S. 5672 — Patients First Act of 2026

This section modifies updates to the Medicare physician fee schedule conversion factors beginning in 2027. It sets the annual update to the nonqualifying APM conversion factor at the Secretary’s estimate of the percentage increase in the Medicare Economic Index minus 1 percentage point, subject to a floor of 25 percent and a ceiling of 75 percent of that estimate, and sets the qualifying APM conversion factor update 0.5 percentage point higher than the nonqualifying update. It also requires the Secretary of Health and Human Services to submit annual reports to Congress beginning in 2027 analyzing the effects of the updates on beneficiary access to services and on physician practice consolidation.

This section establishes a hybrid payment model for primary care services from 2027 through 2031 under which the Secretary makes monthly payments to qualifying suppliers for each attributed part B enrollee in lieu of fee-for-service payments under the physician fee schedule for designated primary care services. Qualifying suppliers are specified practitioners (physicians in family, internal, geriatric, or pediatric medicine or physician assistants, nurse practitioners, or clinical nurse specialists) not part of excluded practices who received at least 60 percent of prior-year payments for such services; payments are geographically and risk adjusted with no cost sharing applied.

This section raises the floor on the Medicare work geographic index to 1.025 (from 1.00) in high inflationary years, defined as years when the CPI-U rises more than 2 percent over the prior 12 months, and extends the adjustment through 2032 (from 2027). 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 section requires the GAO to 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 version of the existing Merit-based Incentive Payment System (MIPS) under section 1848(q) of the Social Security Act. It directs the Secretary of Health and Human Services to manage an orderly transition in terminology, during which references to POINTS include MIPS.

This section revises the Merit-based Incentive Payment System performance categories for Medicare physician payments by replacing clinical practice improvement activities and meaningful use of certified EHR technology with care efficiency measures for performance periods beginning on or after January 1, 2032 (from before that date). It requires the Secretary to include resource use and care efficiency measures on the annual final measures list starting in 2032, adjusts reporting and scoring rules for new or substantively changed measures effective 2027, and limits inclusion of measures without Task Force recommendations.

This section establishes a Quality Reform Task Force within 6 months of enactment to issue and update recommendations on quality, resource use, and care efficiency measures for the Merit-based Incentive Payment System for performance periods beginning January 1, 2032. The Task Force may have up to 25 members, a majority of whom must be designated health care practitioners or representatives of eligible professional organizations, with at least one practitioner from each relevant specialty or subspecialty under consideration and no more than 3 members from group health plans, health insurance issuers, or Medicare Advantage organizations. The Secretary must transmit a formal written response to each recommendation within 120 days and must include recommended measures in the final measures list unless the Secretary publishes in the Federal Register, within 90 days, a determination explaining the clinical, administrative, or program integrity basis for exclusion; measures supported by at least 75 percent of Task Force members may be excluded only under stricter conditions.

This section modifies the Merit-based Incentive Payment System by setting the maximum positive payment adjustment to 9 percent for 2022 through 2026, 2 percent for 2027 through 2031, 3 percent for 2032, 4 percent for 2033, and 5 percent for 2034. It prohibits negative adjustments when the Secretary fails to provide required quarterly feedback on administrative claims-based measures beginning in 2032. It extends the additional 5 percent incentive payment for exceptional performance to 2032 and subsequent years, excluding professionals in excluded practices, and reduces positive adjustments by 50 percent for those professionals beginning in 2032 in a budget-neutral manner.

This section establishes new requirements, effective January 1, 2027, for qualified clinical data registries under the Medicare physician quality reporting system. Entities must be established and operated by a professional society led by designated practitioners with expertise in evidence-based guidelines and quality measures; adhere to data quality, completeness, and validation standards; generate timely feedback to participating practitioners and track its use; ensure transparency in measure development and risk adjustment; and maintain self-audit processes for data accuracy and measure integrity. It also limits initial approvals or designations made on or after January 1, 2027, to three-year periods, renewable for additional three-year periods upon a showing of continued compliance.

This section directs the Secretary of Health and Human Services to establish, by January 1, 2027, a process allowing qualified clinical data registries under section 1848(m)(3)(E) of the Social Security Act and clinician-led clinical data registries under section 4005 of the 21st Century Cures Act to request Medicare claims data, and if determined appropriate Medicaid and CHIP claims data, for linking with clinical outcomes data, conducting provider quality assessments and improvement activities, performing risk-adjusted analyses, and publishing deidentified research, without requiring the registries to qualify as qualified entities under section 1874(e)(2) of the Social Security Act, at a fee equal to the cost of making the data available.

This section modifies Medicare’s appropriate use criteria program for applicable imaging services by delaying implementation of data reporting and compliance requirements to January 1, 2027 (from January 1, 2017). It requires qualified clinical decision support mechanisms to report consultation data, ordering professional identifiers, and other information to the Secretary; exempts services ordered in clinical trials, by small or rural practices, and specified preventive screenings including mammography, lung cancer screening, and colonography; and replaces the outlier designation with low compliant ordering professionals based on 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 amendments in this title that would transfer ownership of their measures without authorization or require relinquishment of such rights as a condition of measure inclusion in the annual final list. It directs the Secretary of Health and Human Services to recognize measures developed by these registries—including specifications, methodologies, scoring algorithms, and related materials—as the intellectual property of the registries and permits voluntary licensing to the Secretary or other entities.

This section delays the increase in the percentage thresholds required to qualify as an advanced alternative payment model (APM) participant under Medicare to 2029 (from 2026 and 2028) and to 2030 (from 2027 and 2029). It also authorizes the Secretary to specify lower percentage thresholds than the statutory 40 percent and 50 percent levels.

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 model expanded under subsection (c). It also requires each annual CMI report submitted in 2027 or later to describe savings generated by every model tested under subsection (b).

This section requires 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 address ongoing barriers to specialty provider participation in Medicare value-based payment models and include specific policy recommendations to reduce those barriers.

This section raises the budget neutrality threshold for annual adjustments to the Medicare physician fee schedule under 42 U.S.C. 1395w-4(c)(2)(B)(ii)(II) to $57,640,000 for 2028 (from $20,000,000), maintains that amount for 2029 and subsequent years, and requires the Secretary to increase the threshold every fifth year beginning in 2033 by the cumulative percentage increase in the Medicare Economic Index over the preceding five-year period.

This section requires the Secretary of Health and Human Services, beginning in 2029, to reconcile differences between estimated and actual utilization for newly unbundled services whose expected expenditures exceed 0.1 percent of total physician fee schedule spending. If the difference exceeds the 0.1 percent threshold, the Secretary must adjust the conversion factor in the second year after the affected year to correct the discrepancy. The adjustment is exempt from budget neutrality requirements.

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. Updates must occur simultaneously across clinical staff wage rates, medical supplies, equipment, and any other specified inputs, after consultation with physician specialty societies and other stakeholders.

This section limits year-to-year changes in the Medicare physician fee schedule conversion factor to no more than 2.5 percent beginning in 2027 by restricting the application of budget neutrality adjustments. It preserves the requirement that such adjustments maintain overall budget neutrality.