Patients First Act of 2026
- Sponsor
- Rep. Joyce, John [R-PA-13]
- Committees
- Ways and Means Committee (primary)
- Last action
- Jul 15, 2026
Bottom line
This bill aims to stabilize and reform Medicare physician payments, particularly for primary care, by adjusting conversion factors, introducing a new payment model, and overhauling the MIPS program to focus on care efficiency and outcomes.
What it actually does
This bill proposes significant reforms to Medicare physician payments, including modifying the annual conversion factor updates, establishing a new hybrid payment model for primary care services, and overhauling the Merit-based Incentive Payment System (MIPS) by renaming it to the Patient Outcome Improvement National Tabulation System (POINTS) and introducing a 'care efficiency' performance category. It also adjusts geographic practice cost indices, expands access to claims data for research, and revises appropriate use criteria for imaging services.
Proponents argue
Supporters argue that the bill is essential for ensuring the financial stability of physician practices, improving patient access to care, and reducing administrative burdens that divert resources from patient-facing activities. They contend that the reforms will encourage a shift towards value-based care, particularly in primary care, and ensure that quality measures are clinically relevant and developed with significant clinician input.
Opponents contend
Critics may raise concerns about the potential for increased Medicare spending and its long-term impact on the program's solvency, especially given the various payment increases and the higher budget neutrality threshold. Some may also argue that the bill's exclusions for certain practice types from new models or reduced MIPS adjustments could create an uneven playing field or disadvantage larger, integrated health systems.
The bill is moderately complex, requiring dedicated time to understand its intricate changes to Medicare payment systems, which may exceed the typical time allotted for legislative review.
Section 101
Medicare Physician Payment Conversion Factor Updates
This provision modifies how the annual update to the Medicare physician fee schedule conversion factor is calculated starting in 2027. It sets a new formula for non-qualifying Alternative Payment Model (APM) conversion factors, based on the Medicare Economic Index (MEI) minus 1 percentage point, with a floor and ceiling. Qualifying APM conversion factors receive an additional 0.5 percentage point increase.
Supporters argue
Supporters argue this modification provides more predictable and potentially higher reimbursement updates, addressing inflation and supporting the financial viability of physician practices, which is crucial for maintaining patient access to care.
Critics contend
Concerns may be raised about the long-term fiscal impact on the Medicare program, as these updates could lead to increased federal expenditures without explicit offsets.
Tradeoffs
The provision balances the need to ensure physician financial stability and continued participation in Medicare with concerns about the overall solvency and cost control of the Medicare program.
Section 102
Hybrid Payment Model for Primary Care Services
This section establishes a new hybrid payment model for primary care services from 2027 through 2031. Under this model, qualifying suppliers receive a monthly payment for each attributed individual, replacing traditional fee-for-service payments for designated primary care services. The model specifically excludes practices that are not majority-owned and controlled by physicians or designated health care practitioners, with an exception for practices of 15 or fewer practitioners.
Section 103
Work Geographic Floor Adjustment for High Inflationary Years
This provision amends the Medicare physician fee schedule to adjust the work geographic practice cost index (GPCI) for certain localities. For services furnished between 2027 and 2032, if a year is deemed 'high inflationary' (consumer price index increase > 2%), the work GPCI for localities below 1.00 will be increased to 1.025. Other localities will receive a 0.02 point increase in high inflationary years, unless already subject to the 1.025 floor.
Sections 201-204
Renaming MIPS to POINTS and Comprehensive Payment Reform
This bill renames the Merit-based Incentive Payment System (MIPS) to the Patient Outcome Improvement National Tabulation System (POINTS) starting January 1, 2032. It introduces a new 'care efficiency' performance category, modifies the weighting of performance categories (e.g., quality to 65%, resource use to 20%, care efficiency to 15% for 2032+), and adjusts MIPS payment adjustments (e.g., 2% for 2027-2031, increasing to 5% by 2034). Additionally, it reduces positive MIPS adjustments by 50% for professionals in 'excluded practices' starting in 2032.
Section 203
Establishment of Quality Reform Task Force
This section mandates the establishment of a Quality Reform Task Force within six months of the bill's enactment. This Task Force will issue recommendations on quality, resource use, and care efficiency measures for the new POINTS program. Its membership must include a majority of designated health care practitioners, and its recommendations carry significant weight, requiring detailed written explanations from the Secretary of HHS if they are to be overridden.
Section 206
Expanded Access to Medicare Claims Data for Research
This section requires the Secretary of HHS, by January 1, 2027, to establish a process allowing qualified clinical data registries (QCDRs) and clinician-led clinical data registries to request Medicare claims data (and potentially Medicaid/CHIP data). This data can be used for linking with clinical outcomes, conducting quality assessments, and publishing research, without requiring the registries to be 'qualified entities.' Data will be provided at a reasonable fee.
Section 207
Revised Appropriate Use Criteria for Imaging Services
This section modifies requirements for appropriate use criteria (AUC) for applicable imaging services, effective January 1, 2027. Qualified clinical decision support mechanisms (CDSMs) must report specific information to the Secretary. Exemptions are expanded to include clinical trials, small and rural practices, and certain preventive screenings (mammography, lung cancer, colonography, and emergency conditions). It also redefines 'outlier' ordering professionals as 'low compliant' and mandates a study and report on compliance rates and potential improvement mechanisms.
Section 301
Qualifying APM Participant Threshold Freeze
This provision freezes the qualifying APM participant (QP) thresholds for certain years, specifically extending the 2026 and 2028 thresholds through 2029, and the 2027 and 2029 thresholds through 2030. It also grants the Secretary of HHS the authority to specify lower percentages for these thresholds, providing additional flexibility.
Section 401
Increased Budget Neutrality Threshold for Physician Fee Schedule
This provision amends the budget neutrality threshold for the Medicare physician fee schedule. It increases the threshold from $20 million to $57.64 million for 2028, and then indexes this amount annually for subsequent years. Furthermore, every five years, the threshold will be increased by the cumulative percentage increase in the Medicare Economic Index (MEI) over the preceding five-year period.
Section 403
Regular Updates to Practice Expense Direct Costs
This provision mandates that the Secretary of HHS update the prices and rates for direct cost inputs (such as clinical staff wage rates, medical supplies, and equipment) used in calculating practice expense relative value units (RVUs) at least once every five years. All categories of direct cost inputs must be updated simultaneously in the same year, and the Secretary is required to consult with relevant stakeholders, including physician specialty societies, during this process.
Section 404
Cap on Annual Conversion Factor Adjustments
Beginning in 2027, this provision prohibits the Secretary of HHS from applying a budget neutrality adjustment that would cause the Medicare physician fee schedule conversion factor to vary by more than 2.5% compared to the preceding year. This cap applies specifically to budget neutrality adjustments and does not alter the underlying requirement for budget neutrality, nor does it account for other statutory adjustments to the conversion factor.
This provision defines 'excluded practice' for the new hybrid primary care payment model, largely preventing entities not majority-owned and controlled by physicians or designated health care practitioners from participating. The definition includes specific criteria related to ownership interest, de facto control over employment and clinical decisions, voting shares, governing board composition, and director removal processes. An exception is made for practices consisting of 15 or fewer designated health care practitioners.
Section 102, adding new section 1866H(f)(3) to the Social Security Act
Why it matters:While defining terms is standard legislative practice, the specificity and breadth of these exclusion criteria are highly consequential for who can participate in the new payment model, making it a critical detail that could be overlooked.
Case for: Supporters argue this ensures the hybrid model benefits independent, clinician-led practices, preventing corporate entities or private equity from capturing the benefits and potentially influencing clinical decisions in ways that may not align with patient best interests.
Case against: Critics might argue it unfairly excludes larger, integrated health systems or practices with diverse ownership structures that could also provide high-quality primary care, potentially limiting innovation or economies of scale.
Estimated impact: Significantly limits the types of organizations eligible to participate in the new primary care payment model, potentially favoring smaller, independent practices and affecting market consolidation trends.
This provision mandates that the Secretary reduce each positive MIPS (POINTS) adjustment factor by 50% for MIPS eligible professionals who are part of an 'excluded practice' (as defined in the primary care model section), starting in 2032. This reduction is applied in a budget-neutral manner.
Section 204(d), adding new subparagraph 1848(q)(6)(H) to the Social Security Act
Why it matters:This is a technical amendment to an existing payment system, but its cross-reference to a definition in another part of the bill makes it a 'buried treasure' with significant financial implications for a subset of practices. It's a deliberate policy choice to differentiate incentives.
Case for: Proponents argue this provision further incentivizes independent, clinician-led practices by providing a greater relative benefit from MIPS performance, aligning with the bill's broader goal of supporting such practices and potentially counteracting the corporatization of healthcare.
Case against: Opponents would argue it unfairly penalizes larger, integrated practices or those with non-clinician ownership, potentially creating a two-tiered system for MIPS incentives that could hinder collaboration or efficiency in care delivery.
Estimated impact: Significantly alters the financial incentives under the POINTS program for a substantial portion of physician practices, potentially shifting millions in incentive payments away from larger, non-clinician-owned entities.
This provision outlines that while the Quality Reform Task Force's recommendations for measures are generally to be included in the final list, the Secretary of HHS retains the authority to exclude a measure even if it received the support of not fewer than 75% of the Task Force members. However, to do so, the Secretary must consult with the Task Force and publish a written determination explaining a specific finding that the basis for exclusion outweighs the Task Force's clinical judgment.
Section 203, adding new subparagraph 1848(q)(2)(E)(iv)(II)(bb) to the Social Security Act
Why it matters:This is a crucial detail defining the ultimate balance of power and accountability in the measure development process. While it's a procedural safeguard, its location makes it easy to miss the nuanced interplay between expert recommendation and executive discretion.
Case for: Supporters argue this maintains appropriate Secretarial oversight and accountability for the overall Medicare program, ensuring that measures align with broader policy goals, budget considerations, or program integrity concerns that might extend beyond purely clinical judgment.
Case against: Critics might argue it undermines the authority and clinical expertise of the Task Force, potentially allowing political or administrative considerations to override evidence-based, clinician-supported recommendations, thereby reducing the credibility of the measure development process.
Estimated impact: Defines the ultimate authority in setting quality, resource use, and care efficiency measures for the POINTS program, impacting how effectively clinician input translates into policy.