This bill delays a planned Medicare payment adjustment to physician work values until 2030 and modifies annual Medicare payment update rates based on APM participation.
Ron Estes
Representative
KS-4
The Efficiency Adjustment Delay Act postpones a planned Medicare payment adjustment affecting physician work values until at least January 1, 2030. The bill also mandates a report to Congress assessing the need for a one-time adjustment to certain physician service values. Furthermore, it modifies the annual Medicare physician payment updates for 2026 and subsequent years based on participation in Alternative Payment Models.
Medicare Payment Overhaul Delays Efficiency Cuts Until 2030 and Boosts Doctor Raises
The Efficiency Adjustment Delay Act hits the pause button on a major change to how Medicare calculates what your doctor gets paid. Back in 2025, a rule was set to roll out an 'efficiency adjustment' that would have likely trimmed payments for various medical services. This bill pushes that plan all the way back to January 1, 2030, giving the healthcare industry a five-year breather. While that sounds like inside baseball, it directly impacts the financial stability of the clinics where you get your checkups and the overall cost of the Medicare program.
The Five-Year Freeze
Under this bill, the government can’t touch those 'efficiency' calculations for at least five years. Instead of diving into cuts, the Secretary of Health and Human Services has two years to write a report explaining if these adjustments are even necessary for services that haven't been reviewed in a decade. If you're a doctor running a small practice, this is a major win for predictability. You won't wake up next year to find your reimbursement for a standard office visit has been slashed by a new efficiency formula. However, for the average taxpayer, this delay means the Medicare program might miss out on potential savings that 'efficiency' was supposed to create, potentially keeping program costs higher than they otherwise would be.
Pay Raises and the APM Carrot
The bill also changes the math for annual raises. Starting in 2026, doctors will see a split in their pay bumps based on how they run their business. If a doctor participates in an Alternative Payment Model (APM)—think of these as programs that reward quality of care over just the number of tests ordered—they get a 1.24% raise in 2026. If they stick to the traditional 'fee-for-service' model, they only get 0.74%. From 2027 onward, those raises drop to 0.75% for APM doctors and a tiny 0.25% for everyone else. For a patient, this means your doctor has a much stronger financial incentive to join these modern care models, which could change how your care is managed.
Protecting the Status Quo
To make sure future changes don't catch anyone off guard, the bill adds some 'guardrails.' If the government tries to bring back the efficiency adjustment in 2030, they have to talk to the medical specialties affected first. They also can't use a formula that relies on productivity versus inflation unless the standard payment rate is actually keeping up with the Consumer Price Index. It’s essentially a 'no pay cuts during high inflation' clause. While this protects doctors from losing money when the cost of living spikes, it adds layers of bureaucracy that could make it harder for Medicare to adjust to new, cheaper ways of providing medical care in the future.