H.R. 9693 — Patients First Act of 2026

This section modifies annual updates to the Medicare physician fee schedule conversion factors beginning in 2027. For the nonqualifying APM conversion factor, the update equals the Secretary’s estimate of the MEI increase minus 1 percentage point, subject to a floor of 25 percent and a ceiling of 75 percent of that estimate; the qualifying APM conversion factor receives an additional 0.5 percentage point. The section also requires the Secretary to submit annual reports to Congress analyzing effects on beneficiary access and physician practice consolidation.

This section establishes a hybrid payment model for primary care services from 2027 through 2031. Under the model, the Secretary makes monthly payments to qualifying suppliers—specified practitioners with at least 60 percent of prior-year payments for designated primary care services and not part of excluded practices—for each attributed part B enrollee, in lieu of payments under the physician fee schedule. Payments equal one-twelfth of the national average amount for such services, adjusted for geography and risk, with no cost sharing. The Secretary attributes enrollees by designation or claims history. Funding comes from the Supplementary Medical Insurance Trust Fund, and the model has no effect on fee schedule budget neutrality.

This section extends the work geographic index floor for physician fee schedule payments through 2032 (from 2027). It raises the floor to 1.025 (from 1.00) in high inflationary years, defined as years when the consumer price index for all urban consumers rises more than 2 percent over the prior 12 months. It also increases the index by 0.02 points for other localities in such years from 2027 through 2032. Medicare administrative contractors must publish the adjusted work relative value units quarterly beginning January 1, 2027. The Comptroller General must report within one year on economic factors affecting physicians’ geographic practice choices by specialty.

This section establishes the Patient Outcome Improvement National Tabulation System (POINTS) effective January 1, 2032, as the renamed payment system under section 1848(q) of the Social Security Act that currently operates as the Merit-based Incentive Payment System (MIPS). It directs the Secretary of Health and Human Services to manage an orderly transition in terminology, during which references to POINTS are deemed to include MIPS.

This section revises the Merit-based Incentive Payment System (MIPS) under Medicare physician payments. It replaces the clinical practice improvement activities and meaningful use of certified EHR technology performance categories with a new care efficiency category for performance periods beginning on or after January 1, 2032. It requires the annual final measures list to include quality, resource use, and care efficiency measures recommended by the established task force, and it directs that no measure lacking such a recommendation may be included after that date. It also establishes scoring incentives, effective for performance periods beginning on or after January 1, 2027, that award the highest possible score to MIPS-eligible professionals reporting new, substantively changed, or unbenchmarked measures.

This section establishes a Quality Reform Task Force of up to 25 members, appointed by the Secretary within 6 months of enactment, to recommend quality, resource use, and care efficiency measures for the Merit-based Incentive Payment System. For performance periods beginning January 1, 2032, the Task Force must issue and update recommendations that conform to clinical guidelines, rely on certified EHR, claims, or registry data, and account for non-face-to-face specialties and episodes of care. The Secretary must respond in writing within 120 days to the Task Force and congressional committees on whether each recommendation will be implemented, modified, partially implemented, or declined, and must include recommended measures in the final list unless publishing a clinical, administrative, or program integrity exclusion in the Federal Register within 90 days; measures supported by at least 75 percent of Task Force members may not be excluded.

This section caps MIPS payment adjustments at 9 percent for 2022 through 2026, then reduces them to 2 percent for 2027 through 2031, 3 percent in 2032, 4 percent in 2033, and 5 percent in 2034. It bars negative adjustments when the Secretary fails to provide required quarterly feedback on administrative claims-based measures beginning in 2032. It extends additional incentive payments for certain MIPS-eligible professionals through 2032 and later years, excluding those in excluded practices, and halves positive adjustments for professionals in excluded practices starting in 2032 in a budget-neutral manner.

This section requires qualified clinical data registries, beginning January 1, 2027, to be established and operated by a professional society controlled or led by a designated practitioner with demonstrated expertise in evidence-based guidelines and quality measures. It further requires such registries to meet standards for data quality and fidelity, generate timely practitioner feedback for quality improvement, ensure transparency in measure development and risk adjustment, and maintain self-audit processes for data accuracy. It limits approvals and extensions made on or after January 1, 2027, to 3-year periods based on continued compliance.

This section requires the Secretary of Health and Human Services to establish, not later than January 1, 2027, a process allowing qualified clinical data registries and clinician-led clinical data registries to request Medicare claims data—and, if the Secretary determines appropriate, Medicaid and CHIP claims data—for linking with clinical outcomes data, conducting provider quality assessments and improvement activities, and publishing research. Registries access the data at cost and need not qualify as qualified entities.

This section requires qualified clinical decision support mechanisms to report consultation data, ordering professional national provider identifiers, and other specified information directly to the Secretary beginning January 1, 2027 (from January 1, 2017). It exempts mammography, lung cancer screening using computed tomography, colonography using computed tomography, services for emergency medical conditions, and certain preventive services from the consultation requirement. It directs the Secretary to designate low compliant ordering professionals based on annual compliance rates below a threshold set by the Secretary.

This section protects the intellectual property rights of qualified clinical data registries by prohibiting any construction of the title's amendments that would transfer ownership of their developed measures without authorization or require relinquishment of such rights as a condition for inclusion in the annual final list of measures. It directs the Secretary of Health and Human Services to recognize these measures—including specifications, methodologies, scoring algorithms, and related materials—as the registries' property and permits voluntary licensing to the Secretary or other entities under agreed terms.

This section freezes the thresholds for qualifying as an Advanced Alternative Payment Model participant at current levels through payment year 2029 (from 2026 and 2028) and through payment year 2030 (from 2027 and 2029). It authorizes the Secretary of Health and Human Services to specify lower percentage thresholds than the statutory 40 percent and 50 percent requirements.

This section requires the Secretary to use notice-and-comment rulemaking when selecting models for testing by the Center for Medicare and Medicaid Innovation and when terminating any expanded model before its scheduled end date. It also directs that each annual CMI report submitted in 2027 or later describe any savings generated by each model tested.

This section directs the Comptroller General, in consultation with the Medicare Payment Advisory Commission, to submit a report by December 31, 2029, to the House Committees on Energy and Commerce and Ways and Means and the Senate Committee on Finance. The report must identify ongoing barriers to specialty provider participation in Medicare value-based payment models and include specific policy recommendations to reduce those barriers.

This section increases the budget neutrality threshold for relative value unit adjustments under the Medicare physician fee schedule to $57,640,000 for 2028 (from $20,000,000). The threshold remains at that level for 2029 and later years until the Secretary increases it in 2033 and every fifth year thereafter by the cumulative Medicare Economic Index growth over the prior five-year period.

This section requires the Secretary to reconcile differences between estimated and actual utilization for specified services in the Medicare physician fee schedule. Beginning with 2029, for any newly unbundled service whose estimated expenditures exceed 0.1 percent of total Part B spending, the Secretary must adjust the conversion factor in the second following year to correct the difference if it exceeds the 0.1 percent threshold; such adjustments are exempt from budget neutrality.

This section requires the Secretary to update prices and rates for all categories of direct cost inputs used to calculate practice expense relative value units under the Medicare physician fee schedule at least once every 5 years, with simultaneous updates across clinical staff wage rates, medical supplies, equipment, and any other specified inputs. It also requires consultation with physician specialty societies and other stakeholders.

This section limits year-to-year changes in the Medicare physician fee schedule conversion factor. Beginning in 2027, the Secretary may not apply a budget neutrality adjustment that would cause the conversion factor to vary by more than 2.5 percent from the factor established for the preceding year.