership interests2 7iv7 that has a governing board in which physicians or designated health care practitioners constitute less than #ej percent of the members2 or 7v7 in the case such practice is a corporation or professional association1 that permits the removal of directors or officers that are physicians or designated health care practitioners except by majority vote of stakeholders that are physicians or designated health care practitioners4 7,b7 ,exception ,the term excluded practice does not include any practice consisting of #ae or fewer designated health care practitioners4 7#d7 ,specified practitioner ,the term specified practitioner means-- 7,a7 a physician with a primary specialty or practice area of family medicine1 internal medicine1 geriatric medicine1 or pediatric medicine2 or 7,b7 a physician assistant1 a nurse practitioner1 or a clinical nurse specialist4 7#e7 ,qualifying supplier ,the term qualifying supplier means1 with respect to a year1 a specified practitioner-- 7,a7 who is not part of an excluded practice2 7,b7 who furnished items and services under this title during the preceding year2 7,c7 for whom1 with respect to payments under this title for all items and services furnished by such practitioner during the preceding year1 at least #fj percent of such payments were for designated primary care services2 and 7,d7 who has elected to participate in the model for such year through such process as the ,secretary shall establish4 4 #ajc4 ,work geographic floor adjustment for high inflationary years 7a7 ,in general ,section #ahdh7;e77#a77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is amended-- 7#a7 by striking the header and inserting ,work geographic index2 7#b7 by striking ,after calculating and inserting the following3 7i7 ,in general ,after calculating 2 7#c7 in clause 7i7 7as so inserted7-- 7,a7 by inserting 7or #a4jbe1 in the case such year is a high inflationary year 7as defined in clause 7iii777 after to #a4jj2 and 7,b7 by striking #bjbg and inserting #bjcb2 and 7#d7 by adding at the end the following new clauses3 7ii7 ,increase in high inflationary years for other localities ,after calculating the work geographic index in subparagraph 7,a77iii71 for purposes of payment for services furnished on or after ,january #a1 #bjbg1 and before ,january #a1 #bjcc1 the ,secretary shall increase the work geographic index by 4#jb points if such year is a high inflationary year1 unless such work geographic index is subject to an increase under clause 7i7 for such year4 7iii7 ,definition ,in this subparagraph1 the term high inflationary year means a year if1 over the #ab-month period ending on the last day of the preceding year1 the consumer price index for all urban consumers 7,u4,s4 city average7 increased by more than #b percent4 7iv7 ,publication ,medicare administrative contractors shall publish the geographically adjusted work relative value units for both the inflation adjustments under clauses 7i7 and 7ii7 and the work geographic adjustment for all services on a quarterly basis effective ,january #a1 #bjbg1 for each of their geographic areas4 4 7b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to the ,committee on ,energy and ,commerce and the ,committee on ,ways and ,means of the ,house of ,representatives and the ,committee on ,finance of the ,senate a study on the economic factors that are impacting physician choice1 by specialty1 regarding the geographic area in which such physicians choose to practice1 including salaries1 contract terms1 cost of living1 availability of capital1 volume of services1 and costs to conduct a practice4 ,,ii ,,points #bja4 ,implementation of the ,patient ,outcome ,improvement ,national ,tabulation ,system 7a7 ,in general ,effective ,january #a1 #bjcb1 there is established the ,patient ,outcome ,improvement ,national ,tabulation ,system1 which shall consist of the payment system under section #ahdh7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q771 including as amended by this title4 7b7 ,references ,subject to subsection 7c71 any reference to the payment system under section #ahdh7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q771 including the terms ,merit-based ,incentive ,payment ,system and ,,mips1 shall be deemed a reference to the ,patient ,outcome ,improvement ,national ,tabulation ,system and ,,points1 respectively4 7c7 ,transition ,in order to provide for an orderly transition and avoid provider confusion1 the ,secretary of ,health and ,human ,services shall provide for an appropriate transition in the use of the terms ,merit-based ,incentive ,payment ,system 7and ,,mips7 and ,patient ,outcome ,improvement ,national ,tabulation ,system 7and ,,points7 in reference to the payment system under section #ahdh7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q774 ,before the completion of such transition1 any reference to the ,patient ,outcome ,improvement ,national ,tabulation ,system 7or ,,points7 shall be deemed to include a reference to the ,merit-based ,incentive ,payment ,system4 #bjb4 ,payment reform 7a7 ,in general ,section #ahdh7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77 is amended-- 7#a7 in paragraph 7#a77;,d77i77,,ii71 by striking 7iv7 and inserting 7v72 7#b7 in paragraph 7#b7-- 7,a7 in subparagraph 7,a7-- 7i7 in clause 7iii71 by striking ,clinical practice and inserting ,for performance periods beginning before ,january #a1 #bjcb1 clinical practice2 7ii7 in clause 7iv71 by striking ,meaningful use and inserting ,for performance periods before ,january #a1 #bjcb1 meaningful use2 and 7iii7 by adding at the end the following new clause3 7v7 ,for performance periods beginning on or after ,january #a1 #bjcb1 care efficiency4 2 7,b7 in subparagraph 7,b7-- 7i7 in clause 7ii7-- 7,i7 by striking subparagraph 7,a77ii71 the measurement and inserting the following3 subparagraph 7,a77ii7-- 7,i7 for performance periods beginning before ,january #a1 #bjcb1 the measurement 2 and 7,,ii7 by striking the period at the end and inserting the following3 2 and 7,,ii7 for performance periods beginning on or after ,january #a1 #bjcb1 the measurement described in subclause 7,i7 and any resource use measures included in the final measures list published under subparagraph 7,d77i7 for such period4 2 and 7ii7 by inserting after clause 7iv7 the following new clause3 7v7 ,care efficiency ,for the performance category described in subparagraph 7,a77v71 care efficiency measures 7such as measures relating to reductions in avoidable hospitalizations1 reductions in medication burden 7when clinically appropriate71 reductions in complications from chronic diseases1 and referral patterns to the lowest-cost clinically appropriate settings7 included in the final measures list published under subparagraph 7,d77i7 for such period4 2 and 7,c7 in subparagraph 7,d7-- 7i7 in the header1 by striking quality2 7ii7 in clause 7i7-- 7,i7 in the matter preceding subclause 7,i71 by inserting 7or1 with respect to performance periods beginning on or after ,january #a1 #bjcb1 an annual final list of quality measures1 resource use measures 7if determined appropriate by the ,secretary71 and care efficiency measures7 after quality measures2 and 7,,ii7 in subclause 7,,ii7-- 7aa7 in item 7aa71 by striking quality measures and inserting measures2 7bb7 in item 7bb71 by inserting 7or1 with respect to a final list for a performance period beginning on or after ,january #a1 #bjcb1 new quality measures1 resource use measures1 or care efficiency measures7 after quality measures2 and 7cc7 in item 7cc71 by striking quality measures and inserting measures2 7iii7 in clause 7ii7-- 7,i7 in the header1 by striking quality2 and 7,,ii7 in subclause 7,i7-- 7aa7 by inserting 7or1 with respect to such an annual list for a performance period beginning on or after ,january #a1 #bjcb1 quality measures1 resource use measures1 and care efficiency measures7 after submit quality measures2 and 7bb7 by striking quality measures published and inserting measures published2 7iv7 in clause 7iii7-- 7,i7 in the matter preceding subclause 7,i71 by striking quality2 7,,ii7 in subclause 7,i71 by striking and at the end2 7,,iii7 in subclause 7,,ii7-- 7aa7 by striking ensure that and inserting with respect to such an annual final list for a performance period beginning before ,january #a1 #bjcb1 ensure that2 and 7bb7 by striking the period at the end and inserting 2 and2 and 7,,iv7 by adding at the end the following new subclause3 7,,iii7 with respect to such an annual final list for a performance period beginning on or after ,january #a1 #bjcb1 provide that-- 7aa7 no quality measure applicable to a medical specialty is included on such list if-- 7,,aa7 the ,task ,force established under subparagraph 7,e7 has issued recommendations on quality measures for use under this subsection with respect to such specialty2 and 7,,bb7 the quality measure does not have in effect such a recommendation2 and 7bb7 no resource use measure or care efficiency measure is included on such list unless such measure has in effect a recommendation from such ,task ,force4 2 7v7 in clause 7v71 in the matter preceding subclause 7,i71 by inserting for a performance period beginning before ,january #a1 #bjcb1 after published under clause 7i72 7vi7 in clause 7vi71 by striking under clauses 7i71 7iv71 and 7v7 and inserting under this subparagraph2 and 7vii7 in clause 7vii77,,ii71 by striking shall be and inserting subject to clause 7iii77,,iii77aa71 shall be2 7#c7 in paragraph 7#e7-- 7,a7 in subparagraph 7,b7-- 7i7 in clause 7ii7-- 7,i7 in subclause 7,i7-- 7aa7 by striking encourage and inserting with respect to a performance period beginning before ,january #a1 #bjcb1 encourage2 and 7bb7 by striking and at the end2 7,,ii7 in subclause 7,,ii71 by striking the period and inserting 2 and2 and 7,,iii7 by adding at the end the following new subclause3 7,,iii7 with respect to a performance period beginning on or after ,january #a1 #bjcb1 with respect to a year1 provide that in the case of a ,,mips eligible professional who fails to report on an applicable quality measure through the use of certified ,,ehr technology or clinical data registries1 the professional shall be treated as achieving the lowest potential score applicable to such measure4 2 and 7ii7 by adding at the end the following new clause3 7iii7 ,incentive to report on certain measures 7,i7 ,in general ,with respect to performance periods for years beginning on or after ,january #a1 #bjbg1 in the case a ,,mips eligible professional elects to report on a measure for such period that1 with respect to such professional and such period1 is a new measure described in subclause 7,,ii71 a substantively changed measure described in subclause 7,,iii71 or a measure described in paragraph 7#b77;,b77i7 for which the ,secretary is unable to establish a benchmark1 such professional shall be treated as achieving the highest possible score with respect to such measure4 7,,ii7 ,new measures ,for purposes of subclause 7,i71 a new measure described in this subclause1 with respect to a ,,mips eligible professional and performance period for a year1 is a measure applicable to such professional with respect to the performance category described in paragraph 7#b77;,a77i7 that is included in the final list of quality measures published under paragraph 7#b77;,d77i7 7or the list of quality measures described in paragraph 7#b77;,d77vi7 used by qualified clinical data registries under subsection 7m77#c77;,e77 for such year but was not included in such final list under paragraph 7#b77;,d77i7 7or the list under paragraph 7#b77;,d77vi77 for any of the previous #c years4 7,,iii7 ,substantively changed measure ,for purposes of subclause 7,i71 a substantively changed measure described in this subclause1 with respect to a ,,mips eligible professional and performance period for a year1 is a measure applicable to such professional with respect to the performance category described in paragraph 7#b77;,a77i7 that is included in the final list of quality measures published under paragraph 7#b77;,d77i7 7or the list of quality measures described in paragraph 7#b77;,d77vi7 used by qualified clinical data registries under subsection 7m77#c77;,e77 for such year and each of the previous #c years but that underwent a substantive change 7as defined by the ,secretary7 during any of such previous #c years4 2 and 7,b7 in subparagraph 7,e7-- 7i7 in clause 7i7-- 7,i7 in subclause 7,i77aa71 by inserting 7or1 with respect to #bjcb and subsequent years1 #fe percent7 after thirty percent2 7,,ii7 in subclause 7,,ii77aa71 by inserting 7or1 with respect to #bjcb and subsequent years1 #bj percent7 after thirty percent2 7,,iii7 in subclause 7,,iii71 by inserting 7or1 with respect to #bjcb and subsequent years1 #j percent7 after fifteen percent2 7,,iv7 in subclause 7,,iv71 by inserting 7or1 with respect to #bjcb and subsequent years1 #j percent7 after twenty-five percent2 and 7,v7 by adding at the end the following new subclause3 7,v7 ,care efficiency ,with respect to #bjcb and subsequent years1 #ae percent of such score shall be based on performance with respect to the category described in clause 7v7 of paragraph 7#b77;,a74 2 and 7ii7 in clause 7ii71 by inserting 7before #bjcb7 after ,in any year2 7#d7 in paragraph 7#aa77;,a77i71 by striking clauses 7i7 through 7iv7 of2 and 7#e7 in paragraph 7#ab77;,a77i77,,ii71 by striking and 7iv7 and inserting through 7v74 7b7 ,improvements to resource use performance category ,section #ahdh7r7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7r77 is amended-- 7#a7 in paragraph 7#b77;,h71 by adding at the end the following new sentence3 ,in making such revisions for #bjbg and subsequent years1 the ,secretary shall revise care episode groups and patient condition groups without regard to any target described in subparagraph 7,d77i77,i742 and 7#b7 in paragraph 7#e77;,c77i7-- 7,a7 by inserting 1 for years before #bjbg1 after shall2 and 7,b7 by inserting and shall1 for #bjbg and subsequent years1 use such care episode codes and patient condition codes before the semicolon4 #bjc4 ,quality reform task force ,section #ahdh7q77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#b77 is amended by adding at the end the following new subparagraph3 7,e7 ,quality ,reform ,task ,force 7i7 ,in general ,not later than #f months after the date of the enactment of this subparagraph1 the ,secretary shall establish a ,quality ,reform ,task ,force 7in this subparagraph referred to as the ,task ,force7 for purposes of issuing recommendations with respect to the use of quality1 resource use1 and care efficiency measures under this subsection4 7ii7 ,membership 7,i7 ,in general ,members of the ,task ,force shall be appointed by the ,secretary and shall include-- 7aa7 representatives of the ,department of ,health and ,human ,services2 7bb7 representatives of eligible professional organizations 7as defined in subparagraph 7,d77ii77,,ii772 and 7cc7 other experts determined appropriate by the ,secretary4 7,,ii7 ,appropriate representation ,in making appointments under subclause 7,i71 the ,secretary shall ensure that-- 7aa7 each medical specialty or subspecialty as determined appropriate by the ,secretary in which a ,,mips eligible professional may practice is adequately represented on the ,task ,force through a relevant organization described in subclause 7,i77bb7 if a measure relating to such specialty or subspecialty is under consideration2 7bb7 a majority of the ,task ,force is comprised of designated health care practitioners 7as defined in section #ahff;,h7f77 or representatives of eligible professional organizations described in subclause 7,i77bb72 7cc7 not more than #c members of the ,task ,force are representatives of group health plans1 health insurance issuers1 or ,medicare ,advantage organizations2 and 7dd7 at least #a designated health care practitioner who is not part of an excluded practice 7as defined in section #ahff;,h7f77 who practices in a medical specialty or subspecialty is included on the ,task ,force when the ,task ,force is considering measures relating to such specialty or subspecialty4 7,,iii7 ,maximum number of members ,the number of members of the ,task ,force may not exceed #be4 7iii7 ,duties 7,i7 ,in general ,the ,task ,force shall1 with respect to each performance period beginning on or after ,january #a1 #bjcb-- 7aa7 issue recommendations on quality1 resource use1 and care efficiency measures for use under this subsection2 and 7bb7 update any recommendations previously issued by the ,task ,force as determined appropriate by the ,task ,force4 7,,ii7 ,requirements ,the ,task ,force-- 7aa7 shall ensure that any measure recommended under subclause 7,i7 conforms with applicable clinical guidelines developed by a professional organization representing the medical specialty or subspecialty to be subject to such measure and is designed to promote quality of care1 improve resource use1 or reduce costs2 7bb7 may only recommend a quality measure to the extent that data for such measure can be submitted through certified ,,ehr technology1 administrative or billing claims1 or a qualified clinical data registry2 7cc7 shall take into account the circumstances of practitioners in specialty types that furnish services that do not typically involve face-to-face interaction with patients 7or that typically involve such interaction only at the direction of another practitioner ordering such services72 7dd7 shall1 in reviewing measures and making recommendations1 take into account-- 7,,aa7 how the measure relates to an episode of care or a continuum of health care1 as applicable1 involved2 7,,bb7 the context of the respective performance category of such measure and how the measure may serve to complement or align with measures applicable in other performance categories under this subsection2 7,,cc7 measures developed by qualified clinical data registries2 and 7,,dd7 consult with such registries as necessary in the development and evaluation of measures2 and 7ee7 ensure that the role of qualified clinical data registries in the development1 maintenance1 and refinement of measures is preserved or strengthened4 7iv7 ,secretarial response to recommendations 7,i7 ,in general ,not later than #abj days after the ,task ,force issues recommendations with respect to measures for a performance period1 the ,secretary shall transmit to the ,task ,force and to the ,committee on ,ways and ,means and the ,committee on ,energy and ,commerce of the ,house of ,representatives and the ,committee on ,finance of the ,senate a formal written response that1 with respect to each such recommendation1 affirmatively states one of the following3 7aa7 ,the ,secretary will implement the recommendation as issued4 7bb7 ,the ,secretary will implement the recommendation with specified modifications1 accompanied by a written explanation of the modifications and the clinical1 administrative1 or program integrity basis for each such modification4 7cc7 ,the ,secretary will implement the recommendation in part1 accompanied by a written explanation of which elements will be implemented and the basis for declining the remainder4 7dd7 ,the ,secretary declines to implement the recommendation1 accompanied by a detailed written explanation of the clinical1 administrative1 or program integrity basis for the decision4 7,,ii7 ,inclusion of measures 7aa7 ,in general ,the ,secretary shall include a measure receiving a recommendation from the ,task ,force for a performance period in the final measures list published under subparagraph 7,d77i7 for such performance period unless the ,secretary1 not later than #ij days after receiving the recommendation1 publishes in the ,federal ,register a written determination explaining the specific clinical1 administrative1 or program integrity basis for excluding the measure4 7bb7 ,further requirements for certain recommendations ,notwithstanding item 7aa71 with respect to any measure recommended by the ,task ,force for a performance period with the support of not fewer than #ge percent of the members of the ,task ,force1 the ,secretary may not exclude such measure from the final measures list published under subparagraph 7,d77i7 for such performance period unless the ,secretary-- 7,,aa7 consults with the ,task ,force regarding such proposed exclusion2 and 7,,bb7 includes in the written determination under subclause 7,i7 a response to the ,task ,force's position and a specific finding that the basis for exclusion outweighs the clinical judgment of the ,task ,force4 7,,iii7 ,annual report ,not later than ,march #a of each year beginning with the first calendar year after the ,task ,force issues its initial recommendations1 the ,secretary shall submit to the ,committee on ,ways and ,means and the ,committee on ,energy and ,commerce of the ,house of ,representatives and the ,committee on ,finance of the ,senate1 and shall make publicly available on the website of the ,centers for ,medicare ,medicaid ,services1 a report that includes1 for each recommendation issued by the ,task ,force during the preceding calendar year-- 7aa7 the text of the recommendation and the vote of the ,task ,force2 7bb7 the ,secretary's response under subclause 7,i72 7cc7 the outcome with respect to the final measures list published under subparagraph 7,d77i71 including whether the recommended measure was included1 included with modifications1 or excluded2 and 7dd7 if the measure was excluded or modified1 the written justification provided under subclause 7,i74 4 #bjd4 ,modification of ,,mips payment adjustments 7a7 ,in general ,section #ahdh7q77#f77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#f77;,b77 is amended-- 7#a7 in clause 7iii71 by striking and at the end2 7#b7 in clause 7iv71 by amending such clause to read as follows3 7iv7 for #bjbb through #bjbf1 #i percent2 2 and 7#c7 by adding at the end the following new clauses3 7v7 for #bjbg through #bjca1 #b percent2 7vi7 for #bjcb1 #c percent2 7vii7 for #bjcc1 #d percent2 and 7viii7 for #bjcd1 #e percent4 4 7b7 ,no reduction in case of failure ,to provide feedback 7#a7 ,in general ,section #ahdh7q77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#f77 is amended by adding at the end the following new subparagraph3 7,g7 ,no reduction in payments in case of failure to provide feedback ,notwithstanding the preceding provisions of this paragraph1 in the case that the ,secretary fails to provide a ,,mips eligible professional feedback required under paragraph 7#ab7 with respect to the performance of such professional for a performance period with respect to a year for administrative claims-based measures included in the performance categories described in subparagraph 7,a77i77,,ii7 of such paragraph1 if application of subparagraph 7,e7 would result in a negative adjustment to payment for covered professional services furnished by such professional during such year1 the product otherwise determined under such subparagraph for such professional and year shall be deemed to be zero4 4 7#b7 ,modification of feedback requirements ,section #ahdh7q77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#ab77 is amended-- 7,a7 in subparagraph 7,a77i77,,ii71 by inserting 7and1 beginning with #bjcb1 shall1 on a quarterly basis and with respect to administrative claims-based measures in accordance with clause 7vi77 after may2 and 7,b7 by adding at the end the following new clause3 7vi7 ,feedback on administrative-claims based measures ,with respect to quarters beginning on or after ,january #a1 #bjcb1 the ,secretary shall1 not later than #fj days after each such quarter1 provide to each ,,mips eligible professional1 with respect to administrative claims-based measures included in the performance categories described in subparagraph 7,a77i77,,ii71 feedback on such professional's performance1 including-- 7,i7 a description of the patients and episodes attributed with respect to such measures for purposes of assessing the performance of such professional during such quarter2 7,,ii7 an identification of the items and services furnished by such professional or another individual that will contribute to the assessment of the performance of such professional during such quarter with respect to such measures2 and 7,,iii7 an identification of whether each item or service identified under subclause 7,,ii7 for the quarter was furnished by such professional or another individual 7and1 in the case that the performance of such professional for such quarter with respect to such measures is assessed based on participation in a group practice or other group1 whether each such item or service was furnished by such professional1 another individual in such group1 or another individual outside of such group74 4 7c7 ,extension of additional incentive payments for certain professionals ,section #ahdh7q77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#f77 is amended-- 7#a7 in subparagraph 7,c7-- 7,a7 by inserting and for #bjcb and each subsequent year after #bjbd12 and 7,b7 by inserting 7other than1 with respect to #bjcb and each subsequent year1 such a professional that is part of an excluded practice 7as defined in section #ahff;,h7f777 after ,,mips eligible professional2 and 7#b7 in subparagraph 7,f77iv77,i71 by inserting and for #bjcb and each subsequent year before the period4 7d7 ,reduction in positive adjustments for certain professionals ,section #ahdh7q77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#f771 as amended by subsection 7b77#a71 is further amended by adding at the end the following new subparagraph3 7,h7 ,reduction in positive adjustments for certain professionals ,the ,secretary shall reduce each positive ,,mips adjustment factor otherwise determined under this paragraph for a year 7beginning with #bjcb7 for a ,,mips eligible professional who is part of an excluded practice 7as defined in section #ahff;,h7f77 by #ej percent4 ,the preceding sentence shall be applied in a budget neutral manner4 4 #bje4 ,modifying requirements and approval periods for qualified clinical data registries ,section #ahdh7m77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 is amended-- 7#a7 in clause 7i71 by adding at the end the following3 ,beginning ,january #a1 #bjbg1 such requirements shall include a requirement that the entity-- 7,i7 be established and operated by a professional society that is controlled or led by a designated practitioner 7as defined in section #ahff;,h7 and that has demonstrated expertise in developing evidence-based clinical practice guidelines and quality measures for improving patient outcomes2 7,,ii7 demonstrates adherence to data quality and fidelity standards1 including standards relating to data elements1 data completeness1 and validation processes2 7,,iii7 demonstrates capacity to generate timely1 actionable feedback to participating practitioners to support continuous quality improvement and track practitioner use of such feedback2 7,,iv7 demonstrates transparency in measure development 7including the methodology used in such measures and any risk adjustment used in such measures72 and 7,v7 has established self-audit or review processes focusing on data accuracy1 measure integrity1 and appropriate use of results4 2 and 7#b7 in clause 7v71 by adding the following flush matter at the end3 ,a determination or designation made under this clause on or after ,january #a1 #bjbg1 shall be effective for a period of #c years4 ,at the end of such period1 the ,secretary 7or1 in the case of a designation made by an organization1 such organization7 may extend such determination or designation 7as applicable7 for subsequent #c-year periods based on a showing by such entity that such entity continues to meet the requirements of clause 7i74 4 #bjf4 ,expanded access to claims data to facilitate research and quality improvement 7a7 ,in general ,not later than ,january #a1 #bjbg1 the ,secretary of ,health and ,human ,services shall establish a process to allow a qualified clinical data registry under section #ahdh7m77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7m77#c77;,e77 or a clinician-led clinical data registry under section #djje of the #bast ,century ,cures ,act 7#db ,u4,s4,c4 #cjj;jj-#ad note7 to request claims data described in subsection 7b7 7in a form and manner determined to be appropriate by the ,secretary7 for the purposes of-- 7#a7 linking such data with clinical outcomes data2 7#b7 conducting quality assessments and quality improvement activities of providers of services 7as defined in subsection 7u7 of section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 and suppliers 7as defined in subsection 7d7 of such section771 reporting the results of such assessments and activities to such providers and suppliers1 and performing risk-adjusted1 scientifically valid analyses and research to support quality improvement or patient safety2 and 7#c7 publishing research and quality improvement analyses1 which may include deidentified combined claims and clinical outcomes data4 7b7 ,claims data described ,for purposes of subsection 7a71 the claims data described in this subsection-- 7#a7 are-- 7,a7 claims data under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq472 and 7,b7 if the ,secretary determines appropriate1 claims data under the ,medicaid program under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq47 and the ,state ,children's ,health ,insurance ,program under title ,,xxi of such ,act 7#db ,u4,s4,c4 #acig;aa et seq472 and 7#b7 may include provider-specific claims data1 clinical specialty-specific claims data1 ,state-specific claims data1 or nationwide claims data4 7c7 ,treatment of qualified clinical data registries and clinician-,led clinical data registries ,for the purposes of this section1 qualified clinical data registries and clinician-led clinical data registries shall not be required to be qualified entities1 as defined in section #ahgd7;e77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7e77#b771 or quasi-qualified entities1 to access claims data pursuant to subsection 7a74 7d7 ,fee ,data described in subsection 7b7 shall be made available to a qualified clinical data registry or clinician-led clinical data registry under this section at a reasonable fee equal to the cost of making such data available4 ,any fee collected pursuant to the preceding sentence shall be deposited into the ,centers for ,medicare ,medicaid ,services ,program ,management ,account4 #bjg4 ,modification of appropriate use criteria data collection for applicable imaging services 7a7 ,in general ,section #ahcd7q7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7q77 is amended-- 7#a7 in paragraph 7#c77;,b77ii7-- 7,a7 in subclause 7,,iv71 by striking generates and provides to the ordering professional a certification or documentation that2 and 7,b7 by adding at the end the following new subclause3 7,,viii7 ,beginning ,january #a1 #bjbg1 the mechanism provides to the ,secretary-- 7aa7 the information described in subclauses 7,,iii7 and 7,,iv72 7bb7 the information described in paragraph 7#d77;,b72 and 7cc7 such other information as the ,secretary determines to be appropriate1 at such time1 and in such form and manner1 as the ,secretary may specify4 2 7#b7 in paragraph 7#d7-- 7,a7 in subparagraph 7,a71 by striking clause 7ii7 and inserting the following3 7ii7 beginning ,january #a1 #bjbg1 comply with such requirements as the ,secretary may establish4 2 7,b7 in subparagraph 7,b7-- 7i7 in the heading1 by striking furnishing professional and inserting qualified clinical decision support mechanism2 7ii7 in the matter preceding clause 7i7-- 7,i7 by striking with ,january #a1 #bjag and inserting ,january #a1 #bjbg2 and 7,,ii7 by striking payment for such service may only be made if the claim for the service includes and inserting the qualified decision support mechanism shall maintain and report to the ,secretary under subparagraph 7,f72 and 7iii7 in clause 7iii71 by striking 7if different from the furnishing professional72 7,c7 in subparagraph 7,c71 by adding at the end the following new clauses3 7iv7 ,clinical trials ,an applicable imaging service that is ordered for an individual as part of a clinical trial4 7v7 ,small and rural practices ,an applicable imaging service ordered by an ordering professional practicing in a small practice 7consisting of #ae or fewer ordering professionals71 or a practice in a health professional shortage area 7as designated under section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act7 located in a rural area4 7vi7 ,specified exemptions ,the following types of applicable imaging services3 7,i7 ,a mammography4 7,,ii7 ,a lung cancer screening performed using computed tomography4 7,,iii7 ,a colonography performed using computed tomography4 7,,iv7 ,such a service furnished to treat an emergency medical condition or a suspected emergency medical condition4 7,v7 ,such other preventive or screening imaging services as the ,secretary determines appropriate4 2 7,d7 in subparagraph 7,d71 by adding at the end the following new clause3 7iv7 ,any other payment system determined appropriate by the ,secretary4 2 and 7,e7 by adding at the end the following new subparagraphs3 7,e7 ,furnishing professional requirement ,beginning ,january #a1 #bjbg1 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 the furnishing professional shall include the national provider identifier of the ordering professional 7if different from the furnishing professional7 on the claim for the service4 7,f7 ,reporting requirements ,the ,secretary shall provide1 through guidance or rulemaking1 information on appropriate ways that each qualified clinical decision support mechanism may report the information maintained under subparagraph 7,b7 to the ,secretary to support the ,secretary in implementing paragraphs 7#e7 and 7#f74 2 7#c7 in paragraph 7#e7-- 7,a7 in the heading1 by striking outlier and inserting low compliant2 7,b7 by striking subparagraphs 7,a7 and 7,b7 and inserting the following3 7,a7 ,in general ,with respect to applicable imaging services furnished on or after ,january #a1 #bjbg1 the ,secretary shall determine on an annual basis the total number of ordering professionals who are designated as low compliant ordering professionals under subparagraph 7,b74 7,b7 ,low compliant ordering professionals ,the ,secretary shall designate ordering professionals with a compliance rate 7as determined under subparagraph 7,d77 lower than an amount determined by the ,secretary as low compliant ordering professionals4 2 7,c7 in paragraph 7,c71 by striking outlier and inserting low compliant2 7,d7 by striking subparagraph 7,d7 and inserting the following3 7,d7 ,determination of compliance rate 7i7 ,in general 7,i7 ,compliance rates ,for applicable imaging services furnished on or after ,january #a1 #bjbg1 the ,secretary shall determine a compliance rate 7as defined in clause 7ii77 for each ordering professional for a period specified by the ,secretary4 7,,ii7 ,use of data ,in determining a compliance rate for an ordering professional under subclause 7,i71 the ,secretary shall use data made available to the ,secretary by qualified clinical decision support mechanisms published in the list under paragraph 7#c77;,c7 that were consulted by the ordering professional for the period specified by the ,secretary under subclause 7,i74 7ii7 ,definition of compliance rate 7,i7 ,in general ,in this subparagraph1 the term #8compliance rate' means1 with respect to the requirement under paragraph 7#d77;,a7 that an order from an ordering professional for an applicable imaging service was the subject of consultation with a qualified decision support mechanism1 the ratio 7expressed as a percentage7 of-- 7aa7 the number of orders from such ordering professional included in a report from one or more qualified decision support mechanisms described in paragraph 7#c77;,b72 and 7bb7 the aggregate number of such orders from such ordering professional for such period4 7,,ii7 ,exclusion of excepted orders ,in calculating the compliance rate for an ordering professional under subclause 7,i71 the ,secretary shall exclude from the total number of orders in item 7bb7 of such subclause any order for an applicable imaging service described in paragraph 7#d77;,c74 2 and 7,e7 in subparagraph 7,e71 by striking outlier and inserting low compliant2 7#d7 by striking paragraph 7#f7 and inserting the following3 7#f7 ,study and report on low compliant ordering professionals and utilization of applicable imaging services 7,a7 ,in general ,not later than ,january #a1 #bjca1 and every #e years thereafter1 the ,secretary shall conduct a study regarding the compliance rates calculated under paragraph 7#e7 and submit a report to ,congress that-- 7i7 discusses-- 7,i7 such rates and compliance with this subsection2 7,,ii7 the impact this subsection has on the utilization of applicable imaging services2 and 7,,iii7 potential mechanisms for improving compliance with this subsection1 including-- 7aa7 prior authorization for applicable imaging services ordered by low compliant ordering professionals2 7bb7 any payment adjustment related to the services1 or a subset of services1 that the ,secretary may designate under the fee schedule under section #ahdh2 or 7cc7 other mechanisms determined appropriate by the ,secretary2 and 7ii7 proposes alternative compliance rate thresholds for low compliant ordering professionals for purposes of paragraph 7#e77;,b74 2 and 7#e7 by adding at the end the following new paragraph3 7#h7 ,specialty society endorsement ,in specifying applicable appropriate use criteria for applicable imaging services under paragraph 7#b7 and qualified clinical decision support mechanisms under paragraph 7#c71 the ,secretary shall substantially adhere to the approach described in section #dad4id of title #db1 ,code of ,federal ,regulations 7as in effect on ,january #a1 #bjbc74 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall apply with respect to items and services furnished on or after ,january #a1 #bjbg4 #bjh4 ,rules of construction 7a7 ,in general ,none of the amendments made by this title may be construed to-- 7#a7 transfer ownership of a measure developed by a qualified clinical data registry to the ,secretary or any other entity without the authorization of the qualified clinical data registry2 or 7#b7 require a qualified clinical data registry to relinquish intellectual property rights as a condition of having a measure considered for inclusion in the annual final list of measures4 7b7 ,,ip ,the ,secretary of ,health and ,human ,services shall recognize that measures developed by qualified clinical data registries are the intellectual property of such registries1 including any specifications1 methodologies1 scoring algorithms1 specialty or subspecialty guidelines1 and related materials associated with such measures4 ,nothing in this title shall prohibit a qualified clinical data registry from voluntarily licensing a measure to the ,secretary or other entities under terms agreed to by such registry4 ,,iii ,,apm improvement #cja4 ,qualifying ,,apm participant threshold freeze 7a7 ,in general ,section #ahcc7z77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7z77#b77 is amended-- 7#a7 in subparagraph 7,b7-- 7,a7 in the header1 by striking #bjbf and #bjbh and inserting #bjbi2 and 7,b7 in the matter preceding clause 7i71 by striking #bjbf and #bjbh and inserting #bjbi2 and 7#b7 in subparagraph 7,c7-- 7,a7 in the header1 by striking #bjbg and #bjbi and inserting #bjcj2 and 7,b7 in the matter preceding clause 7i71 by striking #bjbg and #bjbi and inserting #bjcj4 7b7 ,conforming amendments ,section #ahdh7q77#a77;,c77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#a77;,c77iii77 is amended-- 7#a7 in subclause 7,,ii71 in the matter preceding item 7aa71 by striking #bjbf and #bjbh and inserting #bjbi2 and 7#b7 in subclause 7,,iii71 the matter preceding item 7aa71 by striking #bjbg and #bjbi and inserting #bjcj4 7c7 ,authority ,to modify thresholds ,section #ahdh7q77#a77;,c77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7q77#a77;,c77iii77 is amended-- 7#a7 in subclause 7,,ii7-- 7,a7 in item 7aa71 by inserting 7or such lower percentage as may be specified by the ,secretary7 after #dj percent2 and 7,b7 in item 7bb71 by inserting 7or such lower percentages as may be specified by the ,secretary7 after respectively2 and 7#b7 in subclause 7,,iii7-- 7,a7 in item 7aa71 by inserting 7or such lower percentage as may be specified by the ,secretary7 after #ej percent2 and 7,b7 in item 7bb71 by inserting 7or such lower percentages as may be specified by the ,secretary7 after respectively4 #cjb4 ,,cmi model requirements ,section #aaae;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 is amended-- 7#a7 in subsection 7b77#c77;,b71 by inserting 1 pursuant to notice-and-comment rulemaking1 after ,the ,secretary shall2 7#b7 in subsection 7c71 in the flush matter at the end1 by adding at the end the following new sentence3 ,the ,secretary may terminate a model expanded under this subsection prior to the date set for such termination at the time of such expansion only pursuant to notice and comment rulemaking42 and 7#c7 in subsection 7g71 by adding at the end the following new sentence3 ,each such report submitted in #bjbg or a subsequent year shall contain1 with respect to each model tested under subsection 7b71 a description of any savings generated by such model44 #cjc4 ,report on barriers to participation in value-based payment models ,not later than ,december #ca1 #bjbi1 the ,comptroller ,general of the ,united ,states1 in consultation with the ,medicare ,payment ,advisory ,commission1 shall submit to the ,committees on ,energy and ,commerce and ,ways and ,means of the ,house of ,representatives1 and the ,committee on ,finance of the ,senate1 a report on ongoing barriers to participation in value-based payment models for specialty providers under the ,medicare program4 ,such report shall contain specific policy recommendations to reduce such barriers4 ,,iv ,physician payment improvements #dja4 ,updating the budget neutrality threshold ,section #ahdh7;c77#b77;,b77ii77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77ii77,,ii77 is amended-- 7#a7 by striking ,subject to and inserting the following3 7aa7 ,in general ,subject to 2 7#b7 in item 7aa71 as inserted by paragraph 7#a71 by striking #bj1jjj1jjj and inserting the amount specified in item 7bb7 for such year2 and 7#c7 by adding at the end the following new items3 7bb7 ,amount specified ,for purposes of item 7aa71 subject to item 7cc71 the amount specified in this item is-- 7,,aa7 for years before #bjbh1 #bj1jjj1jjj2 7,,bb7 for #bjbh1 #eg1fdj1jjj2 and 7,,cc7 for #bjbi and each subsequent year1 the amount specified in this item for the preceding year4 7cc7 ,indexing limitation on annual adjustments ,for #bjcc and every subsequent fifth year1 the ,secretary shall increase the amount specified in item 7bb7 for such year by the cumulative percentage increase in the ,,mei 7as defined in section #ahdb7;i77#c77 applicable to physicians' services for each year occurring during the #e-year period ending on the last day of the preceding year4 4 #djb4 ,budget neutrality corrections relating to estimated utilization 7a7 ,in general ,section #ahdh7;c77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77 is amended by adding at the end the following new clause3 7vii7 ,budget neutrality corrections relating to estimated utilization 7,i7 ,in general ,in the case of a budget neutrality adjustment applied pursuant to clause 7ii77,,ii7 for a year 7beginning with #bjbi7 that is determined in part using estimated utilization 7as defined in subclause 7,,ii77bb77 with respect to a specified service 7as defined in subclause 7,,ii77cc771 the ,secretary shall1 as part of the final rule establishing the physician fee schedule under this section for the assumption correction period 7as defined in subclause 7,,ii77aa77 with respect to such year-- 7aa7 determine the difference between expenditures for such service in such year using estimated utilization and actual utilization for such service 7in a manner determined appropriate by the ,secretary72 and 7bb7 in the case that the ,secretary determines the difference described in item 7aa7 is greater than the threshold amount 7as defined in subclause 7,,ii77dd77 for such year1 adjust the conversion factor under this section for such assumption correction period by such amount to reconcile such difference 7which may be positive or negative71 as determined by the ,secretary4 7,,ii7 ,definitions ,for purposes of this clause3 7aa7 ,assumption correction period ,the term assumption correction period means1 with respect to a year1 the second year beginning after such year4 7bb7 ,estimated utilization ,the term estimated utilization means an estimate of utilization used for purposes of applying clause 7ii77,,ii74 7cc7 ,specified service ,the term specified service means1 with respect to a year1 a service-- 7,,aa7 with expected expenditures for such year under this section based on estimated utilization that exceed the threshold amount 7as defined in item 7dd77 for such year2 and 7,,bb7 for which payment had been bundled into payment for another service during the preceding year and for which a separate payment or add-on payment is made during such year4 7dd7 ,threshold amount ,the term threshold amount means1 with respect to a year1 #j4a percent of the total estimated expenditures under this part for services furnished under this section during such year4 4 7b7 ,nonapplication of budget neutrality to reconciliation adjustments ,section #ahdh7;c77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b77 is amended-- 7#a7 in clause 7iv7-- 7,a7 in subclause 7,v71 by striking and at the end2 7,b7 in subclause 7,,vi71 by striking the period and inserting 2 and2 and 7,c7 by adding at the end the following new subclause3 7,,vii7 clause 7vii77,i77bb7 for an assumption correction period 7as defined in clause 7vii77,,ii77 shall not be taken into account in applying clause 7ii77,,ii7 with respect to such period4 2 and 7#b7 in clause 7v71 by adding at the end the following new subclause3 7,,xii7 ,reductions attributable to an assumption correction ,for an assumption correction period 7as defined in clause 7vii77,,ii771 reduced expenditures attributable to application of clause 7vii77,i77bb7 with respect to such period4 4 #djc4 ,timely updates to direct costs used to calculate practice expense ,r,v,us ,section #ahdh7;c77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b771 as amended by section #djb1 is further amended by adding at the end the following new clause3 7viii7 ,timely updates to direct costs used to calculate practice expense relative value units 7,i7 ,simultaneous updates to direct cost inputs at least once every #e years ,the ,secretary shall1 not less often than every #e years1 update the prices and rates1 as applicable1 on a category-wide basis for each of the categories of direct cost inputs described in subclause 7,,ii7 used in the methodology for calculating the practice expense relative value units under this subsection for physicians' services4 ,updates made pursuant to the previous sentence shall be made in the same year for all categories of direct cost inputs described in such subclause4 7,,ii7 ,direct cost inputs categories described ,for purposes of this clause1 the categories of direct cost inputs described in this subclause are clinical staff wage rates1 prices of medical supplies1 prices of equipment1 and any other category of such inputs used in the methodology described in subclause 7,i7 7as specified by the ,secretary74 7,,iii7 ,consultation ,in making the updates under this clause1 the ,secretary shall consult with relevant stakeholders1 including physician specialty societies4 4 #djd4 ,limitation on year-to-year conversion factor variance ,section #ahdh7;c77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;c77#b77;,b771 as amended by sections #djb and #djc1 is further amended by adding at the end the following new clause3 7ix7 ,limitation on conversion factor variance 7,i7 ,in general ,beginning with #bjbg1 the ,secretary may not1 for purposes of complying with clause 7ii77,,ii71 apply a budget neutrality adjustment to a conversion factor established under subsection 7d7 for such year that would cause such factor1 not taking into account any adjustment to such factor for such year provided under such subsection1 to vary by more than #b4e percent compared to such factor so established for the preceding year4 7,,ii7 ,continued applicability of budget neutrality requirement ,nothing in subclause 7,i7 may be construed to alter the requirement described in clause 7ii77,,ii74 4