Title IV, SEC. 4111. ESTABLISHMENT OF CUMULATIVE EXPENDITURE GOALS FOR 
PHYSICIAN SERVICES. 
      (a) Use of Cumulative Performance Standard. Section 1848(f)(2) (42 U.S.C. 
    1395w	4(f)(2)) is amended 

        (1) in subparagraph (A) 

          (A) in the heading, by striking ``In general'' and inserting ``Fiscal 
        years 1991 through 1993. '', 

          (B) in the matter preceding clause (i), by striking ``a fiscal year 
        (beginning with fiscal year 1991)'' and inserting ``fiscal years 1991, 
        1992, and 1993'', and 

          (C) in the matter following clause (iv), by striking ``subparagraph 
        (B)'' and inserting ``subparagraph (C)''; 

        (2) in subparagraph (B), by striking ``subparagraph (A)'' and inserting 
      ``subparagraphs (A) and (B)''; 

        (3) by redesignating subparagraphs (B) and (C) as subparagraphs (C) and 
      (D); and 

        (4) by inserting after subparagraph (A) the following new subparagraph: 

        ``(B) Fiscal years beginning with fiscal year 1994. Unless Congress 
      otherwise provides, the performance standard rate of increase, for all 
      physicians' services and for each category of physicians's services, for 
      a fiscal year beginning with fiscal year 1994 shall be equal to the 
      performance standard rate of increase determined under this paragraph for 
      the previous fiscal year, increased by the product of 

        ``(i) 1 plus the Secretary's estimate of the weighted average 
      percentage increase (divided by 100) in the fees for all physicians' 
      services or for the category of physicians' services, respectively, under 
      this part for portions of calendar years included in the fiscal year 
      involved, 

        ``(ii) 1 plus the Secretary's estimate of the percentage increase or 
      decrease (divided by 100) in the average number of individuals enrolled 
      under this part (other than HMO enrollees) from the previous fiscal year 
      to the fiscal year involved, 

        ``(iii) 1 plus the Secretary's estimate of the average annual 
      percentage growth (divided by 100) in volume and intensity of all 
      physicians' services or of the category of physicians' services, 
      respectively, under this part for the 5-fiscal-year period ending with 
      the preceding fiscal year (based upon information contained in the most 
      recent annual report made pursuant to section 1841(b)(2)), and 

        ``(iv) 1 plus the Secretary's estimate of the percentage increase or 
      decrease (divided by 100) in expenditures for all physicians' services or 
      of the category of physicians' services, respectively, in the fiscal year 
      (compared with the previous fiscal year) which are estimated to result 
      from changes in law or regulations affecting the percentage increase 
      described in clause (i) and which is not taken into account in the 
      percentage increase described in clause (i), 

        ``minus 1, multiplied by 100, and reduced by the performance standard 
      factor (specified in subparagraph (C)).''. 

      (b) Treatment of Default Update. 

        (1) In general. Section 1848(d)(3)(B) (42 U.S.C. 1395w	4(d)(3)(B)) is 
      amended 

          (A) in clause (i) 

            (i) in the heading, by striking ``In general'' and inserting ``1992 
          through 1995'', and 

            (ii) by striking ``for a year'' and inserting ``for 1992, 1993, 
          1994, and 1995''; and 

          (B) by adding after clause (ii) the following new clause: 

          ``(iii) Years beginning with 1996. 

          ``(I) In general. The update for a category of physicians' services 
        for a year beginning with 1996 provided under subparagraph (A) shall be 
        increased or decreased by the same percentage by which the cumulative 
        percentage increase in actual expenditures for such category of 
        physicians' services for such year was less or greater, respectively, 
        than the performance standard rate of increase (established under 
        subsection (f)) for such category of services for such year. 

          ``(II) Cumulative percentage increase defined. In subclause (I), the 
        `cumulative percentage increase in actual expenditures' for a year 
        shall be equal to the product of the adjusted increases for each year 
        beginning with 1994 up to and including the year involved, minus 1 and 
        multiplied by 100. In the previous sentence, the `adjusted increase' 
        for a year is equal to 1 plus the percentage increase in actual 
        expenditures for the year.''. 

        (2) Conforming amendment. Section 1848(d)(3)(A)(i) (42 U.S.C. 
      1395w	4(d)(3)(A)(i)) is amended by striking ``subparagraph (B)'' and 
      inserting ``subparagraphs (B) and (C)''.