S. 5672
Patients First Act of 2026
Sponsor: Roger Marshall · 0 cosponsors
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
I Strengthening reimbursement and patient access
II POINTS
III APM improvement
IV Physician payment improvements
(a) In general. Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended by adding at the end the following new clause:
(vii) Budget neutrality corrections relating to estimated utilization
(I) In general. In the case of a budget neutrality adjustment applied pursuant to clause (ii)(II) for a year (beginning with 2029) that is determined in part using estimated utilization (as defined in subclause (II)(bb)) with respect to a specified service (as defined in subclause (II)(cc)), the Secretary shall, as part of the final rule establishing the physician fee schedule under this section for the assumption correction period (as defined in subclause (II)(aa)) with respect to such year—
(aa) determine the difference between expenditures for such service in such year using estimated utilization and actual utilization for such service (in a manner determined appropriate by the Secretary); and
(bb) in the case that the Secretary determines the difference described in item (aa) is greater than the threshold amount (as defined in subclause (II)(dd)) for such year, adjust the conversion factor under this section for such assumption correction period by such amount to reconcile such difference (which may be positive or negative), as determined by the Secretary.
(II) Definitions. For purposes of this clause:
(aa) Assumption correction period. The term assumption correction period means, with respect to a year, the second year beginning after such year.
(bb) Estimated utilization. The term estimated utilization means an estimate of utilization used for purposes of applying clause (ii)(II).
(cc) Specified service. The term specified service means, with respect to a year, a service—
(AA) with expected expenditures for such year under this section based on estimated utilization that exceed the threshold amount (as defined in item (dd)) for such year; and
(BB) for which payment had been bundled into payment for another service during the preceding year and for which a separate payment or add-on payment is made during such year.
(dd) Threshold amount. The term threshold amount means, with respect to a year, 0.1 percent of the total estimated expenditures under this part for services furnished under this section during such year.
(b) Nonapplication of budget neutrality to reconciliation adjustments. Section 1848(c)(2)(B) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended—
(1) in clause (iv)—
(A) in subclause (V), by striking and at the end;
(B) in subclause (VI), by striking the period and inserting ; and; and
(C) by adding at the end the following new subclause:
(VII) clause (vii)(I)(bb) for an assumption correction period (as defined in clause (vii)(II)) shall not be taken into account in applying clause (ii)(II) with respect to such period.
; and
(2) in clause (v), by adding at the end the following new subclause:
(XII) Reductions attributable to an assumption correction. For an assumption correction period (as defined in clause (vii)(II)), reduced expenditures attributable to application of clause (vii)(I)(bb) with respect to such period.