; and (II) with respect to a performance period with respect to a consequence year beginning with the fourth consequence year, at least 6 clinical quality measures for providers and suppliers of air ambulance services. (iv) Updates The Secretary, in consultation with providers and suppliers of air ambulance services, shall periodically update, as determined necessary by the Secretary, the measures to be applied pursuant to this subparagraph. (E) Definitions For purposes of this paragraph: (i) The term consequence year means a year beginning with the 5th year starting at least 12 months after the date of the enactment of this paragraph. The terms first consequence year , second consequence year, and third consequence year mean such 5th year starting at least 12 months after such date of enactment, the 6th year starting at least 12 months after such date of enactment, and the 7th year starting at least 12 months after such date of enactment, respectively. (ii) The term performance period means, with respect to a consequence year, such period as specified by the Secretary. . 6. MedPAC study on access, quality, costs, and reimbursement (a) Evaluation Not later than three years after December 31 of the first year to which paragraph (18) of section 1834(l) of the Social Security Act, as added by section 4, applies, the Medicare Payment Advisory Commission shall submit to Congress a report containing an evaluation of the costs of air providers and suppliers. Such evaluation shall— (1) be derived from the cost and other data submitted under such paragraph (18) of such section 1834(l); and (2) differentiate as appropriate to recognize variation or higher costs related to— (A) aviation instrument flight control; (B) provision of care to critically ill or injured patients; (C) the provision of services in geographically isolated areas