H.R. 8622

119 HR 8622 IH: Medicare Physician Data-driven Performance Payment System Act of 2026
 U.S. House of Representatives
 2026-04-30
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 I  119th CONGRESS  2d Session  H. R. 8622  IN THE HOUSE OF REPRESENTATIVES   April 30, 2026   Mrs. Miller-Meeks  (for herself and  Mr. Conaway ) introduced the following bill; which was referred to the  Committee on Energy and Commerce , and in addition to the Committee on  Ways and Means , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned   A BILL
To amend title XVIII of the Social Security Act to transform the Merit-based Incentive Payment System into the Data-driven Performance Payment System under the Medicare physician fee schedule, and for other purposes.
1.
Short title
This Act may be cited as the   Medicare Physician Data-driven Performance Payment System Act of 2026  .
2.
Transforming the Merit-based Incentive Payment System into the Data-driven Performance Payment System
(a)
Implementation of the Data-driven Performance Payment System
(1)
In general
Effective January 1, 2027, there is established the Data-driven Performance Payment System, which shall consist of the payment system under section 1848(q) of the Social Security Act ( 42 U.S.C. 1395w–4(q) ), including as amended by this section.
(2)
References
Subject to paragraph (3), any reference to the payment system under section 1848(q) of the Social Security Act ( 42 U.S.C. 1395w–4(q) ), including the terms  Merit-based Incentive Payment System  and  MIPS , shall be deemed a reference to the  Data-driven Performance Payment System  and  DPPS , respectively.
(3)
Transition
In order to provide for an orderly transition and avoid provider confusion, the Secretary of Health and Human Services shall provide for an appropriate transition in the use of the terms  Merit-based Incentive Payment System  (and  MIPS ) and  Data-driven Performance Payment System  (and  DPPS ) in reference to the payment system under section 1848(q) of the Social Security Act ( 42 U.S.C. 1395w–4(q) ). Before the completion of such transition, any reference to the  Data-driven Performance Payment System  (or  DPPS ) shall be deemed to include a reference to the  Merit-based Incentive Payment System .
(b)
Reforming application of adjustment factors
(1)
In general
Section 1848(q)(6) of the Social Security Act ( 42 U.S.C. 1395w–4(q)(6) ) is amended—
(A)
in subparagraph (A)—
(i)
by inserting  for years before 2028,  after  Taking into account paragraph (1)(G), ;
(ii)
in clause (ii)—
(I)
in subclause (I), by striking  clause (iii)  and inserting  subclause (III) ;
(II)
in subclause (II), by striking  clause (iv)  and inserting  subclause (IV) ; and
(III)
by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively, and adjusting the margins accordingly;
(iii)
in clause (iii), by striking  clause (ii)(I)  and inserting  subclause (II)(aa) ;
(iv)
in clause (iv)—
(I)
by striking  subclause (II)  and inserting  item (bb) ;
(II)
by striking  clause (ii)(II)  and inserting  subclause (II)(bb) ; and
(III)
by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively, and adjusting the margins accordingly;
(v)
by redesignating clauses (i) through (iv) as subclauses (I) through (IV) and adjusting the margins accordingly;
(vi)
by striking  Taking into account  and inserting the following:
(i)
Adjustment factors for years before 2028
Taking into account
 ; and
(vii)
by adding at the end the following new clause:
(ii)
Adjustment factors for 2028 and subsequent years
For 2028 and each subsequent year, the DPPS adjustment factor specified under this subparagraph for a DPPS eligible professional for such year shall be equal to—
(I)
subject to subparagraph (F)(v), in the case of a DPPS eligible professional with a composite performance score for such year above the performance threshold established under subparagraph (D) for such year, 1.25;
(II)
in the case of a DPPS eligible professional with a composite performance score for such year equal to such performance threshold, 1;
(III)
in the case of a DPPS eligible professional not described in  subclause (IV)  with a composite performance score for such year below such performance threshold, 0.75; and
(IV)
in the case of a DPPS eligible professional who is treated under paragraph (5)(B)(i) as achieving the lowest potential score applicable to each applicable measure or activity that is required to be reported by the professional for such year, 0.5.
 ;
(B)
in subparagraph (B)(iv), by striking  and subsequent years  and inserting  and each subsequent year through 2027 ;
(C)
in subparagraph (D)(i), by striking  that are positive, negative, and zero ; and
(D)
in subparagraph (E)—
(i)
by inserting  and ending with 2027  after  beginning with 2019 ;
(ii)
in clause (ii)—
(I)
by striking  subparagraph (A)  and inserting  subparagraph (A)(i) ; and
(II)
by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively;
(iii)
by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively;
(iv)
by striking  In the case of  and inserting the following:
(i)
Application of adjustment factors for years before 2028
In the case of
 ; and
(v)
by adding at the end the following new clause:
(ii)
Application of adjustment factors for 2028 and subsequent years
(I)
In general
In the case of covered professional services (as defined in subsection (k)(3)(A)) furnished by a DPPS eligible professional during a year (beginning with 2028), subject to subclauses (II) and (III), for purposes of determining the amount paid under this part with respect to such covered professional services and DPPS eligible professional for such year, the update to the nonqualifying APM conversion factor established under subsection (d) applicable to such services and such professional for such year shall be multiplied by the adjustment factor specified under subparagraph (A)(ii) with respect to such professional and such year.
(II)
Nonapplication to certain updates
 Subclause (I)  shall not apply with respect to covered professional services furnished during a year in the case that the update to the conversion factor described in such subclause for such year is less than 0 percent.
(III)
Nonapplication of certain adjustment factors for lack of timely feedback reports
(aa)
In general
 Subclause (I)  shall not apply with respect to covered professional services furnished by a DPPS eligible professional during a year if the DPPS eligible professional does not receive timely feedback in accordance with  item (bb)  with respect to each quarter of the performance period for such year and would, without application of this item, otherwise be subject to the DPPS adjustment factor described in subparagraph (A)(ii)(III) for such year.
(bb)
Timely feedback described
For purposes of  item (aa) , a DPPS eligible professional receives timely feedback in accordance with this item with respect to a quarter of a performance period if, not later than the date that is 60 days after the last day of such quarter, such professional receives the confidential feedback required under paragraph (12) on the performance of such professional during such quarter with respect to administrative claims-based measures included in the performance categories described in subparagraph (A)(i)(II) of such paragraph, including—
(AA)
a description of the patients and episodes attributed with respect to such measures for purposes of assessing the performance of such professional during such quarter;
(BB)
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 measures; and
(CC)
an identification of whether each item or service identified under  subitem (BB)  for the quarter was furnished by such professional or another individual (and, 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 group, whether each such item or service was furnished by such professional, another individual in such group, or another individual outside of such group).
(IV)
Hold harmless
In computing the amount of any coinsurance under section 1833(a)(1) and the expenses incurred for applying the deductible under section 1833(b) with respect to covered professional services furnished by a DPPS eligible professional for a year, such coinsurance and incurred expenses shall be computed as if the update to the conversion factor applicable to such services and professional for such year were not subject to the adjustment factor under subclause (I).
 .
(2)
Conforming amendment
Section 1848(d)(20) of the Social Security Act ( 42 U.S.C. 1395w–4(d)(20) ) is amended by inserting  , subject to subsection (q)(6)(E)(ii),  before  the update to the nonqualifying APM conversion factor .
(c)
Reforming performance thresholds
Section 1848(q)(6)(D) of the Social Security Act ( 42 U.S.C. 1395w–4(q)(6)(D) ) is amended—
(1)
in clause (i), by striking  clauses (iii) and (iv)  and inserting  clauses (iii) through (vi) ; and
(2)
by adding at the end the following new clauses:
(v)
Temporary extension of special rules
(I)
In general
With respect to each of 2028 through 2033 (or such later year as determined by the Secretary pursuant to  subclause (II) ), the Secretary shall establish a performance threshold for purposes of determining DPPS adjustment factors under subparagraph (A) for such year in accordance with the requirements described in clause (iii), except that such performance threshold may not be greater than 75 points.
(II)
Flexibility to extend special rule
In the case that extraordinary circumstances, including a natural disaster, a public health emergency, or cybersecurity incident, affect reporting, data collection, or the assessment of performance under this subsection for 2034, the Secretary may extend the application of  subclause (I)  until the first year for which such extraordinary circumstances do not affect reporting, data collection, or assessment of performance under this subsection (as determined by the Secretary).
(III)
Optional transition period
With respect to the year immediately following the last year with respect to which  subclause (I)  applies (after application of  subclause (II) , if applicable), the Secretary may, pursuant to notice and comment rulemaking, establish a performance threshold for purposes of determining DPPS adjustment factors under subparagraph (A) for such year and such subsequent consecutive years as specified by the Secretary in a manner that provides for a gradual and incremental transition from the performance threshold established under  subclause (I)  to the performance threshold established under  clause (vi) .
(vi)
Replacement performance threshold
(I)
In general
With respect to the year immediately following the last year with respect to which  clause (v)  applies and each subsequent year, the performance threshold established under this subparagraph for purposes of determining DPPS adjustment factors under subparagraph (A) shall be computed in accordance with the replacement performance threshold methodology established by the Secretary under in  subclause (II) .
(II)
Replacement performance threshold methodology
For purposes of  subclause (I) , the Secretary shall, pursuant to notice and comment rulemaking and based on the recommendations submitted under subclause (III), establish a methodology (referred to in this clause as the  replacement performance threshold methodology ) to be used instead of the mean or median described in clause (i) for computing the performance threshold applied under this subparagraph.
(III)
Recommendations for replacement performance threshold methodology
Not later than December 31, 2029, the Comptroller General of the United States shall, in accordance with  subclause (IV) , submit to Congress and the Secretary a report including detailed recommendations on a methodology to be used instead of the mean or median described in clause (i) for computing the performance threshold described in  subclause (I)  and that is based on data that are accurate and reliable.
(IV)
Recommendation requirements
In making the recommendations required under  subclause (III) , the Comptroller General of the United States shall—
(aa)
seek to prevent unintended consequences that may result from weighing quality and cost performance categories;
(bb)
consider the impact of such recommendations on different types of DPPS eligible professionals, including such professionals in a small group practice and such professionals that serve rural or underserved communities; and
(cc)
consult with stakeholders, including organizations representing physicians.
  .
(d)
Maintaining budget neutrality
Section 1848(q)(6)(F) of the Social Security Act ( 42 U.S.C. 1395w–4(q)(6)(F) ) is amended—
(1)
in clause (i)—
(A)
in the clause heading, by inserting
for years before 2028   after
factor  ; and
(B)
in subclause (I)—
(i)
by striking  With respect  and inserting  For years before 2028, with respect ; and
(ii)
by striking  subparagraph (A)(ii)(I)  and inserting  subparagraph (A)(i)(II)(aa) ;
(2)
in clause (ii)—
(A)
in the clause heading, by inserting
for years before 2028   after
requirement  ; and
(B)
in subclause (I), by striking  Subject to  and inserting  For years before 2028, subject to ;
(3)
in clause (iii)—
(A)
in subclause (I), by inserting  before 2028  before  that are below ; and
(B)
in subclause (II), by inserting  before 2028  after  with respect to a year ; and
(4)
by adding at the end the following new clause:
(v)
Budget neutrality for 2028 and subsequent years
For 2028 and each subsequent year, the Secretary shall decrease DPPS adjustment factors under subparagraph (A)(ii)(I) for DPPS eligible professionals whose composite performance score for such year is above the performance threshold established under subparagraph (D) for such year in order to ensure that the estimated increase in the aggregate allowed charges resulting from the application of such adjustment factors (after application of this clause) to such professionals for such year is not more than the estimated decrease in such charges resulting from the application for such year of DPPS adjustment factors under subclauses (III) and (IV) of subparagraph (A)(ii) to DPPS eligible professionals whose composite performance score for such year is below such performance threshold.
 .
(e)
Investing in under-resourced practices to assist in value-based care and quality improvement
Section 1848(q)(6) of the Social Security Act ( 42 U.S.C. 1395w–4(q)(6) ) is amended by adding at the end the following new subparagraph:
(G)
Investing in under-resourced practices to assist in value-based care and quality improvement
(i)
In general
In the case of a DPPS eligible professional who furnishes covered professional services during a year that is a DPPS savings year (as defined in clause (v)) and for which the professional meets the criteria specified in clause (ii), in addition to the amount of payment that would otherwise be made for such services under this part for such year, there also shall be paid to such professional, from the amount specified in clause (iv)(I) for such DPPS savings year, a lump-sum incentive payment (in such amount as specified by the Secretary) which shall be used by such professional to improve care management, address health-related social needs, implement and further the use of certified EHR technology (as defined in subsection (o)(4)), improve performance with respect to the performance categories described in paragraph (2)(A), or implement and participate in value-based care models.
(ii)
Criteria
(I)
Attestation
A DPPS eligible professional meets the criteria specified in this clause for a year if, with respect to such year and professional, data was submitted under this subsection and, for purposes of this subparagraph, it is demonstrated through an attestation that the professional is in a small practice described in subclause (II).
(II)
Small practices
Subject to clause (iii), a small practice described in this subclause is a practice of 15 or fewer professionals.
(iii)
Secretarial authority to give priority to certain small practices
The Secretary may, with respect to a DPPS savings year and based on the amount specified in clause (iv)(I) with respect to such year, for purposes of this subparagraph give priority to DPPS eligible professionals in certain small practices by applying clause (ii)(II) for such year as if instead of describing a practice of 15 or fewer professionals, such clause described any one or more of the following:
(I)
A practice of 15 or fewer professionals located in a rural area.
(II)
A practice of 15 or fewer professionals located in a health professional shortage area (as designated under in section 332(a)(1)(A) of such Act).
(III)
A practice of 15 or fewer professionals located in a medically underserved area.
(IV)
A practice of 15 or fewer professionals with a low composite score.
(iv)
Funding for incentive payments
(I)
Amount available
The amount specified in this subclause, with respect to a DPPS savings year, is the amount by which the amount described in subclause (II) for such year exceeds the amount described in subclause (III) for such year.
(II)
Aggregate decrease
The amount described in this subclause is the estimated decrease in the aggregate allowed charges resulting from the application of DPPS adjustment factors under subclauses (III) and (IV) of subparagraph (A)(ii) to DPPS eligible professionals whose composite performance score for a year is below the performance threshold under subparagraph (D) for such year.
(III)
Aggregate increase
The amount described in this subclause is the estimated increase in the aggregate allowed charges resulting from the application of DPPS adjustment factors under subparagraph (A)(ii)(I) (after application of subparagraph (F)(v)) to DPPS eligible professionals whose composite performance score for a year is above the performance threshold under subparagraph (D) for such year.
(IV)
Funding limitation
In no case may the amounts used to carry out this subparagraph with respect to a year exceed the amount specified for such year under subclause (I).
(v)
DPPS savings year
For purposes of this subparagraph, the term  DPPS savings year  means a year (beginning with 2028) for which the amount described in clause (iv)(II) exceeds the amount described in clause (iv)(III).
(vi)
Coordination with other incentive payments
The amount of any additional payment under this subparagraph and any other provision under this section or section 1833, including section 1833(m) shall be determined without regard to any additional payment under such other provision and this subparagraph, respectively.
 .