§1395w–1. Physician Payment Review Commission

(a) Establishment; membership; term of office

(1) The Director of the Congressional Office of Technology Assessment (hereinafter in this section referred to as the "Director" and the "Office", respectively) shall provide for the appointment of a Physician Payment Review Commission (hereinafter in this section referred to as the "Commission"), to be composed of individuals with national recognition for their expertise in health economics, physician reimbursement, medical practice, and other related fields appointed by the Director (without regard to the provisions of title 5 governing appointments in the competitive service).

(2) The Commission shall consist of 13 individuals. Members of the Commission shall first be appointed no later than May 1, 1986, for a term of three years, except that the Director may provide initially for such shorter terms as will insure that (on a continuing basis) the terms of no more than four members expire in any one year.

(3) The membership of the Commission shall include (but need not be limited to) physicians, other health professionals, individuals skilled in the conduct and interpretation of biomedical, health services, and health economics research, and representatives of consumers and the elderly.

(b) Recommendations to Congress

(1) The Commission shall make recommendations to the Congress, not later than March 31 of each year (beginning with 1987), regarding adjustments to the reasonable charge levels for physicians' services recognized under section 1395u(b) of this title and changes in the methodology for determining the rates of payment, and for making payment, for physicians' services under this subchapter and other items and services under this part.

(2) In making its recommendations, the Commission shall-

(A) assess the likely impact of different adjustments in payment rates, particularly their impact on physician participation in the participation program established under section 1395u(h) of this title and on beneficiary access to necessary physicians' services;

(B) make recommendations on ways to increase physician participation in that participation program and the acceptance of payment under this part on an assignment-related basis;

(C) identify those procedures, involving the use of assistants at surgery, for which payment for those assistants should not be made under this subchapter without prior approval;

(D) identify those procedures for which an opinion of a second physician should be required before payment is made under this subchapter;

(E) consider policies for moderating the rate of increase in expenditures under this part and the rate of increase in utilization of services under this part;

(F) make recommendations regarding major issues in the implementation of the resource-based relative value scale established under section 1395w–4(c) of this title;

(G) make recommendations regarding further development of the volume performance standards established under section 1395w–4(f) of this title, including the development of State-based programs;

(H) consider policies to provide payment incentives to increase patient access to primary care and other physician services in large urban and rural areas, including policies regarding payments to physicians pursuant to subchapter XIX of this chapter;

(I) review and consider the number and practice specialties of physicians in training and payments under this subchapter for graduate medical education costs;

(J) make recommendations regarding issues relating to utilization review and quality of care, including the effectiveness of peer review procedures and other quality assurance programs applicable to physicians and providers under this subchapter and physician certification and licensing standards and procedures;

(K) make recommendations regarding options to help constrain the costs of health insurance to employers, including incentives under this subchapter;

(L) comment on the recommendations affecting physician payment under the medicare program that are included in the budget submitted by the President pursuant to section 1105 of title 31; and

(M) make recommendations regarding medical malpractice liability reform and physician certification and licensing standards and procedures.

(c) Applicability of provisions relating to Prospective Payment Assessment Commission; collection and assessment of information

(1) The following provisions of section 1395ww(e)(6) of this title shall apply to the Commission in the same manner as they apply to the Prospective Payment Assessment Commission:

(A) Subparagraph (C) (relating to staffing and administration generally).

(B) Subparagraph (D) (relating to compensation of members).

(C) Subparagraph (F) (relating to access to information).

(D) Subparagraph (G) (relating to use of funds).

(E) Subparagraph (H) (relating to periodic GAO audits).

(F) Subparagraph (J) (relating to requests for appropriations).

(2) In order to carry out its functions, the Commission shall collect and assess information on medical and surgical procedures and services, including information on regional variations of medical practice. In collecting and assessing information, the Commission shall-

(A) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section,

(B) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate for the development of useful and valid guidelines by the Commission, and

(C) adopt procedures allowing any interested party to submit information with respect to physicians' services (including new practices, such as the use of new technologies and treatment modalities), which information the Commission shall consider in making reports and recommendations to the Secretary and Congress.

(d) Authorization of appropriations

There are authorized to be appropriated such sums as may be necessary to carry out the provisions of this section. Such sums shall be payable from the Federal Supplementary Medical Insurance Trust Fund.

(e) Prompt submittal of data by Secretary

(1) Not later than December 31st of each year (beginning with 1988), the Secretary shall transmit to the Physician Payment Review Commission, to the Congressional Budget Office, and to the Congressional Research Service of the Library of Congress national data (known as the Part B Medicare Annual Data System) for the previous year respecting part B of this subchapter.

(2) The Secretary, in consultation with the Physician Payment Review Commission, the Congressional Budget Office, and the Congressional Research Service of the Library of Congress, shall establish and annually revise standards for the data reporting system described in paragraph (1).

(3) The Secretary shall also provide to the entities described in paragraph (1) additional data respecting the program under this part as may be reasonably requested by them on an agreed-upon schedule.

(4) The Secretary shall develop, in consultation with the Physician Payment Review Commission, the Congressional Budget Office, and the Congressional Research Service of the Library of Congress, a system for providing to each of such entities on a quarterly basis summary data on aggregate expenditures under this part by type of service and by type of provider. Such data shall be provided not later than 90 days after the end of each quarter (for quarters beginning with the calendar quarter ending on March 31, 1989).

(Aug. 14, 1935, ch. 531, title XVIII, §1845, as added and amended Apr. 7, 1986, Pub. L. 99–272, title IX, §9305, 100 Stat. 190 ; Oct. 21, 1986, Pub. L. 99–509, title IX, §§9331(e), 9344(a)(1), 100 Stat. 2021 , 2042; Dec. 22, 1987, Pub. L. 100–203, title IV, §§4045(b), 4083(a)(1), (c)(1), 4085(a), (i)(8), 101 Stat. 1330–87 , 1330-129, 1330-130, 1330-132; July 1, 1988, Pub. L. 100–360, title IV, §411(i)(4)(A), 102 Stat. 788 ; Nov. 10, 1988, Pub. L. 100–647, title VIII, §8425(a), 102 Stat. 3803 ; Nov. 5, 1990, Pub. L. 101–508, title IV, §§4002(g)(3), 4118(j)(1), 104 Stat. 1388–37 , 1388-70; Oct. 31, 1994, Pub. L. 103–432, title I, §126(g)(8), 108 Stat. 4416 .)

References in Text

The provisions of title 5 governing appointments in the competitive service, referred to in subsec. (a)(1), are classified generally to section 3301 et seq. of Title 5, Government Organization and Employees.

Amendments

1994-Subsec. (e)(2) to (5). Pub. L. 103–432 redesignated pars. (3) to (5) as (2) to (4), respectively, and struck out former par. (2) which read as follows: "In order to ensure that the data are available for transmittal under paragraph (1) on a timely basis, the Secretary shall require, in the standards and criteria established under section 1395u(b)(2) of this title, that carriers submit data for a year under the system referred to in paragraph (1) not later than the later of (A) July 1st of the following year, or (B) 45 days after the date of a reasonable charge update."

1990-Subsec. (a)(3). Pub. L. 101–508, §4118(j)(1)(A), substituted "include (but need not be limited to) physicians" for "include physicians".

Subsec. (b)(2)(A). Pub. L. 101–508, §4118(j)(1)(C)(iii), (iv), redesignated subpar. (D) as (A) and struck out former subpar. (A) which read as follows: "consider, and make recommendations on the feasibility and desirability of reducing, the differences in payment amounts for physicians' services under this part which are based on differences in geographic location or specialty;".

Subsec. (b)(2)(B). Pub. L. 101–508, §4118(j)(1)(C)(iii), (iv), redesignated subpar. (E) as (B) and struck out former subpar. (B) which read as follows: "review the input costs (including time, professional skills, and risks) associated with the provision of different physicians' services;".

Subsec. (b)(2)(C). Pub. L. 101–508, §4118(j)(1)(C)(iii), (iv), redesignated subpar. (G) as (C) and struck out former subpar. (C) which read as follows: "identify those charges recognized as reasonable under section 1395u(b) of this title which are significantly out-of-line, based on the considerations of subparagraphs (A) and (B);".

Subsec. (b)(2)(D), (E). Pub. L. 101–508, §4118(j)(1)(C)(iv), redesignated subpars. (H) and (I) as (D) and (E), respectively. Former subpars. (D) and (E) redesignated (A) and (B), respectively.

Subsec. (b)(2)(F). Pub. L. 101–508, §4118(j)(1)(C)(iii), (v), added subpar. (F) and struck out former subpar. (F) which read as follows: "make recommendations respecting the advisability and feasibility of making changes in the payment system for physicians' services under this part based on (i) the Secretary's study under section 603(b)(2) of the Social Security Amendments of 1983 (relating to payments for physicians' services furnished to hospital inpatients on the basis of diagnosis-related groups) and (ii) the Office's report under section 2309 of the Deficit Reduction Act of 1984 (relating to physician reimbursement under this part);".

Subsec. (b)(2)(G) to (M). Pub. L. 101–508, §4118(j)(1)(C)(v), added subpars. (G) to (M). Former subpars. (G) to (I) redesignated (C) to (E), respectively.

Subsec. (b)(3). Pub. L. 101–508, §4118(j)(1)(B), struck out par. (3) which read as follows: "The Commission also shall advise and make recommendations to the Secretary respecting the development of the relative value scale under subsection (e) of this section and respecting the index and the adjustment described in subsection (e)(4)(A) of this section."

Subsec. (c)(1)(D). Pub. L. 101–508, §4002(g)(3), struck out "reports and" before "use of funds".

Subsecs. (e), (f). Pub. L. 101–508, §4118(j)(1)(D), redesignated subsec. (f) as (e) and struck out former subsec. (e) which required Secretary to develop a relative value scale for physicians' services and report to Congress not later than July 1, 1989.

1988-Subsec. (b)(2)(I). Pub. L. 100–647 added subpar. (I).

Subsec. (f)(1). Pub. L. 100–360, §411(i)(4)(A)(i), substituted "December 31st" for "October 1st".

Subsec. (f)(2). Pub. L. 100–360, §411(i)(4)(A)(ii), substituted "the later of (A) July 1st of the following year, or (B) 45 days after the date of a reasonable charge update" for "July 1st of the following year".

1987-Subsec. (a)(1). Pub. L. 100–203, §4083(a)(1)(A), substituted "with national recognition for their expertise in health economics, physician reimbursement, medical practice, and other related fields" for "with expertise in the provision and financing of physicians' services".

Subsec. (a)(3). Pub. L. 100–203, §4083(a)(1)(B), struck out last sentence setting forth wide range of groups from which the Director was to seek nominations.

Subsec. (b)(1). Pub. L. 100–203, §4083(c)(1), substituted "March 31" for "March 1".

Subsec. (e)(4). Pub. L. 100–203, §4085(i)(8), realigned margins of par. (4) and its clauses.

Subsec. (e)(4)(A)(i). Pub. L. 100–203, §4045(b), inserted "and costs of living". after "costs of practice".

Subsec. (f). Pub. L. 100–203, §4085(a), added subsec. (f).

1986-Subsec. (a)(2). Pub. L. 99–509, §9344(a)(1), substituted "13 individuals" for "11 individuals".

Subsec. (b)(3). Pub. L. 99–509, §9331(e)(2), inserted "and respecting the index and adjustment described in subsection (e)(4)(A) of this section" after "subsection (e) of this section".

Subsec. (e). Pub. L. 99–272, §9305(b), added subsec. (e).

Subsec. (e)(3). Pub. L. 99–509, §9331(e)(3), substituted "July 1, 1989" for "July 1, 1987", and "after December 31, 1989" for "on or after January 1, 1988".

Subsec. (e)(4). Pub. L. 99–509, §9331(e)(1), added par. (4).

Effective Date of 1994 Amendment

Amendment by Pub. L. 103–432 effective as if included in the enactment of Pub. L. 101–508, see section 126(i) of Pub. L. 103–432, set out as a note under section 1395m of this title.

Effective Date of 1988 Amendments

Section 8425(b) of Pub. L. 100–647 provided that: "The amendments made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [Nov. 10, 1988] and shall first apply to recommendations submitted in 1989."

Except as specifically provided in section 411 of Pub. L. 100–360, amendment by Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.

Effective Date of 1987 Amendment

Amendment by section 4045(b) of Pub. L. 100–203 applicable to items and services furnished on or after Apr. 1, 1988, see section 4045(d) of Pub. L. 100–203, set out as a note under section 1395u of this title.

Section 4083(a)(2) of Pub. L. 100–203 provided that: "The amendment made by paragraph (1) [amending this section] shall apply to appointments made after the date of the enactment of this Act [Dec. 22, 1987]."

Section 4083(c)(2) of Pub. L. 100–203 provided that: "The amendment made by paragraph (1) [amending this section] shall apply with respect to reports for years after 1987."

PHYSPRC Study of Payments for Assistants at Surgery

Pub. L. 101–239, title VI, §6138, Dec. 19, 1989, 103 Stat. 2224 , provided that:

"(a) Study; Contents.-The Physician Payment Review Commission shall conduct a study of the payments made under title XVIII of the Social Security Act [this subchapter] for assistants at surgery. Such study shall examine-

"(1) the necessity and appropriateness of using an assistant at surgery;

"(2) the use of physician and non-physician assistants at surgery;

"(3) the appropriateness of providing for payments, and the appropriate level of payment, under title XVIII of the Social Security Act for assistants at surgery; and

"(4) the effect of the amendments made by section 9338 of the Omnibus Budget Reconciliation Act of 1986 [Pub. L. 99–509, amending sections 1395u and 1395x of this title] on the employment of registered nurses as assistants at surgery, and whether or not the reductions described in subsection (d) of such section have been implemented.

"(b) Report.-By not later than April 1, 1991, the Commission shall submit a report to Congress on the study conducted under subsection (a), and shall include in the report such recommendations as it deems appropriate."

Expansion of Relative Value Scale (RVS) Study

Section 4056(b), formerly §4055(b), of Pub. L. 100–203, as renumbered and amended by Pub. L. 100–360, title IV, §411(f)(13)(B), (14), July 1, 1988, 102 Stat. 781 ; Pub. L. 101–508, title IV, §4118(g)(5), Nov. 5, 1990, 104 Stat. 1388–70 , provided that:

"(1) Additional services.-The Secretary shall expand the study being conducted, under section 1845(e) of the Social Security Act [subsec. (e) of this section], to develop a relative value scale for physicians' services to include physicians' services in the fields of cardiology, emergency medicine, gastroenterology, hematology, infectious disease, nephrology, neurology, neurosurgery, nuclear medicine, oncology, physical medicine and rehabilitation, plastic surgery, pulmonary medicine, and radiation therapy, and for physicians who specialize in osteopathic procedures.

"(2) No delay in current study.-The expansion under paragraph (1) shall not be conducted in a manner that delays the completion of the current study or the report to Congress required under section 1845(e)(3) of the Social Security Act.

"(3) Prompt submittal of study results to physician payment review commission.-The Secretary shall submit to the Physician Payment Review Commission a copy of any report submitted to the Secretary pursuant to a cooperative agreement in the fulfillment of the requirement of section 1845(e) of such Act, with all relevant supporting data (including survey data, analytic data files, and file documentation), by no later than 30 days after the date the final report is received by the Secretary."

Appointment of Additional Members

Section 9344(a)(2) of Pub. L. 99–509 provided that: "The Director of the Congressional Office of Technology Assessment shall appoint the two additional members of the Physician Payment Review Commission, as required by the amendment made by paragraph (1) [amending this section], no later than 60 days after the date of the enactment of this Act [Oct. 21, 1986], for terms of 3 years, except that the Director may provide initially for such terms as will insure that (on a continuing basis) the terms of no more than five members expire in any one year."

Section Referred to in Other Sections

This section is referred to in section 1395u of this title.