PRINTER'S NO. 4210
No. 2708 Session of 2008
INTRODUCED BY STERN, BOYD, REICHLEY, NAILOR, MAJOR, CAPPELLI,
WATSON, SAINATO, MARSHALL, BAKER, PERRY, SAYLOR, CUTLER,
RUBLEY, MILNE, ROHRER, TRUE, COX, FLECK, YOUNGBLOOD, HANNA,
ADOLPH, PHILLIPS, SONNEY, McILHATTAN, MOYER, HERSHEY, MOUL,
LONGIETTI, HESS, GRELL, CAUSER, COHEN AND MANN, JULY 9, 2008
REFERRED TO COMMITTEE ON INSURANCE, JULY 9, 2008
AN ACT
1 Reenacting and amending the act of July 8, 1986 (P.L.408,
2 No.89), entitled, as reenacted, "An act providing for the
3 creation of the Health Care Cost Containment Council, for its
4 powers and duties, for health care cost containment through
5 the collection and dissemination of data, for public
6 accountability of health care costs and for health care for
7 the indigent; and making an appropriation," further providing
8 for sunset.
9 The General Assembly of the Commonwealth of Pennsylvania
10 hereby enacts as follows:
11 Section 1. The title and sections 1, 2, 3, 4, 5, 6, 7, 8, 9,
12 10, 11, 12, 13, 14, 15, 16, 17.1 and 18 of the act of July 8,
13 1986 (P.L.408, No.89), known as the Health Care Cost Containment
14 Act, reenacted and amended July 17, 2003 (P.L.31, No.14), are
15 reenacted to read:
16 AN ACT
17 Providing for the creation of the Health Care Cost Containment
18 Council, for its powers and duties, for health care cost
19 containment through the collection and dissemination of data,
1 for public accountability of health care costs and for health
2 care for the indigent; and making an appropriation.
3 Section 1. Short title.
4 This act shall be known and may be cited as the Health Care
5 Cost Containment Act.
6 Section 2. Legislative finding and declaration.
7 The General Assembly finds that there exists in this
8 Commonwealth a major crisis because of the continuing escalation
9 of costs for health care services. Because of the continuing
10 escalation of costs, an increasingly large number of
11 Pennsylvania citizens have severely limited access to
12 appropriate and timely health care. Increasing costs are also
13 undermining the quality of health care services currently being
14 provided. Further, the continuing escalation is negatively
15 affecting the economy of this Commonwealth, is restricting new
16 economic growth and is impeding the creation of new job
17 opportunities in this Commonwealth.
18 The continuing escalation of health care costs is
19 attributable to a number of interrelated causes, including:
20 (1) Inefficiency in the present configuration of health
21 care service systems and in their operation.
22 (2) The present system of health care cost payments by
23 third parties.
24 (3) The increasing burden of indigent care which
25 encourages cost shifting.
26 (4) The absence of a concentrated and continuous effort
27 in all segments of the health care industry to contain health
28 care costs.
29 Therefore, it is hereby declared to be the policy of the
30 Commonwealth of Pennsylvania to promote health care cost
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1 containment and to identify appropriate utilization practices by
2 creating an independent council to be known as the Health Care
3 Cost Containment Council.
4 It is the purpose of this legislation to promote the public
5 interest by encouraging the development of competitive health
6 care services in which health care costs are contained and to
7 assure that all citizens have reasonable access to quality
8 health care.
9 It is further the intent of this act to facilitate the
10 continuing provision of quality, cost-effective health services
11 throughout the Commonwealth by providing current, accurate data
12 and information to the purchasers and consumers of health care
13 on both cost and quality of health care services and to public
14 officials for the purpose of determining health-related programs
15 and policies and to assure access to health care services.
16 Nothing in this act shall prohibit a purchaser from obtaining
17 from its third-party insurer, carrier or administrator, nor
18 relieve said third-party insurer, carrier or administrator from
19 the obligation of providing, on terms consistent with past
20 practices, data previously provided to a purchaser pursuant to
21 any existing or future arrangement, agreement or understanding.
22 Section 3. Definitions.
23 The following words and phrases when used in this act shall
24 have the meanings given to them in this section unless the
25 context clearly indicates otherwise:
26 "Ambulatory service facility." A facility licensed in this
27 Commonwealth, not part of a hospital, which provides medical,
28 diagnostic or surgical treatment to patients not requiring
29 hospitalization, including ambulatory surgical facilities,
30 ambulatory imaging or diagnostic centers, birthing centers,
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1 freestanding emergency rooms and any other facilities providing
2 ambulatory care which charge a separate facility charge. This
3 term does not include the offices of private physicians or
4 dentists, whether for individual or group practices.
5 "Charge" or "rate." The amount billed by a provider for
6 specific goods or services provided to a patient, prior to any
7 adjustment for contractual allowances.
8 "Council." The Health Care Cost Containment Council.
9 "Covered services." Any health care services or procedures
10 connected with episodes of illness that require either inpatient
11 hospital care or major ambulatory service such as surgical,
12 medical or major radiological procedures, including any initial
13 and follow-up outpatient services associated with the episode of
14 illness before, during or after inpatient hospital care or major
15 ambulatory service. The term does not include routine outpatient
16 services connected with episodes of illness that do not require
17 hospitalization or major ambulatory service.
18 "Data source." A hospital; ambulatory service facility;
19 physician; health maintenance organization as defined in the act
20 of December 29, 1972 (P.L.1701, No.364), known as the Health
21 Maintenance Organization Act; hospital, medical or health
22 service plan with a certificate of authority issued by the
23 Insurance Department, including, but not limited to, hospital
24 plan corporations as defined in 40 Pa.C.S. Ch. 61 (relating to
25 hospital plan corporations) and professional health services
26 plan corporations as defined in 40 Pa.C.S. Ch. 63 (relating to
27 professional health services plan corporations); commercial
28 insurer with a certificate of authority issued by the Insurance
29 Department providing health or accident insurance; self-insured
30 employer providing health or accident coverage or benefits for
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1 employees employed in the Commonwealth; administrator of a self-
2 insured or partially self-insured health or accident plan
3 providing covered services in the Commonwealth; any health and
4 welfare fund that provides health or accident benefits or
5 insurance pertaining to covered service in the Commonwealth; the
6 Department of Public Welfare for those covered services it
7 purchases or provides through the medical assistance program
8 under the act of June 13, 1967 (P.L.31, No.21), known as the
9 Public Welfare Code, and any other payor for covered services in
10 the Commonwealth other than an individual.
11 "Health care facility." A general or special hospital,
12 including tuberculosis and psychiatric hospitals, kidney disease
13 treatment centers, including freestanding hemodialysis units,
14 and ambulatory service facilities as defined in this section,
15 and hospices, both profit and nonprofit, and including those
16 operated by an agency of State or local government.
17 "Health care insurer." Any person, corporation or other
18 entity that offers administrative, indemnity or payment services
19 for health care in exchange for a premium or service charge
20 under a program of health care benefits, including, but not
21 limited to, an insurance company, association or exchange
22 issuing health insurance policies in this Commonwealth; hospital
23 plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to
24 hospital plan corporations); professional health services plan
25 corporation as defined in 40 Pa.C.S. Ch. 63 (relating to
26 professional health services plan corporations); health
27 maintenance organization; preferred provider organization;
28 fraternal benefit societies; beneficial societies; and third-
29 party administrators; but excluding employers, labor unions or
30 health and welfare funds jointly or separately administered by
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1 employers or labor unions that purchase or self-fund a program
2 of health care benefits for their employees or members and their
3 dependents.
4 "Health maintenance organization." An organized system which
5 combines the delivery and financing of health care and which
6 provides basic health services to voluntarily enrolled
7 subscribers for a fixed prepaid fee, as defined in the act of
8 December 29, 1972 (P.L.1701, No.364), known as the Health
9 Maintenance Organization Act.
10 "Hospital." An institution, licensed in this Commonwealth,
11 which is a general, tuberculosis, mental, chronic disease or
12 other type of hospital, or kidney disease treatment center,
13 whether profit or nonprofit, and including those operated by an
14 agency of State or local government.
15 "Indigent care." The actual costs, as determined by the
16 council, for the provision of appropriate health care, on an
17 inpatient or outpatient basis, given to individuals who cannot
18 pay for their care because they are above the medical assistance
19 eligibility levels and have no health insurance or other
20 financial resources which can cover their health care.
21 "Major ambulatory service." Surgical or medical procedures,
22 including diagnostic and therapeutic radiological procedures,
23 commonly performed in hospitals or ambulatory service
24 facilities, which are not of a type commonly performed or which
25 cannot be safely performed in physicians' offices and which
26 require special facilities such as operating rooms or suites or
27 special equipment such as fluoroscopic equipment or computed
28 tomographic scanners, or a postprocedure recovery room or short-
29 term convalescent room.
30 "Medical procedure incidence variations." The variation in
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1 the incidence in the population of specific medical, surgical
2 and radiological procedures in any given year, expressed as a
3 deviation from the norm, as these terms are defined in the
4 classical statistical definition of "variation," "incidence,"
5 "deviation" and "norm."
6 "Medically indigent" or "indigent." The status of a person
7 as described in the definition of indigent care.
8 "Payment." The payments that providers actually accept for
9 their services, exclusive of charity care, rather than the
10 charges they bill.
11 "Payor." Any person or entity, including, but not limited
12 to, health care insurers and purchasers, that make direct
13 payments to providers for covered services.
14 "Physician." An individual licensed under the laws of this
15 Commonwealth to practice medicine and surgery within the scope
16 of the act of October 5, 1978 (P.L.1109, No.261), known as the
17 Osteopathic Medical Practice Act, or the act of December 20,
18 1985 (P.L.457, No.112), known as the Medical Practice Act of
19 1985.
20 "Preferred provider organization." Any arrangement between a
21 health care insurer and providers of health care services which
22 specifies rates of payment to such providers which differ from
23 their usual and customary charges to the general public and
24 which encourage enrollees to receive health services from such
25 providers.
26 "Provider." A hospital, an ambulatory service facility or a
27 physician.
28 "Provider quality." The extent to which a provider renders
29 care that, within the capabilities of modern medicine, obtains
30 for patients medically acceptable health outcomes and prognoses,
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1 adjusted for patient severity, and treats patients
2 compassionately and responsively.
3 "Provider service effectiveness." The effectiveness of
4 services rendered by a provider, determined by measurement of
5 the medical outcome of patients grouped by severity receiving
6 those services.
7 "Purchaser." All corporations, labor organizations and other
8 entities that purchase benefits which provide covered services
9 for their employees or members, either through a health care
10 insurer or by means of a self-funded program of benefits, and a
11 certified bargaining representative that represents a group or
12 groups of employees for whom employers purchase a program of
13 benefits which provide covered services, but excluding entities
14 defined in this section as "health care insurers."
15 "Raw data" or "data." Data collected by the council under
16 section 6 in the form initially received. No data shall be
17 released by the council except as provided for in section 11.
18 "Severity." In any patient, the measureable degree of the
19 potential for failure of one or more vital organs.
20 Section 4. Health Care Cost Containment Council.
21 (a) Establishment.--The General Assembly hereby establishes
22 an independent council to be known as the Health Care Cost
23 Containment Council.
24 (b) Composition.--The council shall consist of voting
25 members, composed of and appointed in accordance with the
26 following:
27 (1) The Secretary of Health.
28 (2) The Secretary of Public Welfare.
29 (3) The Insurance Commissioner.
30 (4) Six representatives of the business community, at
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1 least one of whom represents small business, who are
2 purchasers of health care as defined in section 3, none of
3 which is primarily involved in the provision of health care
4 or health insurance, three of which shall be appointed by the
5 President pro tempore of the Senate and three of which shall
6 be appointed by the Speaker of the House of Representatives
7 from a list of twelve qualified persons recommended by the
8 Pennsylvania Chamber of Business and Industry. Three nominees
9 shall be representatives of small business.
10 (5) Six representatives of organized labor, three of
11 which shall be appointed by the President pro tempore of the
12 Senate and three of which shall be appointed by the Speaker
13 of the House of Representatives from a list of twelve
14 qualified persons recommended by the Pennsylvania AFL-CIO.
15 (6) One representative of consumers who is not primarily
16 involved in the provision of health care or health care
17 insurance, appointed by the Governor from a list of three
18 qualified persons recommended jointly by the Speaker of the
19 House of Representatives and the President pro tempore of the
20 Senate.
21 (7) Two representatives of hospitals, appointed by the
22 Governor from a list of five qualified hospital
23 representatives recommended by the Hospital and Health System
24 Association of Pennsylvania one of whom shall be a
25 representative of rural hospitals. Each representative under
26 this paragraph may appoint two additional delegates to act
27 for the representative only at meetings of committees, as
28 provided for in subsection (f).
29 (8) Two representatives of physicians, appointed by the
30 Governor from a list of five qualified physician
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1 representatives recommended jointly by the Pennsylvania
2 Medical Society and the Pennsylvania Osteopathic Medical
3 Society. The representative under this paragraph may appoint
4 two additional delegates to act for the representative only
5 at meetings of committees, as provided for in subsection (f).
6 (8.1) An individual appointed by the Governor who has
7 expertise in the application of continuous quality
8 improvement methods in hospitals.
9 (8.2) One representative of nurses, appointed by the
10 Governor from a list of three qualified representatives
11 recommended by the Pennsylvania State Nurses Association.
12 (9) One representative of the Blue Cross and Blue Shield
13 plans in Pennsylvania, appointed by the Governor from a list
14 of three qualified persons recommended jointly by the Blue
15 Cross and Blue Shield plans of Pennsylvania.
16 (10) One representative of commercial insurance
17 carriers, appointed by the Governor from a list of three
18 qualified persons recommended by the Insurance Federation of
19 Pennsylvania, Inc.
20 (11) One representative of health maintenance
21 organizations, appointed by the Governor from a list of three
22 qualified persons recommended by the Managed Care Association
23 of Pennsylvania.
24 (12) In the case of each appointment to be made from a
25 list supplied by a specified organization, it is incumbent
26 upon that organization to consult with and provide a list
27 which reflects the input of other equivalent organizations
28 representing similar interests. Each appointing authority
29 will have the discretion to request additions to the list
30 originally submitted. Additional names will be provided not
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1 later than 15 days after such request. Appointments shall be
2 made by the appointing authority no later than 90 days after
3 receipt of the original list. If, for any reason, any
4 specified organization supplying a list should cease to
5 exist, then the respective appointing authority shall specify
6 a new equivalent organization to fulfill the responsibilities
7 of this act.
8 (c) Chairperson and vice chairperson.--The members shall
9 annually elect, by a majority vote of the members, a chairperson
10 and a vice chairperson of the council from among the business
11 and labor representatives on the council.
12 (d) Quorum.--Thirteen members, at least six of whom must be
13 made up of representatives of business and labor, shall
14 constitute a quorum for the transaction of any business, and the
15 act by the majority of the members present at any meeting in
16 which there is a quorum shall be deemed to be the act of the
17 council.
18 (e) Meetings.--All meetings of the council shall be
19 advertised and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating
20 to open meetings), unless otherwise provided in this section.
21 (1) The council shall meet at least once every two
22 months, and may provide for special meetings as it deems
23 necessary. Meeting dates shall be set by a majority vote of
24 the members of the council or by the call of the chairperson
25 upon seven days' notice to all council members.
26 (2) All meetings of the council shall be publicly
27 advertised, as provided for in this subsection, and shall be
28 open to the public, except that the council, through its
29 bylaws, may provide for executive sessions of the council on
30 subjects permitted to be discussed in such sessions under 65
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1 Pa.C.S. Ch. 7. No act of the council shall be taken in an
2 executive session.
3 (3) The council shall publish a schedule of its meetings
4 in the Pennsylvania Bulletin and in at least one newspaper in
5 general circulation in the Commonwealth. Such notice shall be
6 published at least once in each calendar quarter and shall
7 list the schedule of meetings of the council to be held in
8 the subsequent calendar quarter. Such notice shall specify
9 the date, time and place of the meeting and shall state that
10 the council's meetings are open to the general public, except
11 that no such notice shall be required for executive sessions
12 of the council.
13 (4) All action taken by the council shall be taken in
14 open public session, and action of the council shall not be
15 taken except upon the affirmative vote of a majority of the
16 members of the council present during meetings at which a
17 quorum is present.
18 (f) Bylaws.--The council shall adopt bylaws, not
19 inconsistent with this act, and may appoint such committees or
20 elect such officers subordinate to those provided for in
21 subsection (c) as it deems advisable. The council shall provide
22 for the approval and participation of additional delegates
23 appointed under subsection (b)(7) and (8) so that each
24 organization represented by delegates under those paragraphs
25 shall not have more than one vote on any committee to which they
26 are appointed. The council shall also appoint a technical
27 advisory group which shall, on an ad hoc basis, respond to
28 issues presented to it by the council or committees of the
29 council and shall make recommendations to the council. The
30 technical advisory group shall include physicians, researchers,
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1 biostatisticians, one representative of the Hospital and
2 Healthsystem Association of Pennsylvania and one representative
3 of the Pennsylvania Medical Society. The Hospital and
4 Healthsystem Association of Pennsylvania and the Pennsylvania
5 Medical Society representatives shall not be subject to
6 executive committee approval. In appointing other physicians,
7 researchers and biostatisticians to the technical advisory
8 group, the council shall consult with and take nominations from
9 the representatives of the Hospital Association of Pennsylvania,
10 the Pennsylvania Medical Society, the Pennsylvania Osteopathic
11 Medical Society or other like organizations. At its discretion
12 and in accordance with this section, nominations shall be
13 approved by the executive committee of the council. If the
14 subject matter of any project exceeds the expertise of the
15 technical advisory group, physicians in appropriate specialties
16 who possess current knowledge of the issue under study may be
17 consulted. The technical advisory group shall also review the
18 availability and reliability of severity of illness measurements
19 as they relate to small hospitals and psychiatric,
20 rehabilitation and children's hospitals and shall make
21 recommendations to the council based upon this review.
22 (g) Compensation and expenses.--The members of the council
23 shall not receive a salary or per diem allowance for serving as
24 members of the council but shall be reimbursed for actual and
25 necessary expenses incurred in the performance of their duties.
26 Said expenses may include reimbursement of travel and living
27 expenses while engaged in council business.
28 (h) Terms of council members.--
29 (1) The terms of the Secretary of Health, the Secretary
30 of Public Welfare and the Insurance Commissioner shall be
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1 concurrent with their holding of public office. The council
2 members under subsection (b)(4) through (11) shall each serve
3 for a term of four years and shall continue to serve
4 thereafter until their successor is appointed.
5 (2) Vacancies on the council shall be filled in the
6 manner designated under subsection (b), within 60 days of the
7 vacancy, except that when vacancies occur among the
8 representatives of business or organized labor, two
9 nominations shall be submitted by the organization specified
10 in subsection (b) for each vacancy on the council. If the
11 officer required in subsection (b) to make appointments to
12 the council fails to act within 60 days of the vacancy, the
13 council chairperson may appoint one of the persons
14 recommended for the vacancy until the appointing authority
15 makes the appointment.
16 (3) A member may be removed for just cause by the
17 appointing authority after recommendation by a vote of at
18 least 14 members of the council.
19 (4) No appointed member under subsection (b)(4) through
20 (11) shall be eligible to serve more than two full
21 consecutive terms of four years beginning on the effective
22 date of this paragraph.
23 (j) Subsequent appointments.--Submission of lists of
24 recommended persons and appointments of council members for
25 succeeding terms shall be made in the same manner as prescribed
26 in subsection (b), except that:
27 (1) Organizations required under subsection (b) to
28 submit lists of recommended persons shall do so at least 60
29 days prior to expiration of the council members' terms.
30 (2) The officer required under subsection (b) to make
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1 appointments to the council shall make said appointments at
2 least 30 days prior to expiration of the council members'
3 terms. If the appointments are not made within the specified
4 time, the council chairperson may make interim appointments
5 from the lists of recommended individuals. An interim
6 appointment shall be valid only until the appropriate officer
7 under subsection (b) makes the required appointment. Whether
8 the appointment is by the required officer or by the
9 chairperson of the council, the appointment shall become
10 effective immediately upon expiration of the incumbent
11 member's term.
12 Section 5. Powers and duties of the council.
13 (a) General powers.--The council shall exercise all powers
14 necessary and appropriate to carry out its duties, including the
15 following:
16 (1) To employ an executive director, investigators and
17 other staff necessary to comply with the provisions of this
18 act and regulations promulgated thereunder, to employ or
19 retain legal counsel and to engage professional consultants,
20 as it deems necessary to the performance of its duties. Any
21 consultants, other than sole source consultants, engaged by
22 the council shall be selected in accordance with the
23 provisions for contracting with vendors set forth in section
24 16.
25 (2) To fix the compensation of all employees and to
26 prescribe their duties. Notwithstanding the independence of
27 the council under section 4(a), employees under this
28 paragraph shall be deemed employees of the Commonwealth for
29 the purposes of participation in the Pennsylvania Employee
30 Benefit Trust Fund.
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1 (3) To make and execute contracts and other instruments,
2 including those for purchase of services and purchase or
3 leasing of equipment and supplies, necessary or convenient to
4 the exercise of the powers of the council. Any such contract
5 shall be let only in accordance with the provision for
6 contracting with vendors set forth in section 16.
7 (4) To conduct examinations and investigations, to
8 conduct audits, pursuant to the provisions of subsection (c),
9 and to hear testimony and take proof, under oath or
10 affirmation, at public or private hearings, on any matter
11 necessary to its duties.
12 (4.1) To provide hospitals with individualized data on
13 patient safety indicators pursuant to section 6(c)(7). The
14 data shall be risk adjusted and made available to hospitals
15 electronically and free of charge on a quarterly basis within
16 45 days of receipt of the corrected quarterly data from the
17 hospitals. The data is intended to provide the patient safety
18 committee of each hospital with information necessary to
19 assist in conducting patient safety analysis.
20 (5) To do all things necessary to carry out its duties
21 under the provisions of this act.
22 (b) Rules and regulations.--The council shall promulgate
23 rules and regulations in accordance with the act of June 25,
24 1982 (P.L.633, No.181), known as the Regulatory Review Act,
25 necessary to carry out its duties under this act. This
26 subsection shall not apply to regulations in effect on June 30,
27 2003.
28 (c) Audit powers.--The council shall have the right to
29 independently audit all information required to be submitted by
30 data sources as needed to corroborate the accuracy of the
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1 submitted data, pursuant to the following:
2 (1) Audits of information submitted by providers or
3 health care insurers shall be performed on a sample and
4 issue-specific basis, as needed by the council, and shall be
5 coordinated, to the extent practicable, with audits performed
6 by the Commonwealth. All health care insurers and providers
7 are hereby required to make those books, records of accounts
8 and any other data needed by the auditors available to the
9 council at a convenient location within 30 days of a written
10 notification by the council.
11 (2) Audits of information submitted by purchasers shall
12 be performed on a sample basis, unless there exists
13 reasonable cause to audit specific purchasers, but in no case
14 shall the council have the power to audit financial
15 statements of purchasers.
16 (3) All audits performed by the council shall be
17 performed at the expense of the council.
18 (d) General duties and functions.--The council is hereby
19 authorized to and shall perform the following duties and
20 functions:
21 (1) Develop a computerized system for the collection,
22 analysis and dissemination of data. The council may contract
23 with a vendor who will provide such data processing services.
24 The council shall assure that the system will be capable of
25 processing all data required to be collected under this act.
26 Any vendor selected by the council shall be selected in
27 accordance with the provisions of section 16, and said vendor
28 shall relinquish any and all proprietary rights or claims to
29 the data base created as a result of implementation of the
30 data processing system.
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1 (2) Establish a Pennsylvania Uniform Claims and Billing
2 Form for all data sources and all providers which shall be
3 utilized and maintained by all data sources and all providers
4 for all services covered under this act.
5 (3) Collect and disseminate data, as specified in
6 section 6, and other information from data sources to which
7 the council is entitled, prepared according to formats, time
8 frames and confidentiality provisions as specified in
9 sections 6 and 10, and by the council.
10 (4) Adopt and implement a methodology to collect and
11 disseminate data reflecting provider quality and provider
12 service effectiveness pursuant to section 6.
13 (5) Subject to the restrictions on access to raw data
14 set forth in section 10, issue special reports and make
15 available raw data as defined in section 3 to any purchaser
16 requesting it. Sale by any recipient or exchange or
17 publication by a recipient, other than a purchaser, of raw
18 council data to other parties without the express written
19 consent of, and under terms approved by, the council shall be
20 unauthorized use of data pursuant to section 10(c).
21 (6) On an annual basis, publish in the Pennsylvania
22 Bulletin a list of all the raw data reports it has prepared
23 under section 10(f) and a description of the data obtained
24 through each computer-to-computer access it has provided
25 under section 10(f) and of the names of the parties to whom
26 the council provided the reports or the computer-to-computer
27 access during the previous month.
28 (7) Promote competition in the health care and health
29 insurance markets.
30 (8) Assure that the use of council data does not raise
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1 access barriers to care.
2 (10) Make annual reports to the General Assembly on the
3 rate of increase in the cost of health care in the
4 Commonwealth and the effectiveness of the council in carrying
5 out the legislative intent of this act. In addition, the
6 council may make recommendations on the need for further
7 health care cost containment legislation. The council shall
8 also make annual reports to the General Assembly on the
9 quality and effectiveness of health care and access to health
10 care for all citizens of the Commonwealth.
11 (12) Conduct studies and publish reports thereon
12 analyzing the effects that noninpatient, alternative health
13 care delivery systems have on health care costs. These
14 systems shall include, but not be limited to: HMO's; PPO's;
15 primary health care facilities; home health care; attendant
16 care; ambulatory service facilities; freestanding emergency
17 centers; birthing centers; and hospice care. These reports
18 shall be submitted to the General Assembly and shall be made
19 available to the public.
20 (13) Conduct studies and make reports concerning the
21 utilization of experimental and nonexperimental transplant
22 surgery and other highly technical and experimental
23 procedures, including costs and mortality rates.
24 (14) In order to ensure that the council adopts and
25 maintains both scientifically credible and cost-effective
26 methodology to collect and disseminate data reflecting
27 provider quality and effectiveness, the council shall, within
28 one year of the effective date of this paragraph, utilizing
29 current Commonwealth agency guidelines and procedures, issue
30 a request for information from any vendor that wishes to
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1 provide data collection or risk adjustment methodology to the
2 council to help meet the requirements of this subsection and
3 section 6. The council shall establish an independent Request
4 for Information Review Committee to review and rank all
5 responses and to make a final recommendation to the council.
6 The Request for Information Review Committee shall consist of
7 the following members appointed by the Governor:
8 (i) One representative of the Hospital and
9 Healthsystem Association of Pennsylvania.
10 (ii) One representative of the Pennsylvania Medical
11 Society.
12 (iii) One representative of insurance.
13 (iv) One representative of labor.
14 (v) One representative of business.
15 (vi) Two representatives of the general public.
16 (15) The council shall execute a request for proposals
17 with third-party vendors for the purpose of demonstrating a
18 methodology for the collection, analysis and reporting of
19 hospital-specific complication rates. The results of this
20 demonstration shall be provided to the chairman and minority
21 chairman of the Public Health and Welfare Committee of the
22 Senate and the chairman and minority chairman of the Health
23 and Human Services Committee of the House of Representatives.
24 This methodology may be utilized by the council for public
25 reporting on comparative hospital complication rates.
26 Section 6. Data submission and collection.
27 (a) (1) Submission of data.--The council is hereby
28 authorized to collect and data sources are hereby required to
29 submit, upon request of the council, all data required in
30 this section, according to uniform submission formats, coding
20080H2708B4210 - 20 -
1 systems and other technical specifications necessary to
2 render the incoming data substantially valid, consistent,
3 compatible and manageable using electronic data processing
4 according to data submission schedules, such schedules to
5 avoid, to the extent possible, submission of identical data
6 from more than one data source, established and promulgated
7 by the council in regulations pursuant to its authority under
8 section 5(b). If payor data is requested by the council, it
9 shall, to the extent possible, be obtained from primary payor
10 sources.
11 (2) Except as provided in this section, the council may
12 adopt any nationally recognized methodology to adjust data
13 submitted under subsection (c) for severity of illness. Every
14 three years after the effective date of this paragraph, the
15 council shall solicit bids from third-party vendors to adjust
16 the data. The solicitation shall be in accordance with 62
17 Pa.C.S. (relating to procurement). Except as provided in
18 subparagraph (i), in carrying out its responsibilities, the
19 council shall not require health care facilities to report
20 data elements which are not included in the manual developed
21 by the national uniform billing committee. The following
22 apply:
23 (i) Within 60 days of the effective date of this
24 paragraph, the council shall publish in the Pennsylvania
25 Bulletin a list of diseases, procedures and medical
26 conditions, not to exceed 35, for which data under
27 subsections (c)(21) and (d) shall be required. The chosen
28 list shall not represent more than 50% of total hospital
29 discharges, based upon the previous year's hospital
30 discharge data. Subsequent to the publication of the
20080H2708B4210 - 21 -
1 list, any data submission requirements under subsections
2 (c)(21) and (d) previously in effect shall be null and
3 void for diseases, procedures and medical conditions not
4 found on the list. All other data elements pursuant to
5 subsection (c) shall continue to be required from data
6 sources. The council shall review the list and may add no
7 more than a net of three diseases, procedures or medical
8 conditions per year over a five-year period starting on
9 the effective date of this subparagraph. The adjusted
10 list of diseases, procedures and medical conditions shall
11 at no time be more than 50% of total hospital discharges.
12 (ii) If the current data vendor is unable to
13 achieve, on a per-chart basis, savings of at least 40% in
14 the cost of hospital compliance with the data abstracting
15 and submission requirements of this act by June 30, 2004,
16 as compared to June 30, 2003, then the council shall
17 disqualify the current vendor and reopen the bidding
18 process. The independent auditor shall determine the
19 extent and validity of the savings. In determining any
20 demonstrated cost savings, surveys of all hospitals in
21 this Commonwealth shall be conducted and consideration
22 shall be given at a minimum to:
23 (A) new costs, in terms of making the
24 methodology operational, associated with laboratory,
25 pharmacy and other information systems a hospital is
26 required to purchase in order to reduce hospital
27 compliance costs, including the cost of electronic
28 transfer of required data; and
29 (B) the audited direct personnel and related
30 costs of data abstracting and submission required.
20080H2708B4210 - 22 -
1 (iii) Review by the independent auditor shall
2 commence by March 1, 2004, and shall conclude with a
3 report of findings by July 31, 2004. The report shall be
4 delivered to the council, the Governor, the Health and
5 Human Services Committee of the House of Representatives
6 and the Public Health and Welfare Committee of the
7 Senate.
8 (a.1) Abstraction and technology work group.--
9 (1) The council shall establish a data abstraction and
10 technology work group to produce recommendations for
11 improving and refining the data required by the council and
12 reducing, through innovative direct data collection
13 techniques, the cost of collecting required data. The work
14 group shall consist of the following members appointed by the
15 council:
16 (i) one member representing the Office of Health
17 Care Reform;
18 (ii) one member representing the business community;
19 (iii) one member representing labor;
20 (iv) one member representing consumers;
21 (v) two members representing physicians;
22 (vi) two members representing nurses;
23 (vii) two members representing hospitals;
24 (viii) one member representing health underwriters;
25 and
26 (ix) one member representing commercial insurance
27 carriers.
28 (2) The work group, with approval of the council, may
29 hire an independent auditor to determine the value of various
30 data sets. The work group shall have no more than one year to
20080H2708B4210 - 23 -
1 study current data requirements and methods of collecting and
2 transferring data and to make recommendations for changes to
3 produce a 50% overall reduction in the cost of collecting and
4 reporting required data to the council while maintaining the
5 scientific credibility of the council's analysis and
6 reporting. The work group recommendations shall be presented
7 to the council for a vote.
8 (b) Pennsylvania Uniform Claims and Billing Form.--The
9 council shall adopt, within 180 days of the commencement of its
10 operations pursuant to section 4(i), a Pennsylvania Uniform
11 Claims and Billing Form format. The council shall furnish said
12 claims and billing form format to all data sources, and said
13 claims and billing form shall be utilized and maintained by all
14 data sources for all services covered by this act. The
15 Pennsylvania Uniform Claims and Billing Form shall consist of
16 the Uniform Hospital Billing Form UB-82/HCFA-1450, and the HCFA-
17 1500, or their successors, as developed by the National Uniform
18 Billing Committee, with additional fields as necessary to
19 provide all of the data set forth in subsections (c) and (d).
20 (c) Data elements.--For each covered service performed in
21 Pennsylvania, the council shall be required to collect the
22 following data elements:
23 (1) uniform patient identifier, continuous across
24 multiple episodes and providers;
25 (2) patient date of birth;
26 (3) patient sex;
27 (3.1) patient race, consistent with the method of
28 collection of race/ethnicity data by the United States Bureau
29 of the Census and the United States Standard Certificates of
30 Live Birth and Death;
20080H2708B4210 - 24 -
1 (4) patient ZIP Code number;
2 (5) date of admission;
3 (6) date of discharge;
4 (7) principal and secondary diagnoses by standard code,
5 including external cause of injury, complication, infection
6 and childbirth;
7 (8) principal procedure by council-specified standard
8 code and date;
9 (9) up to three secondary procedures by council-
10 specified standard codes and dates;
11 (10) uniform health care facility identifier, continuous
12 across episodes, patients and providers;
13 (11) uniform identifier of admitting physician, by
14 unique physician identification number established by the
15 council, continuous across episodes, patients and providers;
16 (12) uniform identifier of consulting physicians, by
17 unique physician identification number established by the
18 council, continuous across episodes, patients and providers;
19 (13) total charges of health care facility, segregated
20 into major categories, including, but not limited to, room
21 and board, radiology, laboratory, operating room, drugs,
22 medical supplies and other goods and services according to
23 guidelines specified by the council;
24 (14) actual payments to health care facility,
25 segregated, if available, according to the categories
26 specified in paragraph (13);
27 (15) charges of each physician or professional rendering
28 service relating to an incident of hospitalization or
29 treatment in an ambulatory service facility;
30 (16) actual payments to each physician or professional
20080H2708B4210 - 25 -
1 rendering service pursuant to paragraph (15);
2 (17) uniform identifier of primary payor;
3 (18) ZIP Code number of facility where health care
4 service is rendered;
5 (19) uniform identifier for payor group contract number;
6 (20) patient discharge status; and
7 (21) provider service effectiveness and provider quality
8 pursuant to section 5(d)(4) and subsection (d).
9 (d) Provider quality and provider service effectiveness data
10 elements.--In carrying out its duty to collect data on provider
11 quality and provider service effectiveness under section 5(d)(4)
12 and subsection (c)(21), the council shall define a methodology
13 to measure provider service effectiveness which may include
14 additional data elements to be specified by the council
15 sufficient to carry out its responsibilities under section
16 5(d)(4). The council may adopt a nationally recognized
17 methodology of quantifying and collecting data on provider
18 quality and provider service effectiveness until such time as
19 the council has the capability of developing its own methodology
20 and standard data elements. The council shall include in the
21 Pennsylvania Uniform Claims and Billing Form a field consisting
22 of the data elements required pursuant to subsection (c)(21) to
23 provide information on each provision of covered services
24 sufficient to permit analysis of provider quality and provider
25 service effectiveness within 180 days of commencement of its
26 operations pursuant to section 4. In carrying out its
27 responsibilities, the council shall not require health care
28 insurers to report on data elements that are not reported to
29 nationally recognized accrediting organizations, to the
30 Department of Health or to the Insurance Department in quarterly
20080H2708B4210 - 26 -
1 or annual reports. The council shall not require reporting by
2 health care insurers in different formats than are required for
3 reporting to nationally recognized accrediting organizations or
4 on quarterly or annual reports submitted to the Department of
5 Health or to the Insurance Department. The council may adopt the
6 quality findings as reported to nationally recognized
7 accrediting organizations.
8 (e) Reserve field utilization and addition or deletion of
9 data elements.--The council shall include in the Pennsylvania
10 Uniform Claims and Billing Form a reserve field. The council may
11 utilize the reserve field by adding other data elements beyond
12 those required to carry out its responsibilities under section
13 5(d)(3) and (4) and subsections (c) and (d), or the council may
14 delete data elements from the Pennsylvania Uniform Claims and
15 Billing Form only by a majority vote of the council and only
16 pursuant to the following procedure:
17 (1) The council shall obtain a cost-benefit analysis of
18 the proposed addition or deletion which shall include the
19 cost to data sources of any proposed additions.
20 (2) The council shall publish notice of the proposed
21 addition or deletion, along with a copy or summary of the
22 cost-benefit analysis, in the Pennsylvania Bulletin, and such
23 notice shall include provision for a 60-day comment period.
24 (3) The council may hold additional hearings or request
25 such other reports as it deems necessary and shall consider
26 the comments received during the 60-day comment period and
27 any additional information gained through such hearings or
28 other reports in making a final determination on the proposed
29 addition or deletion.
30 (f) Other data required to be submitted.--Providers are
20080H2708B4210 - 27 -
1 hereby required to submit and the council is hereby authorized
2 to collect, in accordance with submission dates and schedules
3 established by the council, the following additional data,
4 provided such data is not available to the council from public
5 records:
6 (1) Audited annual financial reports of all hospitals
7 and ambulatory service facilities providing covered services
8 as defined in section 3.
9 (2) The Medicare cost report (OMB Form 2552 or
10 equivalent Federal form), or the AG-12 form for Medical
11 Assistance or successor forms, whether completed or partially
12 completed, and including the settled Medicare cost report and
13 the certified AG-12 form.
14 (3) Additional data, including, but not limited to, data
15 which can be used to provide at least the following
16 information:
17 (i) the incidence of medical and surgical procedures
18 in the population for individual providers;
19 (ii) physicians who provide covered services and
20 accept medical assistance patients;
21 (iii) physicians who provide covered services and
22 accept Medicare assignment as full payment;
23 (v) mortality rates for specified diagnoses and
24 treatments, grouped by severity, for individual
25 providers;
26 (vi) rates of infection for specified diagnoses and
27 treatments, grouped by severity, for individual
28 providers;
29 (vii) morbidity rates for specified diagnoses and
30 treatments, grouped by severity, for individual
20080H2708B4210 - 28 -
1 providers;
2 (viii) readmission rates for specified diagnoses and
3 treatments, grouped by severity, for individual
4 providers; and
5 (ix) rate of incidence of postdischarge professional
6 care for selected diagnoses and procedures, grouped by
7 severity, for individual providers.
8 (4) Any other data the council requires to carry out its
9 responsibilities pursuant to section 5(d).
10 (f.1) Review and correction of data.--The council shall
11 provide a reasonable period for data sources to review and
12 correct the data submitted under section 6 which the council
13 intends to prepare and issue in reports to the General Assembly,
14 to the general public or in special studies and reports under
15 section 11. When corrections are provided, the council shall
16 correct the appropriate data in its data files and subsequent
17 reports.
18 (g) Allowance for clarification or dissents.--The council
19 shall maintain a file of written statements submitted by data
20 sources who wish to provide an explanation of data that they
21 feel might be misleading or misinterpreted. The council shall
22 provide access to such file to any person and shall, where
23 practical, in its reports and data files indicate the
24 availability of such statements. When the council agrees with
25 such statements, it shall correct the appropriate data and
26 comments in its data files and subsequent reports.
27 (g.1) Allowance for correction.--The council shall verify
28 the patient safety indicator data submitted by hospitals
29 pursuant to subsection (c)(7) within 60 days of receipt. The
30 council may allow hospitals to make changes to the data
20080H2708B4210 - 29 -
1 submitted during the verification period. After the verification
2 period, but within 45 days of receipt of the adjusted hospital
3 data, the council shall risk adjust the information and provide
4 reports to the patient safety committee of the relevant
5 hospital.
6 (h) Availability of data.--Nothing in this act shall
7 prohibit a purchaser from obtaining from its health care
8 insurer, nor relieve said health care insurer from the
9 obligation of providing said purchaser, on terms consistent with
10 past practices, data previously provided or additional data not
11 currently provided to said purchaser by said health care insurer
12 pursuant to any existing or future arrangement, agreement or
13 understanding.
14 Section 7. Data dissemination and publication.
15 (a) Public reports.--Subject to the restrictions on access
16 to council data set forth in section 10 and utilizing the data
17 collected under section 6 as well as other data, records and
18 matters of record available to it, the council shall prepare and
19 issue reports to the General Assembly and to the general public
20 according to the following provisions:
21 (1) The council shall, for every provider of both
22 inpatient and outpatient services within this Commonwealth
23 and within appropriate regions and subregions, prepare and
24 issue reports on provider quality and service effectiveness
25 on diseases or procedures that, when ranked by volume, cost,
26 payment and high variation in outcome, represent the best
27 opportunity to improve overall provider quality, improve
28 patient safety and provide opportunities for cost reduction.
29 These reports shall provide comparative information on the
30 following:
20080H2708B4210 - 30 -
1 (i) Differences in mortality rates; differences in
2 length of stay; differences in complication rates;
3 differences in readmission rates; differences in
4 infection rates; and other comparative outcome measures
5 the council may develop that will allow purchasers,
6 providers and consumers to make purchasing and quality
7 improvement decisions based upon quality patient care and
8 to restrain costs.
9 (ii) The incidence rate of selected medical or
10 surgical procedures, the quality and service
11 effectiveness and the payments received for those
12 providers, identified by the name and type or specialty,
13 for which these elements vary significantly from the
14 norms for all providers.
15 (2) In preparing its reports under paragraph (1), the
16 council shall ensure that factors which have the effect of
17 either reducing provider revenue or increasing provider costs
18 and other factors beyond a provider's control which reduce
19 provider competitiveness in the marketplace are explained in
20 the reports. The council shall also ensure that any
21 clarifications and dissents submitted by individual providers
22 under section 6(g) are noted in any reports that include
23 release of data on that individual provider.
24 (b) Raw data reports and computer access to council data.--
25 The council shall provide special reports derived from raw data
26 and a means for computer-to-computer access to its raw data to
27 any purchaser, pursuant to section 10(f). The council shall
28 provide such reports and computer-to-computer access, at its
29 discretion, to other parties, pursuant to section 10(g). The
30 council shall provide these special reports and computer-to-
20080H2708B4210 - 31 -
1 computer access in as timely a fashion as the council's
2 responsibilities to publish the public reports required in this
3 section will allow. Any such provision of special reports or
4 computer-to-computer access by the council shall be made only
5 subject to the restrictions on access to raw data set forth in
6 section 10(b) and only after payment for costs of preparation or
7 duplication pursuant to section 10(f) or (g).
8 Section 8. Health care for the medically indigent.
9 (a) Declaration of policy.--The General Assembly finds that
10 every person in this Commonwealth should receive timely and
11 appropriate health care services from any provider operating in
12 this Commonwealth; that, as a continuing condition of licensure,
13 each provider should offer and provide medically necessary,
14 lifesaving and emergency health care services to every person in
15 this Commonwealth, regardless of financial status or ability to
16 pay; and that health care facilities may transfer patients only
17 in instances where the facility lacks the staff or facilities to
18 properly render definitive treatment.
19 (b) Studies on indigent care.--To reduce the undue burden on
20 the several providers that disproportionately treat medically
21 indigent people on an uncompensated basis, to contain the long-
22 term costs generated by untreated or delayed treatment of
23 illness and disease and to determine the most appropriate means
24 of treating and financing the treatment of medically indigent
25 persons, the council, at the request of the Governor or the
26 General Assembly, may undertake studies and utilize its current
27 data base to:
28 (1) Study and analyze the medically indigent population,
29 the magnitude of uncompensated care for the medically
30 indigent, the degree of access to and the result of any lack
20080H2708B4210 - 32 -
1 of access by the medically indigent to appropriate care, the
2 types of providers and the settings in which they provide
3 indigent care and the cost of the provision of that care
4 pursuant to subsection (c).
5 (2) Determine, from studies undertaken under paragraph
6 (1), a definition of the medically indigent population and
7 the most appropriate method for the delivery of timely and
8 appropriate health care services to the medically indigent.
9 (c) Studies.--The council shall conduct studies pursuant to
10 subsection (b)(1) and thereafter report to the Governor and the
11 General Assembly the results of the studies and its
12 recommendations. The council may contract with an independent
13 vendor to conduct the study in accordance with the provisions
14 for selecting vendors in section 16. The study shall include,
15 but not be limited to, the following:
16 (1) the number and characteristics of the medically
17 indigent population, including such factors as income,
18 employment status, health status, patterns of health care
19 utilization, type of health care needed and utilized,
20 eligibility for health care insurance, distribution of this
21 population on a geographic basis and by age, sex and racial
22 or linguistic characteristics, and the changes in these
23 characteristics, including the following:
24 (i) the needs and problems of indigent persons in
25 urban areas;
26 (ii) the needs and problems of indigent persons in
27 rural areas;
28 (iii) the needs and problems of indigent persons who
29 are members of racial or linguistic minorities;
30 (iv) the needs and problems of indigent persons in
20080H2708B4210 - 33 -
1 areas of high unemployment; and
2 (v) the needs and problems of the underinsured;
3 (2) the degree of and any change in access of this
4 population to sources of health care, including hospitals,
5 physicians and other providers;
6 (3) the distribution and means of financing indigent
7 care between and among providers, insurers, government,
8 purchasers and consumers, and the effect of that distribution
9 on each;
10 (4) the major types of care rendered to the indigent,
11 the setting in which each type of care is rendered and the
12 need for additional care of each type by the indigent;
13 (5) the likely impact of changes in the health delivery
14 system, including managed care entities, and the effects of
15 cost containment in the Commonwealth on the access to,
16 availability of and financing of needed care for the
17 indigent, including the impact on providers which provide a
18 disproportionate amount of care to the indigent;
19 (6) the distribution of delivered care and actual cost
20 to render such care by provider, region and subregion;
21 (7) the provision of care to the indigent through
22 improvements in the primary health care system, including the
23 management of needed hospital care by primary care providers;
24 (8) innovative means to finance and deliver care to the
25 medically indigent; and
26 (9) reduction in the dependence of indigent persons on
27 hospital services through improvements in preventive health
28 measures.
29 Section 9. Mandated health benefits.
30 In relation to current law or proposed legislation, the
20080H2708B4210 - 34 -
1 council shall, upon the request of the appropriate committee
2 chairman in the Senate and in the House of Representatives or
3 upon the request of the Secretary of Health, provide information
4 on the proposed mandated health benefit pursuant to the
5 following:
6 (1) The General Assembly hereby declares that proposals
7 for mandated health benefits or mandated health insurance
8 coverage should be accompanied by adequate, independently
9 certified documentation defining the social and financial
10 impact and medical efficacy of the proposal. To that end the
11 council, upon receipt of such requests, is hereby authorized
12 to conduct a preliminary review of the material submitted by
13 both proponents and opponents concerning the proposed
14 mandated benefit. If, after this preliminary review, the
15 council is satisfied that both proponents and opponents have
16 submitted sufficient documentation necessary for a review
17 pursuant to paragraphs (3) and (4), the council is directed
18 to contract with individuals, pursuant to the selection
19 procedures for vendors set forth in section 16, who will
20 constitute a Mandated Benefits Review Panel to review
21 mandated benefits proposals and provide independently
22 certified documentation, as provided for in this section.
23 (2) The panel shall consist of senior researchers, each
24 of whom shall be a recognized expert:
25 (i) one in health research;
26 (ii) one in biostatistics;
27 (iii) one in economic research;
28 (iv) one, a physician, in the appropriate specialty
29 with current knowledge of the subject being proposed as a
30 mandated benefit; and
20080H2708B4210 - 35 -
1 (v) one with experience in insurance or actuarial
2 research.
3 (3) The Mandated Benefits Review Panel shall have the
4 following duties and responsibilities:
5 (i) To review documentation submitted by persons
6 proposing or opposing mandated benefits within 90 days of
7 submission of said documentation to the panel.
8 (ii) To report to the council, pursuant to its
9 review in subparagraph (i), the following:
10 (A) Whether or not the documentation is complete
11 as defined in paragraph (4).
12 (B) Whether or not the research cited in the
13 documentation meets professional standards.
14 (C) Whether or not all relevant research
15 respecting the proposed mandated benefit has been
16 cited in the documentation.
17 (D) Whether or not the conclusions and
18 interpretations in the documentation are consistent
19 with the data submitted.
20 (4) To provide the Mandated Benefits Review Panel with
21 sufficient information to carry out its duties and
22 responsibilities pursuant to paragraph (3), persons proposing
23 or opposing legislation mandating benefits coverage should
24 submit documentation to the council, pursuant to the
25 procedure established in paragraph (5), which demonstrates
26 the following:
27 (i) The extent to which the proposed benefit and the
28 services it would provide are needed by, available to and
29 utilized by the population of the Commonwealth.
30 (ii) The extent to which insurance coverage for the
20080H2708B4210 - 36 -
1 proposed benefit already exists, or if no such coverage
2 exists, the extent to which this lack of coverage results
3 in inadequate health care or financial hardship for the
4 population of the Commonwealth.
5 (iii) The demand for the proposed benefit from the
6 public and the source and extent of opposition to
7 mandating the benefit.
8 (iv) All relevant findings bearing on the social
9 impact of the lack of the proposed benefit.
10 (v) Where the proposed benefit would mandate
11 coverage of a particular therapy, the results of at least
12 one professionally accepted, controlled trial comparing
13 the medical consequences of the proposed therapy,
14 alternative therapies and no therapy.
15 (vi) Where the proposed benefit would mandate
16 coverage of an additional class of practitioners, the
17 results of at least one professionally accepted,
18 controlled trial comparing the medical results achieved
19 by the additional class of practitioners and those
20 practitioners already covered by benefits.
21 (vii) The results of any other relevant research.
22 (viii) Evidence of the financial impact of the
23 proposed legislation, including at least:
24 (A) The extent to which the proposed benefit
25 would increase or decrease cost for treatment or
26 service.
27 (B) The extent to which similar mandated
28 benefits in other states have affected charges, costs
29 and payments for services.
30 (C) The extent to which the proposed benefit
20080H2708B4210 - 37 -
1 would increase the appropriate use of the treatment
2 or service.
3 (D) The impact of the proposed benefit on
4 administrative expenses of health care insurers.
5 (E) The impact of the proposed benefits on
6 benefits costs of purchasers.
7 (F) The impact of the proposed benefits on the
8 total cost of health care within the Commonwealth.
9 (5) The procedure for review of documentation is as
10 follows:
11 (i) Any person wishing to submit information on
12 proposed legislation mandating insurance benefits for
13 review by the panel should submit the documentation
14 specified in paragraph (4) to the council.
15 (ii) The council shall, within 30 days of receipt of
16 the documentation:
17 (A) Publish in the Pennsylvania Bulletin notice
18 of receipt of the documentation, a description of the
19 proposed legislation, provision for a period of 60
20 days for public comment and the time and place at
21 which any person may examine the documentation.
22 (B) Submit copies of the documentation to the
23 Secretary of Health and the Insurance Commissioner,
24 who shall review and submit comments to the council
25 on the proposed legislation within 30 days.
26 (C) Submit copies of the documentation to the
27 panel, which shall review the documentation and issue
28 their findings, pursuant to paragraph (3), within 90
29 days.
30 (iii) Upon receipt of the comments of the Secretary
20080H2708B4210 - 38 -
1 of Health and the Insurance Commissioner and of the
2 findings of the panel, pursuant to subparagraph (ii), but
3 no later than 120 days following the publication required
4 in subparagraph (ii), the council shall submit said
5 comments and findings, together with its recommendations
6 respecting the proposed legislation, to the Governor, the
7 President pro tempore of the Senate, the Speaker of the
8 House of Representatives, the Secretary of Health, the
9 Insurance Commissioner and the person who submitted the
10 information pursuant to subparagraph (i).
11 Section 10. Access to council data.
12 (a) Public access.--The information and data received by the
13 council shall be utilized by the council for the benefit of the
14 public and public officials. Subject to the specific limitations
15 set forth in this section, the council shall make determinations
16 on requests for information in favor of access.
17 (a.1) Outreach programs.--The council shall develop and
18 implement outreach programs designed to make its information
19 understandable and usable to purchasers, providers, other
20 Commonwealth agencies and the general public. The programs shall
21 include efforts to educate through pamphlets, booklets, seminars
22 and other appropriate measures and to facilitate making more
23 informed health care choices.
24 (b) Limitations on access.--Unless specifically provided for
25 in this act, neither the council nor any contracting system
26 vendor shall release and no data source, person, member of the
27 public or other user of any data of the council shall gain
28 access to:
29 (1) Any raw data of the council that does not
30 simultaneously disclose payment, as well as provider quality
20080H2708B4210 - 39 -
1 and provider service effectiveness pursuant to sections
2 5(d)(4) and 6(d) or 7(a)(1)(iii).
3 (2) Any raw data of the council which could reasonably
4 be expected to reveal the identity of an individual patient.
5 (3) Any raw data of the council which could reasonably
6 be expected to reveal the identity of any purchaser, as
7 defined in section 3, other than a purchaser requesting data
8 on its own group or an entity entitled to said purchaser's
9 data pursuant to subsection (f).
10 (4) Any raw data of the council relating to actual
11 payments to any identified provider made by any purchaser,
12 except that this provision shall not apply to access by a
13 purchaser requesting data on the group for which it purchases
14 or otherwise provides covered services or to access to that
15 same data by an entity entitled to the purchaser's data
16 pursuant to subsection (f).
17 (5) Any raw data disclosing discounts or differentials
18 between payments accepted by providers for services and their
19 billed charges obtained by identified payors from identified
20 providers unless the data is released in a Statewide,
21 aggregate format that does not identify any individual payor
22 or class of payors and the council assures that the release
23 of such information is not prejudicial or inequitable to any
24 individual payor or provider or group thereof.
25 (c) Unauthorized use of data.--Any person who knowingly
26 releases council data violating the patient confidentiality,
27 actual payments, discount data or raw data safeguards set forth
28 in this section to an unauthorized person commits a misdemeanor
29 of the first degree and shall, upon conviction, be sentenced to
30 pay a fine of $10,000 or to imprisonment for not more than five
20080H2708B4210 - 40 -
1 years, or both. An unauthorized person who knowingly receives or
2 possesses such data commits a misdemeanor of the first degree.
3 (d) Unauthorized access to data.--Should any person
4 inadvertently or by council error gain access to data that
5 violates the safeguards set forth in this section, the data must
6 immediately be returned, without duplication, to the council
7 with proper notification.
8 (e) Public access to records.--All public reports prepared
9 by the council shall be public records and shall be available to
10 the public for a reasonable fee, and copies shall be provided,
11 upon request of the chair, to the Public Health and Welfare
12 Committee of the Senate and the Health and Welfare Committee of
13 the House of Representatives.
14 (f) Access to raw council data by purchasers.--Pursuant to
15 sections 5(d)(5) and 7(b) and subject to the limitations on
16 access set forth in subsection (b), the council shall provide
17 access to its raw data to purchasers in accordance with the
18 following procedure:
19 (1) Special reports derived from raw data of the council
20 shall be provided by the council to any purchaser requesting
21 such reports.
22 (2) A means to enable computer-to-computer access by any
23 purchaser to raw data of the council as defined in section 3
24 shall be developed, adopted and implemented by the council,
25 and the council shall provide such access to its raw data to
26 any purchaser upon request.
27 (3) In the event that any employer obtains from the
28 council, pursuant to paragraph (1) or (2), data pertaining to
29 its employees and their dependents for whom said employer
30 purchases or otherwise provides covered services as defined
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1 in section 3 and who are represented by a certified
2 collective bargaining representative, said collective
3 bargaining representative shall be entitled to that same
4 data, after payment of fees as specified in paragraph (4).
5 Likewise, should a certified collective bargaining
6 representative obtain from the council, pursuant to paragraph
7 (1) or (2), data pertaining to its members and their
8 dependents who are employed by and for whom covered services
9 are purchased or otherwise provided by any employer, said
10 employer shall be entitled to that same data, after payment
11 of fees as specified in paragraph (4).
12 (4) In providing for access to its raw data, the council
13 shall charge the purchasers which originally obtained such
14 access a fee sufficient to cover its costs to prepare and
15 provide special reports requested pursuant to paragraph (1)
16 or to provide computer-to-computer access to its raw data
17 requested pursuant to paragraph (2). Should a second or
18 subsequent party or parties request this same information
19 pursuant to paragraph (3), the council shall charge said
20 party a reasonable fee.
21 (g) Access to raw council data by other parties.--Subject to
22 the limitations on access to raw council data set forth in
23 subsection (b), the council may, at its discretion, provide
24 special reports derived from its raw data or computer-to-
25 computer access to parties other than purchasers. The council
26 shall publish regulations that set forth the criteria and the
27 procedure it shall use in making determinations on such access,
28 pursuant to the powers vested in the council in section 4. In
29 providing such access, the council shall charge the party
30 requesting the access a reasonable fee.
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1 Section 11. Special studies and reports.
2 (a) Special studies.--Any Commonwealth agency may publish or
3 contract for publication of special studies. Any special study
4 so published shall become a public document.
5 (b) Special reports.--
6 (1) Any Commonwealth agency may study and issue a report
7 on the special medical needs, demographic characteristics,
8 access or lack thereof to health care services and need for
9 financing of health care services of:
10 (i) Senior citizens, particularly low-income senior
11 citizens, senior citizens who are members of minority
12 groups and senior citizens residing in low-income urban
13 or rural areas.
14 (ii) Low-income urban or rural areas.
15 (iii) Minority communities.
16 (iv) Women.
17 (v) Children
18 (vi) Unemployed workers.
19 (vii) Veterans.
20 The reports shall include information on the current
21 availability of services to these targeted parts of the
22 population, and whether access to such services has increased
23 or decreased over the past ten years, and specific
24 recommendations for the improvement of their primary care and
25 health delivery systems, including disease prevention and
26 comprehensive health care services. The department may also
27 study and report on the effects of using prepaid, capitated
28 or HMO health delivery systems as ways to promote the
29 delivery of primary health care services to the underserved
30 segments of the population enumerated above.
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1 (2) The department may study and report on the short-
2 term and long-term fiscal and programmatic impact on the
3 health care consumer of changes in ownership of hospitals
4 from nonprofit to profit, whether through purchase, merger or
5 the like. The department may also study and report on factors
6 which have the effect of either reducing provider revenue or
7 increasing provider cost, and other factors beyond a
8 provider's control which reduce provider competitiveness in
9 the marketplace, are explained in the reports.
10 Section 12. Enforcement; penalty.
11 (a) Compliance enforcement.--The council shall have standing
12 to bring an action in law or in equity through private counsel
13 in any court of common pleas to enforce compliance with any
14 provision of this act, except section 11, or any requirement or
15 appropriate request of the council made pursuant to this act. In
16 addition, the Attorney General is authorized and shall bring any
17 such enforcement action in aid of the council in any court of
18 common pleas at the request of the council in the name of the
19 Commonwealth.
20 (b) Penalty.--
21 (1) Any person who fails to supply data pursuant to
22 section 6 may be assessed a civil penalty not to exceed
23 $1,000 for each day the data is not submitted.
24 (2) Any person who knowingly submits inaccurate data
25 under section 6 commits a misdemeanor of the third degree and
26 shall, upon conviction, be sentenced to pay a fine of $1,000
27 or to imprisonment for not more than one year, or both.
28 Section 13. Research and demonstration projects.
29 The council shall actively encourage research and
30 demonstrations to design and test improved methods of assessing
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1 provider quality, provider service effectiveness and efficiency.
2 To that end, provided that no data submission requirements in a
3 mandated demonstration may exceed the current reserve field on
4 the Pennsylvania Uniform Claims and Billing Form, the council
5 may:
6 (1) Authorize contractors engaged in health services
7 research selected by the council, pursuant to the provisions
8 of section 16, to have access to the council's raw data
9 files, providing such entities assume any contractual
10 obligations imposed by the council to assure patient identity
11 confidentiality.
12 (2) Place data sources participating in research and
13 demonstrations on different data submission requirements from
14 other data sources in this Commonwealth.
15 (3) Require data source participation in research and
16 demonstration projects when this is the only testing method
17 the council determines is promising.
18 Section 14. Grievances and grievance procedures.
19 (a) Procedures and requirements.--Pursuant to its powers to
20 publish regulations under section 5(b) and with the requirements
21 of this section, the council is hereby authorized and directed
22 to establish procedures and requirements for the filing, hearing
23 and adjudication of grievances against the council of any data
24 source. Such procedures and requirements shall be published in
25 the Pennsylvania Bulletin pursuant to law.
26 (b) Claims; hearings.--Grievance claims of any data source
27 shall be submitted to the council or to a third party designated
28 by the council, and the council or the designated third party
29 shall convene a hearing, if requested, and adjudicate the
30 grievance.
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1 Section 15. Antitrust provisions.
2 Persons or entities required to submit data or information
3 under this act or receiving data or information from the council
4 in accordance with this act are declared to be acting pursuant
5 to State requirements embodied in this act and shall be exempt
6 from antitrust claims or actions grounded upon submission or
7 receipt of such data or information.
8 Section 16. Contracts with vendors.
9 Any contract with any vendor other than a sole source vendor
10 for purchase of services or for purchase or lease of supplies
11 and equipment related to the council's powers and duties shall
12 be let only after a public bidding process and only in
13 accordance with the following provisions, and no contract shall
14 be let by the council that does not conform to these provisions:
15 (1) The council shall prepare specifications fully
16 describing the services to be rendered or equipment or
17 supplies to be provided by a vendor and shall make these
18 specifications available for inspection by any person at the
19 council's offices during normal working hours and at such
20 other places and such other times as the council deems
21 advisable.
22 (2) The council shall publish notice of invitations to
23 bid in the Pennsylvania Bulletin. The council shall also
24 publish such notice in at least four newspapers in general
25 circulation in the Commonwealth on at least three occasions
26 at intervals of not less than three days. Said notice shall
27 include at least the following:
28 (i) The deadline for submission of bids by
29 prospective vendors, which shall be no sooner than 30
30 days following the latest publication of the notice as
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1 prescribed in this paragraph.
2 (ii) The locations, dates and times during which
3 prospective vendors can examine the specifications
4 required in paragraph (1).
5 (iii) The date, time and place of the meeting or
6 meetings of the council at which bids will be opened and
7 accepted.
8 (iv) A statement to the effect that any person is
9 eligible to bid.
10 (3) Bids shall be accepted as follows:
11 (i) No council member who is affiliated in any way
12 with any bidder shall vote on the awarding of any
13 contract for which said bidder has submitted a bid, and
14 any council member who has an affiliation with a bidder
15 shall state the nature of the affiliation prior to any
16 vote of the council.
17 (ii) Bids shall be opened and reviewed by the
18 appropriate council committee, which shall make
19 recommendations to the council on approval. Bids shall be
20 accepted and such acceptance shall be announced only at a
21 public meeting of the council as defined in section 4(e),
22 and no bids shall be accepted at an executive session of
23 the council.
24 (iii) The council may require that a certified
25 check, in an amount determined by the council, accompany
26 every bid, and, when so required, no bid shall be
27 accepted unless so accompanied.
28 (4) In order to prevent any party from deliberately
29 underbidding contracts in order to gain or prevent access to
30 council data, the council may award any contract at its
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1 discretion, regardless of the amount of the bid, pursuant to
2 the following:
3 (i) Any bid accepted must reasonably reflect the
4 actual cost of services provided.
5 (ii) Any vendor so selected by the council shall be
6 found by the council to be of such character and such
7 integrity as to assure, to the maximum extent possible,
8 adherence to all the provisions of this act in the
9 provision of contracted services.
10 (iii) The council may require the selected vendor to
11 furnish, within 20 days after the contract has been
12 awarded, a bond with suitable and reasonable requirements
13 guaranteeing the services to be performed with sufficient
14 surety in an amount determined by the council, and upon
15 failure to furnish such bond within the time specified,
16 the previous award shall be void.
17 (5) The council shall make efforts to assure that its
18 vendors have established affirmative action plans to assure
19 equal opportunity policies for hiring and promoting
20 employees.
21 Section 17.1. Reporting.
22 The council shall provide an annual report of its financial
23 expenditures to the Appropriations Committee of the Senate and
24 the Appropriations Committee of the House of Representatives.
25 Section 18. Severability.
26 The provisions of this act are severable. If any provision of
27 this act or its application to any person or circumstance is
28 held invalid, the invalidity shall not affect other provisions
29 or applications of this act which can be given effect without
30 the invalid provision or application.
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1 Section 2. Section 19 of the act is reenacted and amended to
2 read:
3 Section 19. Sunset.
4 This act shall expire June 30, [2008] 2009, unless reenacted
5 prior to that date. By September 1, 2007, a written report by
6 the Legislative Budget and Finance Committee evaluating the
7 management, visibility, awareness and performance of the council
8 shall be provided to the Public Health and Welfare Committee of
9 the Senate and the Health and Human Services Committee of the
10 House of Representatives. The report shall include a review of
11 the council's procedures and policies, the availability and
12 quality of data for completing reports [to hospitals and outside
13 vendor purchasers], the ability of the council to become self-
14 sufficient by selling data to outside purchasers, whether there
15 is a more cost-efficient way of accomplishing the objectives of
16 the council and the need for reauthorization of the council.
17 Section 3. Section 20 of the act is reenacted to read:
18 Section 20. Effective date.
19 This act shall take effect immediately.
20 Section 4. This act shall take effect immediately.
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