H.R. 9693

Patients First Act of 2026

Sponsor: John Joyce

69 cosponsors
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Official summary

Written by the Congressional Research Service.

Patients First Act of 2026

This bill modifies payments and incentive programs under the Medicare physician fee schedule.

The bill establishes a temporary program to provide hybrid payments for certain primary care services. Under the program, payments for services relating to care management, behavioral health integration, office-based evaluation and management (including telehealth), and communications (e.g., phone calls) are made on a monthly basis to providers for each individual that is attributed to the provider's practice. The monthly amount is based on the national average amount for such services. Providers may opt into the model; in order to qualify, providers must be owned or controlled by health care practitioners and must have had the majority of their prior year's payments consist of payments for the covered services.

The bill also renames the Merit-based Incentive Payment System (MIPS) and modifies the program to include performance measures relating to care efficiency (e.g., reducing avoidable hospitalizations). (MIPS is an incentive program under Medicare that allows health professionals to receive payment adjustments based on certain performance measures.) The bill generally reduces the program's performance-based payment adjustments, including positive adjustments for providers that are not owned or controlled by health care practitioners.

Finally, the bill allows for larger annual adjustments to the Medicare physician fee schedule and bases these adjustments on inflation. It also requires certain corrections to compensate for expenditures under the fee schedule that exceed a certain amount in a given year, and it limits how much certain adjustment factors may vary each year.

Text of the bill

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I Strengthening reimbursement and patient access

II POINTS

Sec. 202. Payment reform

(a) In general. Section 1848(q) of the Social Security Act (42 U.S.C. 1395w–4(q)) is amended—

(1) in paragraph (1)(D)(i)(II), by striking (iv) and inserting (v);

(2) in paragraph (2)—

(A) in subparagraph (A)—

(i) in clause (iii), by striking Clinical practice and inserting For performance periods beginning before January 1, 2032, clinical practice;

(ii) in clause (iv), by striking Meaningful use and inserting For performance periods before January 1, 2032, meaningful use; and

(iii) by adding at the end the following new clause:

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(v) For performance periods beginning on or after January 1, 2032, care efficiency.

(B) in subparagraph (B)—

(i) in clause (ii)—

(I) by striking subparagraph (A)(ii), the measurement and inserting the following:

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subparagraph (A)(ii)—

(I) for performance periods beginning before January 1, 2032, the measurement

; and

(II) by striking the period at the end and inserting the following:

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; and

(II) for performance periods beginning on or after January 1, 2032, the measurement described in subclause (I) and any resource use measures included in the final measures list published under subparagraph (D)(i) for such period.

; and

(ii) by inserting after clause (iv) the following new clause:

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(v) Care efficiency. For the performance category described in subparagraph (A)(v), care efficiency measures (such as measures relating to reductions in avoidable hospitalizations, reductions in medication burden (when clinically appropriate), reductions in complications from chronic diseases, and referral patterns to the lowest-cost clinically appropriate settings) included in the final measures list published under subparagraph (D)(i) for such period.

(C) in subparagraph (D)—

(i) in the header, by striking quality;

(ii) in clause (i)—

(I) in the matter preceding subclause (I), by inserting (or, with respect to performance periods beginning on or after January 1, 2032, an annual final list of quality measures, resource use measures (if determined appropriate by the Secretary), and care efficiency measures) after quality measures; and

(II) in subclause (II)—

(aa) in item (aa), by striking quality measures and inserting measures;

(bb) in item (bb), by inserting (or, with respect to a final list for a performance period beginning on or after January 1, 2032, new quality measures, resource use measures, or care efficiency measures) after quality measures; and

(cc) in item (cc), by striking quality measures and inserting measures;

(iii) in clause (ii)—

(I) in the header, by striking quality; and

(II) in subclause (I)—

(aa) by inserting (or, with respect to such an annual list for a performance period beginning on or after January 1, 2032, quality measures, resource use measures, and care efficiency measures) after submit quality measures; and

(bb) by striking quality measures published and inserting measures published;

(iv) in clause (iii)—

(I) in the matter preceding subclause (I), by striking quality;

(II) in subclause (I), by striking and at the end;

(III) in subclause (II)—

(aa) by striking ensure that and inserting with respect to such an annual final list for a performance period beginning before January 1, 2032, ensure that; and

(bb) by striking the period at the end and inserting ; and; and

(IV) by adding at the end the following new subclause:

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(III) with respect to such an annual final list for a performance period beginning on or after January 1, 2032, provide that—

(aa) no quality measure applicable to a medical specialty is included on such list if—

(AA) the task force established under subparagraph (E) has issued recommendations on quality measures for use under this subsection with respect to such specialty; and

(BB) the quality measure does not have in effect such a recommendation; and

(bb) no resource use measure or care efficiency measure is included on such list unless such measure has in effect a recommendation from such task force.

(v) in clause (v), in the matter preceding subclause (I), by inserting for a performance period beginning before January 1, 2032, after published under clause (i);

(vi) in clause (vi), by striking under clauses (i), (iv), and (v) and inserting under this subparagraph; and

(vii) in clause (vii)(II), by striking shall be and inserting subject to clause (iii)(III)(aa), shall be;

(3) in paragraph (5)—

(A) in subparagraph (B)—

(i) in clause (ii)—

(I) in subclause (I)—

(aa) by striking encourage and inserting with respect to a performance period beginning before January 1, 2032, encourage; and

(bb) by striking and at the end;

(II) in subclause (II), by striking the period and inserting ; and; and

(III) by adding at the end the following new subclause:

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(III) with respect to a performance period beginning on or after January 1, 2032, with respect to a year, 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 registries, the professional shall be treated as achieving the lowest potential score applicable to such measure.

; and

(ii) by adding at the end the following new clause:

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(iii) Incentive to report on certain measures

(I) In general. With respect to performance periods for years beginning on or after January 1, 2027, in the case a MIPS eligible professional elects to report on a measure for such period that, with respect to such professional and such period, is a new measure described in subclause (II), a substantively changed measure described in subclause (III), or a measure described in paragraph (2)(B)(i) for which the Secretary is unable to establish a benchmark, such professional shall be treated as achieving the highest possible score with respect to such measure.

(II) New measures. For purposes of subclause (I), a new measure described in this subclause, with respect to a MIPS eligible professional and performance period for a year, is a measure applicable to such professional with respect to the performance category described in paragraph (2)(A)(i) that is included in the final list of quality measures published under paragraph (2)(D)(i) (or the list of quality measures described in paragraph (2)(D)(vi) used by qualified clinical data registries under subsection (m)(3)(E)) for such year but was not included in such final list under paragraph (2)(D)(i) (or list under paragraph (2)(D)(vi)) for any of the previous 3 years.

(III) Substantively changed measure. For purposes of subclause (I), a substantively changed measure described in this subclause, with respect to a MIPS eligible professional and performance period for a year, is a measure applicable to such professional with respect to the performance category described in paragraph (2)(A)(i) that is included in the final list of quality measures published under paragraph (2)(D)(i) (or the list of quality measures described in paragraph (2)(D)(vi) used by qualified clinical data registries under subsection (m)(3)(E)) for such year and each of the previous three years but that underwent a substantive change (as defined by the Secretary) during any of such previous three years.

; and

(B) in subparagraph (E)—

(i) in clause (i)—

(I) in subclause (I)(aa), by inserting (or, with respect to 2032 and subsequent years, 65 percent) after thirty percent;

(II) in subclause (II)(aa), by inserting (or, with respect to 2032 and subsequent years, 20 percent) after thirty percent;

(III) in subclause (III), by inserting (or, with respect to 2032 and subsequent years, 0 percent) after fifteen percent;

(IV) in subclause (IV), by inserting (or, with respect to 2032 and subsequent years, 0 percent) after twenty-five percent; and

(V) by adding at the end the following new subclause:

Text this section adds to the law

(V) Care efficiency. With respect to 2032 and subsequent years, 15 percent of such score shall be based on performance with respect to the category described in clause (v) of paragraph (2)(A).

; and

(ii) in clause (ii), by inserting (before 2032) after In any year;

(4) in paragraph (11)(A)(i), by striking clauses (i) through (iv) of; and

(5) in paragraph (12)(A)(i)(II), by striking and (iv) and inserting through (v).

(b) Improvements to resource use performance category. Section 1848(r) of the Social Security Act (42 U.S.C. 1395w–4(r)) is amended—

(1) in paragraph (2)(H), by adding at the end the following new sentence: In making such revisions for 2027 and subsequent years, the Secretary shall revise care episode groups and patient condition groups without regard to any target described in subparagraph (D)(i)(I).; and

(2) in paragraph (5)(C)(i)—

(A) by inserting , for years before 2027, after shall; and

(B) by inserting and shall, for 2027 and subsequent years, use such care episode codes and patient condition codes before the period.

III APM improvement

IV Physician payment improvements