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PRINTER'S NO. 311
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
396
Session of
2015
INTRODUCED BY VANCE, KITCHEN, BAKER, YAW, BREWSTER, FONTANA,
HUGHES, FOLMER, YUDICHAK, TEPLITZ, COSTA, GREENLEAF, SMITH,
SCHWANK, PILEGGI, BROWNE, RAFFERTY AND VULAKOVICH,
FEBRUARY 4, 2015
REFERRED TO PUBLIC HEALTH AND WELFARE, FEBRUARY 4, 2015
AN ACT
Reenacting and amending the act of July 8, 1986 (P.L.408,
No.89), entitled, as reenacted, "An act providing for the
creation of the Health Care Cost Containment Council, for its
powers and duties, for health care cost containment through
the collection and dissemination of data, for public
accountability of health care costs and for health care for
the indigent; and making an appropriation," further providing
for sunset; and making editorial changes.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The title and section 1 of the act of July 8,
1986 (P.L.408, No.89), known as the Health Care Cost Containment
Act, reenacted and amended June 10, 2009 (P.L.10, No.3), are
reenacted to read:
AN ACT
Providing for the creation of the Health Care Cost Containment
Council, for its powers and duties, for health care cost
containment through the collection and dissemination of data,
for public accountability of health care costs and for health
care for the indigent; and making an appropriation.
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Section 1. Short title.
This act shall be known and may be cited as the Health Care
Cost Containment Act.
Section 2. Sections 3 and 4 of the act are reenacted and
amended to read:
Section 3. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Allowance." The maximum allowed combined payment from a
payor and a patient to a provider for services rendered.
"Ambulatory service facility." A facility licensed in this
Commonwealth, not part of a hospital, which provides medical,
diagnostic or surgical treatment to patients not requiring
hospitalization, including ambulatory surgical facilities,
ambulatory imaging or diagnostic centers, birthing centers,
freestanding emergency rooms and any other facilities providing
ambulatory care which charge a separate facility charge. This
term does not include the offices of private physicians or
dentists, whether for individual or group practices.
"Charge" or "rate." The amount billed by a provider for
specific goods or services provided to a patient, prior to any
adjustment for contractual allowances.
"Committee." The Health Care Cost Containment Council Act
Review Committee.
"Council." The Health Care Cost Containment Council.
"Covered services." Any health care services or procedures
connected with episodes of illness that require either inpatient
hospital care or major ambulatory service such as surgical,
medical or major radiological procedures, including any initial
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and follow-up outpatient services associated with the episode of
illness before, during or after inpatient hospital care or major
ambulatory service. The term does not include routine outpatient
services connected with episodes of illness that do not require
hospitalization or major ambulatory service.
"Data source." A health care facility; ambulatory service
facility; physician; health maintenance organization as defined
in the act of December 29, 1972 (P.L.1701, No.364), known as the
Health Maintenance Organization Act; hospital, medical or health
service plan with a certificate of authority issued by the
Insurance Department, including, but not limited to, hospital
plan corporations as defined in 40 Pa.C.S. Ch. 61 (relating to
hospital plan corporations) and professional health services
plan corporations as defined in 40 Pa.C.S. Ch. 63 (relating to
professional health services plan corporations); commercial
insurer with a certificate of authority issued by the Insurance
Department providing health or accident insurance; self-insured
employer providing health or accident coverage or benefits for
employees employed in the Commonwealth; administrator of a self-
insured or partially self-insured health or accident plan
providing covered services in the Commonwealth; any health and
welfare fund that provides health or accident benefits or
insurance pertaining to covered service in the Commonwealth; the
Department of [Public Welfare] Human Services for those covered
services it purchases or provides through the medical assistance
program under the act of June 13, 1967 (P.L.31, No.21), known as
the Public Welfare Code, and any other payor for covered
services in the Commonwealth other than an individual.
"Health care facility." A general or special hospital,
including psychiatric hospitals, kidney disease treatment
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centers, including freestanding hemodialysis units, and
ambulatory service facilities as defined in this section, and
hospices, both profit and nonprofit, and including those
operated by an agency of State or local government.
"Health care insurer." Any person, corporation or other
entity that offers administrative, indemnity or payment services
for health care in exchange for a premium or service charge
under a program of health care benefits, including, but not
limited to, an insurance company, association or exchange
issuing health insurance policies in this Commonwealth; hospital
plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to
hospital plan corporations); professional health services plan
corporation as defined in 40 Pa.C.S. Ch. 63 (relating to
professional health services plan corporations); health
maintenance organization; preferred provider organization;
fraternal benefit societies; beneficial societies; and third-
party administrators; but excluding employers, labor unions or
health and welfare funds jointly or separately administered by
employers or labor unions that purchase or self-fund a program
of health care benefits for their employees or members and their
dependents.
"Health maintenance organization." An organized system which
combines the delivery and financing of health care and which
provides basic health services to voluntarily enrolled
subscribers for a fixed prepaid fee, as defined in the act of
December 29, 1972 (P.L.1701, No.364), known as the Health
Maintenance Organization Act.
"Hospital." An institution, licensed in this Commonwealth,
which is a general, mental, chronic disease or other type of
hospital, or kidney disease treatment center, whether profit or
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nonprofit, and including those operated by an agency of State or
local government.
"Indigent care." The actual costs, as determined by the
council, for the provision of appropriate health care, on an
inpatient or outpatient basis, given to individuals who cannot
pay for their care because they are above the medical assistance
eligibility levels and have no health insurance or other
financial resources which can cover their health care.
"Major ambulatory service." Surgical or medical procedures,
including diagnostic and therapeutic radiological procedures,
commonly performed in hospitals or ambulatory service
facilities, which are not of a type commonly performed or which
cannot be safely performed in physicians' offices and which
require special facilities such as operating rooms or suites or
special equipment such as fluoroscopic equipment or computed
tomographic scanners, or a postprocedure recovery room or short-
term convalescent room.
"Medical procedure incidence variations." The variation in
the incidence in the population of specific medical, surgical
and radiological procedures in any given year, expressed as a
deviation from the norm, as these terms are defined in the
classical statistical definition of "variation," "incidence,"
"deviation" and "norm."
"Medically indigent" or "indigent." The status of a person
as described in the definition of indigent care.
"Payment." The payments that providers actually accept for
their services, exclusive of charity care, rather than the
charges they bill.
"Payor." Any person or entity, including, but not limited
to, health care insurers and purchasers, that make direct
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payments to providers for covered services.
"Physician." An individual licensed under the laws of this
Commonwealth to practice medicine and surgery within the scope
of the act of October 5, 1978 (P.L.1109, No.261), known as the
Osteopathic Medical Practice Act, or the act of December 20,
1985 (P.L.457, No.112), known as the Medical Practice Act of
1985.
"Preferred provider organization." Any arrangement between a
health care insurer and providers of health care services which
specifies rates of payment to such providers which differ from
their usual and customary charges to the general public and
which encourage enrollees to receive health services from such
providers.
"Provider." A hospital, an ambulatory service facility or a
physician.
"Provider quality." The extent to which a provider renders
care that, within the capabilities of modern medicine, obtains
for patients medically acceptable health outcomes and prognoses,
adjusted for patient severity, and treats patients
compassionately and responsively.
"Provider service effectiveness." The effectiveness of
services rendered by a provider, determined by measurement of
the medical outcome of patients grouped by severity receiving
those services.
"Purchaser." All corporations, labor organizations and other
entities that purchase benefits which provide covered services
for their employees or members, either through a health care
insurer or by means of a self-funded program of benefits, and a
certified bargaining representative that represents a group or
groups of employees for whom employers purchase a program of
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benefits which provide covered services, but excluding entities
defined in this section as "health care insurers."
"Raw data" or "data." Data collected by the council under
section 6. No data shall be released by the council except as
provided for in section 11.
"Severity." In any patient, the measureable degree of the
potential for failure of one or more vital organs.
Section 4. Health Care Cost Containment Council.
(a) Establishment.--The General Assembly hereby establishes
an independent council to be known as the Health Care Cost
Containment Council.
(b) Composition.--The council shall consist of voting
members, composed of and appointed in accordance with the
following:
(1) The Secretary of Health.
(2) The Secretary of [Public Welfare] Human Services.
(3) The Insurance Commissioner.
(4) Six representatives of the business community, at
least one of whom represents small business, who are
purchasers of health care as defined in section 3, none of
which is primarily involved in the provision of health care
or health insurance, three of which shall be appointed by the
President pro tempore of the Senate and three of which shall
be appointed by the Speaker of the House of Representatives
from a list of twelve qualified persons recommended by the
Pennsylvania Chamber of Business and Industry. Three nominees
shall be representatives of small business.
(5) Six representatives of organized labor, three of
which shall be appointed by the President pro tempore of the
Senate and three of which shall be appointed by the Speaker
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of the House of Representatives from a list of twelve
qualified persons recommended by the Pennsylvania AFL-CIO.
(6) One representative of consumers who is not primarily
involved in the provision of health care or health care
insurance, appointed by the Governor from a list of three
qualified persons recommended jointly by the Speaker of the
House of Representatives and the President pro tempore of the
Senate.
(7) Two representatives of hospitals, appointed by the
Governor from a list of five qualified hospital
representatives recommended by the Hospital and Health System
Association of Pennsylvania one of whom shall be a
representative of rural hospitals. Each representative under
this paragraph may appoint two additional delegates to act
for the representative only at meetings of committees, as
provided for in subsection (f).
(8) Two representatives of physicians, appointed by the
Governor from a list of five qualified physician
representatives recommended jointly by the Pennsylvania
Medical Society and the Pennsylvania Osteopathic Medical
Society. The representative under this paragraph may appoint
two additional delegates to act for the representative only
at meetings of committees, as provided for in subsection (f).
(8.1) An individual appointed by the Governor who has
expertise in the application of continuous quality
improvement methods in hospitals.
(8.2) One representative of nurses, appointed by the
Governor from a list of three qualified representatives
recommended by the Pennsylvania State Nurses Association.
(9) One representative of the Blue Cross and Blue Shield
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plans in Pennsylvania, appointed by the Governor from a list
of three qualified persons recommended jointly by the Blue
Cross and Blue Shield plans of Pennsylvania.
(10) One representative of commercial insurance
carriers, appointed by the Governor from a list of three
qualified persons recommended by the Insurance Federation of
Pennsylvania, Inc.
(11) One representative of health maintenance
organizations, appointed by the Governor .
(12) In the case of each appointment to be made from a
list supplied by a specified organization, it is incumbent
upon that organization to consult with and provide a list
which reflects the input of other equivalent organizations
representing similar interests. Each appointing authority
will have the discretion to request additions to the list
originally submitted. Additional names will be provided not
later than 15 days after such request. Appointments shall be
made by the appointing authority no later than 90 days after
receipt of the original list. If, for any reason, any
specified organization supplying a list should cease to
exist, then the respective appointing authority shall specify
a new equivalent organization to fulfill the responsibilities
of this act.
(c) Chairperson and vice chairperson.--The members shall
annually elect, by a majority vote of the members, a chairperson
and a vice chairperson of the council from among the business
and labor representatives on the council.
(d) Quorum.--Thirteen members, at least six of whom must be
made up of representatives of business and labor, shall
constitute a quorum for the transaction of any business, and the
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act by the majority of the members present at any meeting in
which there is a quorum shall be deemed to be the act of the
council.
(e) Meetings.--All meetings of the council shall be
advertised and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating
to open meetings), unless otherwise provided in this section.
(1) The council shall meet at least once every two
months, and may provide for special meetings as it deems
necessary. Meeting dates shall be set by a majority vote of
the members of the council or by the call of the chairperson
upon seven days' notice to all council members.
(2) All meetings of the council shall be publicly
advertised, as provided for in this subsection, and shall be
open to the public, except that the council, through its
bylaws, may provide for executive sessions of the council on
subjects permitted to be discussed in such sessions under 65
Pa.C.S. Ch. 7. No act of the council shall be taken in an
executive session.
(3) The council shall publish a schedule of its meetings
in the Pennsylvania Bulletin and in at least one newspaper in
general circulation in the Commonwealth. Such notice shall be
published at least once in each calendar quarter and shall
list the schedule of meetings of the council to be held in
the subsequent calendar quarter. Such notice shall specify
the date, time and place of the meeting and shall state that
the council's meetings are open to the general public, except
that no such notice shall be required for executive sessions
of the council.
(4) All action taken by the council shall be taken in
open public session, and action of the council shall not be
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taken except upon the affirmative vote of a majority of the
members of the council present during meetings at which a
quorum is present.
(f) Bylaws.--The council shall adopt bylaws, not
inconsistent with this act, and may appoint such committees or
elect such officers subordinate to those provided for in
subsection (c) as it deems advisable. The council shall provide
for the approval and participation of additional delegates
appointed under subsection (b)(7) and (8) so that each
organization represented by delegates under those paragraphs
shall not have more than one vote on any committee to which they
are appointed. The council shall also appoint a technical
advisory group which shall, on an ad hoc basis, respond to
issues presented to it by the council or committees of the
council and shall make recommendations to the council. The
technical advisory group shall include physicians, researchers,
biostatisticians, one representative of the Hospital and
Healthsystem Association of Pennsylvania and one representative
of the Pennsylvania Medical Society. The Hospital and
Healthsystem Association of Pennsylvania and the Pennsylvania
Medical Society representatives shall not be subject to
executive committee approval. In appointing other physicians,
researchers and biostatisticians to the technical advisory
group, the council shall consult with and take nominations from
the representatives of the Hospital Association of Pennsylvania,
the Pennsylvania Medical Society, the Pennsylvania Osteopathic
Medical Society or other like organizations. At its discretion
and in accordance with this section, nominations shall be
approved by the executive committee of the council. If the
subject matter of any project exceeds the expertise of the
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technical advisory group, physicians in appropriate specialties
who possess current knowledge of the issue under study may be
consulted. The technical advisory group shall also review the
availability and reliability of severity of illness measurements
as they relate to small hospitals and psychiatric,
rehabilitation and children's hospitals and shall make
recommendations to the council based upon this review. Meetings
of the technical advisory group shall be open to the general
public.
(f.1) Payment data advisory group.--
(1) In order to assure the technical appropriateness and
accuracy of payment data, the council shall establish a
payment data advisory group to produce recommendations
surrounding the collection of payment data, the analysis and
manipulation of payment data and the public reporting of
payment data. The payment data advisory group shall include
technical experts and individuals knowledgeable in payment
systems and discharge claims data. The advisory group shall
consist of the following members appointed by the council:
(i) One member representing each plan under 40
Pa.C.S. Chs. 61 (relating to hospital plan corporations)
and 63 (relating to professional health services plan
corporations).
(ii) Two members representing commercial insurance
carriers.
(iii) Three members representing health care
facilities.
(iv) Three members representing physicians.
(2) The payment data advisory group shall meet at least
four times a year and may provide for special meetings as may
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be necessary.
(3) The payment data advisory group shall review and
concur with the technical appropriateness of the use and
presentation of data and report its findings to the council
prior to any vote to publicly release reports. If the council
elects to release a report without addressing the technical
concerns of the advisory group, it shall prominently disclose
this in the public report and include the comments of the
advisory group in the public report.
(4) The payment data advisory group shall exercise all
powers necessary and appropriate to carry out its duties,
including advising the council on the following:
(i) Collection of payment data by the council.
(ii) Manipulation, adjustments and methods used with
payment data.
(iii) Public reporting of payment data by the
council.
(g) Compensation and expenses.--The members of the council
shall not receive a salary or per diem allowance for serving as
members of the council but shall be reimbursed for actual and
necessary expenses incurred in the performance of their duties.
Said expenses may include reimbursement of travel and living
expenses while engaged in council business.
(h) Terms of council members.--
(1) The terms of the Secretary of Health, the Secretary
of [Public Welfare] Human Services and the Insurance
Commissioner shall be concurrent with their holding of public
office. The council members under subsection (b)(4) through
(11) shall each serve for a term of four years and shall
continue to serve thereafter until their successor is
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appointed.
(2) Vacancies on the council shall be filled in the
manner designated under subsection (b), within 60 days of the
vacancy, except that when vacancies occur among the
representatives of business or organized labor, two
nominations shall be submitted by the organization specified
in subsection (b) for each vacancy on the council. If the
officer required in subsection (b) to make appointments to
the council fails to act within 60 days of the vacancy, the
council chairperson may appoint one of the persons
recommended for the vacancy until the appointing authority
makes the appointment.
(3) A member may be removed for just cause by the
appointing authority after recommendation by a vote of at
least 14 members of the council.
(4) No appointed member under subsection (b)(4) through
(11) shall be eligible to serve more than two full
consecutive terms of four years beginning on the effective
date of this paragraph.
(j) Subsequent appointments.--Submission of lists of
recommended persons and appointments of council members for
succeeding terms shall be made in the same manner as prescribed
in subsection (b), except that:
(1) Organizations required under subsection (b) to
submit lists of recommended persons shall do so at least 60
days prior to expiration of the council members' terms.
(2) The officer required under subsection (b) to make
appointments to the council shall make said appointments at
least 30 days prior to expiration of the council members'
terms. If the appointments are not made within the specified
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time, the council chairperson may make interim appointments
from the lists of recommended individuals. An interim
appointment shall be valid only until the appropriate officer
under subsection (b) makes the required appointment. Whether
the appointment is by the required officer or by the
chairperson of the council, the appointment shall become
effective immediately upon expiration of the incumbent
member's term.
Section 3. Sections 5, 6, 7, 8, 9 and 10 of the act are
reenacted to read:
Section 5. Powers and duties of the council.
(a) General powers.--The council shall exercise all powers
necessary and appropriate to carry out its duties, including the
following:
(1) To employ an executive director, investigators and
other staff necessary to comply with the provisions of this
act and regulations promulgated thereunder, to employ or
retain legal counsel and to engage professional consultants,
as it deems necessary to the performance of its duties. Any
consultants, other than sole source consultants, engaged by
the council shall be selected in accordance with the
provisions for contracting with vendors set forth in section
16.
(2) To fix the compensation of all employees and to
prescribe their duties. Notwithstanding the independence of
the council under section 4(a), employees under this
paragraph shall be deemed employees of the Commonwealth for
the purposes of participation in the Pennsylvania Employee
Benefit Trust Fund.
(3) To make and execute contracts and other instruments,
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including those for purchase of services and purchase or
leasing of equipment and supplies, necessary or convenient to
the exercise of the powers of the council. Any such contract
shall be let only in accordance with the provision for
contracting with vendors set forth in section 16.
(4) To conduct examinations and investigations, to
conduct audits, pursuant to the provisions of subsection (c),
and to hear testimony and take proof, under oath or
affirmation, at public or private hearings, on any matter
necessary to its duties.
(4.1) To provide hospitals with individualized data on
patient safety indicators pursuant to section 6(c)(7). The
data shall be risk adjusted and made available to hospitals
electronically and free of charge on a quarterly basis within
45 days of receipt of the corrected quarterly data from the
hospitals. The data is intended to provide the patient safety
committee of each hospital with information necessary to
assist in conducting patient safety analysis.
(5) To do all things necessary to carry out its duties
under the provisions of this act.
(b) Rules and regulations.--The council shall promulgate
rules and regulations in accordance with the act of June 25,
1982 (P.L.633, No.181), known as the Regulatory Review Act,
necessary to carry out its duties under this act. This
subsection shall not apply to regulations in effect on June 30,
2008.
(c) Audit powers.--The council shall have the right to
independently audit all information required to be submitted by
data sources as needed to corroborate the accuracy of the
submitted data, pursuant to the following:
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(1) Audits of information submitted by providers or
health care insurers shall be performed on a sample and
issue-specific basis, as needed by the council, and shall be
coordinated, to the extent practicable, with audits performed
by the Commonwealth. All health care insurers and providers
are hereby required to make those books, records of accounts
and any other data needed by the auditors available to the
council at a convenient location within 30 days of a written
notification by the council.
(2) Audits of information submitted by purchasers shall
be performed on a sample basis, unless there exists
reasonable cause to audit specific purchasers, but in no case
shall the council have the power to audit financial
statements of purchasers.
(3) All audits performed by the council shall be
performed at the expense of the council.
(4) The results of audits of providers or health care
insurers shall be provided to the audited providers and
health care insurers on a timely basis, not to exceed 30 days
beyond presentation of audit findings to the council.
(d) General duties and functions.--The council is hereby
authorized to and shall perform the following duties and
functions:
(1) Develop a computerized system for the collection,
analysis and dissemination of data. The council may contract
with a vendor who will provide such data processing services.
The council shall assure that the system will be capable of
processing all data required to be collected under this act.
Any vendor selected by the council shall be selected in
accordance with the provisions of section 16, and said vendor
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shall relinquish any and all proprietary rights or claims to
the data base created as a result of implementation of the
data processing system.
(2) Establish a Pennsylvania Uniform Claims and Billing
Form for all data sources and all providers which shall be
utilized and maintained by all data sources and all providers
for all services covered under this act.
(3) Collect and disseminate data, as specified in
section 6, and other information from data sources to which
the council is entitled, prepared according to formats, time
frames and confidentiality provisions as specified in
sections 6 and 10, and by the council.
(4) Adopt and implement a methodology to collect and
disseminate data reflecting provider quality and provider
service effectiveness pursuant to section 6.
(5) Subject to the restrictions on access to raw data
set forth in section 10, issue special reports and make
available raw data as defined in section 3 to any purchaser
requesting it. Sale by any recipient or exchange or
publication by a recipient, other than a purchaser, of raw
council data to other parties without the express written
consent of, and under terms approved by, the council shall be
unauthorized use of data pursuant to section 10(c).
(6) On an annual basis, publish in the Pennsylvania
Bulletin a list of all the raw data reports it has prepared
under section 10(f) and a description of the data obtained
through each computer-to-computer access it has provided
under section 10(f) and of the names of the parties to whom
the council provided the reports or the computer-to-computer
access during the previous month.
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(7) Promote competition in the health care and health
insurance markets.
(8) Assure that the use of council data does not raise
access barriers to care.
(10) Make annual reports to the General Assembly on the
rate of increase in the cost of health care in the
Commonwealth and the effectiveness of the council in carrying
out the legislative intent of this act. In addition, the
council may make recommendations on the need for further
health care cost containment legislation. The council shall
also make annual reports to the General Assembly on the
quality and effectiveness of health care and access to health
care for all citizens of the Commonwealth.
(12) Conduct studies and publish reports thereon
analyzing the effects that noninpatient, alternative health
care delivery systems have on health care costs. These
systems shall include, but not be limited to: HMO's; PPO's;
primary health care facilities; home health care; attendant
care; ambulatory service facilities; freestanding emergency
centers; birthing centers; and hospice care. These reports
shall be submitted to the General Assembly and shall be made
available to the public.
(13) Conduct studies and make reports concerning the
utilization of experimental and nonexperimental transplant
surgery and other highly technical and experimental
procedures, including costs and mortality rates.
Section 6. Data submission and collection.
(a) (1) Submission of data.--The council is hereby
authorized to collect and data sources are hereby required to
submit, upon request of the council, all data required in
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this section, according to uniform submission formats, coding
systems and other technical specifications necessary to
render the incoming data substantially valid, consistent,
compatible and manageable using electronic data processing
according to data submission schedules, such schedules to
avoid, to the extent possible, submission of identical data
from more than one data source, established and promulgated
by the council in regulations pursuant to its authority under
section 5(b). If payor data is requested by the council, it
shall, to the extent possible, be obtained from primary payor
sources. The council shall not require any data sources to
contract with any specific vendor for submission of any
specific data elements to the council.
(1.1) Any data source shall comply with data submission
guidelines established in the report submitted under section
17.2. The council shall maintain a vendor list of at least
two vendors that may be chosen by any data source for
submission of any specific data elements.
(2) Except as provided in this section, the council may
adopt any nationally recognized methodology to adjust data
submitted under subsection (c) for severity of illness. Every
three years after the effective date of this paragraph, the
council shall solicit bids from third-party vendors to adjust
the data. The solicitation shall be in accordance with 62
Pa.C.S. (relating to procurement). In carrying out its
responsibilities, the council shall not require health care
facilities to report data elements which are not included in
the manual developed by the national uniform billing
committee. The council shall publish in the Pennsylvania
Bulletin a list of diseases, procedures and medical
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conditions, not to exceed 35, for which data under
subsections (c)(21) and (d) shall be required. The chosen
list shall not represent more than 50% of total hospital
discharges, based upon the previous year's hospital discharge
data. Subsequent to the publication of the list, any data
submission requirements under subsections (c)(21) and (d)
previously in effect shall be null and void for diseases,
procedures and medical conditions not found on the list. All
other data elements pursuant to subsection (c) shall continue
to be required from data sources. The council shall review
the list and may add no more than a net of three diseases,
procedures or medical conditions per year over a five-year
period starting on the effective date of this paragraph. The
adjusted list of diseases, procedures and medical conditions
shall at no time be more than 50% of total hospital
discharges.
(b) Pennsylvania Uniform Claims and Billing Form.--The
council shall maintain a Pennsylvania Uniform Claims and Billing
Form format. The council shall furnish said claims and billing
form format to all data sources, and said claims and billing
form shall be utilized and maintained by all data sources for
all services covered by this act. The Pennsylvania Uniform
Claims and Billing Form shall consist of the Uniform Hospital
Billing Form , as developed by the National Uniform Billing
Committee, with additional fields as necessary to provide all of
the data set forth in subsections (c) and (d).
(c) Data elements.--For each covered service performed in
Pennsylvania, the council shall be required to collect the
following data elements:
(1) uniform patient identifier, continuous across
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multiple episodes and providers;
(2) patient date of birth;
(3) patient sex;
(3.1) patient race, consistent with the method of
collection of race/ethnicity data by the United States Bureau
of the Census and the United States Standard Certificates of
Live Birth and Death;
(4) patient ZIP Code number;
(5) date of admission;
(6) date of discharge;
(7) principal and secondary diagnoses by standard code,
including external cause of injury, complication, infection
and childbirth;
(8) principal procedure by council-specified standard
code and date;
(9) up to three secondary procedures by council-
specified standard codes and dates;
(10) uniform health care facility identifier, continuous
across episodes, patients and providers;
(11) uniform identifier of admitting physician, by
unique physician identification number established by the
council, continuous across episodes, patients and providers;
(12) uniform identifier of consulting physicians, by
unique physician identification number established by the
council, continuous across episodes, patients and providers;
(13) total charges of health care facility, segregated
into major categories, including, but not limited to, room
and board, radiology, laboratory, operating room, drugs,
medical supplies and other goods and services according to
guidelines specified by the council;
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(14) actual payments to health care facility,
segregated, if available, according to the categories
specified in paragraph (13);
(15) charges of each physician or professional rendering
service relating to an incident of hospitalization or
treatment in an ambulatory service facility;
(16) actual payments to each physician or professional
rendering service pursuant to paragraph (15);
(17) uniform identifier of primary payor;
(18) ZIP Code number of facility where health care
service is rendered;
(19) uniform identifier for payor group contract number;
(20) patient discharge status; and
(21) provider service effectiveness and provider quality
pursuant to section 5(d)(4) and subsection (d).
(d) Provider quality and provider service effectiveness data
elements.--In carrying out its duty to collect data on provider
quality and provider service effectiveness under section 5(d)(4)
and subsection (c)(21), the council shall define a methodology
to measure provider service effectiveness which may include
additional data elements to be specified by the council
sufficient to carry out its responsibilities under section 5(d)
(4). The council shall not require health care insurers to
report on data elements that are not reported to nationally
recognized accrediting organizations, to the Department of
Health or to the Insurance Department in quarterly or annual
reports. The council shall not require reporting by health care
insurers in different formats than are required for reporting to
nationally recognized accrediting organizations or on quarterly
or annual reports submitted to the Department of Health or to
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the Insurance Department. The council may adopt the quality
findings as reported to nationally recognized accrediting
organizations. Additional quality data elements must be defined
and released for public comment prior to the promulgation of
regulations under section 5(b). The public comment period shall
be no less than 30 days from the release of these elements.
(e) Reserve field utilization and addition or deletion of
data elements.--The council shall include in the Pennsylvania
Uniform Claims and Billing Form a reserve field. The council may
utilize the reserve field by adding other data elements beyond
those required to carry out its responsibilities under section
5(d)(3) and (4) and subsections (c) and (d), or the council may
delete data elements from the Pennsylvania Uniform Claims and
Billing Form only by a majority vote of the council and only
pursuant to the following procedure:
(1) The council shall obtain a cost-benefit analysis of
the proposed addition or deletion which shall include the
cost to data sources of any proposed additions.
(2) The council shall publish notice of the proposed
addition or deletion, along with a copy or summary of the
cost-benefit analysis, in the Pennsylvania Bulletin, and such
notice shall include provision for a 60-day comment period.
(3) The council may hold additional hearings or request
such other reports as it deems necessary and shall consider
the comments received during the 60-day comment period and
any additional information gained through such hearings or
other reports in making a final determination on the proposed
addition or deletion.
(f) Other data required to be submitted.--Providers are
hereby required to submit and the council is hereby authorized
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to collect, in accordance with submission dates and schedules
established by the council, the following additional data,
provided such data is not available to the council from public
records:
(1) Audited annual financial reports of all hospitals
and ambulatory service facilities providing covered services
as defined in section 3.
(2) The Medicare cost report for Medical Assistance or
successor forms, including the settled Medicare cost report.
(3) Additional data, including, but not limited to, data
which can be used in reports about:
(i) the incidence of medical and surgical procedures
in the population for individual providers;
(ii) physicians who provide covered services and
accept medical assistance patients;
(iii) physicians who provide covered services and
accept Medicare assignment as full payment;
(v) mortality rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(vi) rates of infection for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(vii) morbidity rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(viii) readmission rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(ix) rate of incidence of postdischarge professional
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care for selected diagnoses and procedures, grouped by
severity, for individual providers; and
(x) data from other public sources.
(4) Any other data the council requires to carry out its
responsibilities pursuant to section 5(d).
(f.1) Review and correction of data.--The council shall
provide a reasonable period for data sources to review and
correct the data submitted under section 6 which the council
intends to prepare and issue in reports to the General Assembly,
to the general public or in special studies and reports under
section 11. When corrections are provided, the council shall
correct the appropriate data in its data files and subsequent
reports.
(g) Allowance for clarification or dissents.--The council
shall maintain a file of written statements submitted by data
sources who wish to provide an explanation of data that they
feel might be misleading or misinterpreted. The council shall
provide access to such file to any person and shall, where
practical, in its reports and data files indicate the
availability of such statements. When the council agrees with
such statements, it shall correct the appropriate data and
comments in its data files and subsequent reports.
(g.1) Allowance for correction.--The council shall verify
the patient safety indicator data submitted by hospitals
pursuant to subsection (c)(7) within 60 days of receipt. The
council may allow hospitals to make changes to the data
submitted during the verification period. After the verification
period, but within 45 days of receipt of the adjusted hospital
data, the council shall risk adjust the information and provide
reports to the patient safety committee of the relevant
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hospital.
(h) Availability of data.--Nothing in this act shall
prohibit a purchaser from obtaining from its health care
insurer, nor relieve said health care insurer from the
obligation of providing said purchaser, on terms consistent with
past practices, data previously provided or additional data not
currently provided to said purchaser by said health care insurer
pursuant to any existing or future arrangement, agreement or
understanding.
Section 7. Data dissemination and publication.
(a) Public reports.--Subject to the restrictions on access
to council data set forth in section 10 and utilizing the data
collected under section 6 as well as other data, records and
matters of record available to it, the council shall prepare and
issue reports to the General Assembly and to the general public
according to the following provisions:
(1) The council shall, for every provider of both
inpatient and outpatient services within this Commonwealth
and within appropriate regions and subregions, prepare and
issue reports on provider quality and service effectiveness
on diseases or procedures that, when ranked by volume, cost,
payment and high variation in outcome, represent the best
opportunity to improve overall provider quality, improve
patient safety and provide opportunities for cost reduction.
These reports shall provide comparative information on the
following:
(i) Differences in mortality rates; differences in
length of stay; differences in complication rates;
differences in readmission rates; differences in
infection rates; and other comparative outcome measures
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the council may develop that will allow purchasers,
providers and consumers to make purchasing and quality
improvement decisions based upon quality patient care and
to restrain costs.
(ii) The incidence rate of selected medical or
surgical procedures, the quality and service
effectiveness and the payments received for those
providers, identified by the name and type or specialty,
for which these elements vary significantly from the
norms for all providers.
(2) In preparing its reports under paragraph (1), the
council shall ensure that factors which have the effect of
either reducing provider revenue or increasing provider costs
and other factors beyond a provider's control which reduce
provider competitiveness in the marketplace are explained in
the reports. The council shall also ensure that any
clarifications and dissents submitted by individual providers
under section 6(g) are noted in any reports that include
release of data on that individual provider.
(b) Raw data reports and computer access to council data.--
The council shall provide special reports derived from raw data
and a means for computer-to-computer access to its raw data to
any purchaser, pursuant to section 10(f). The council shall
provide such reports and computer-to-computer access, at its
discretion, to other parties, pursuant to section 10(g). The
council shall provide these special reports and computer-to-
computer access in as timely a fashion as the council's
responsibilities to publish the public reports required in this
section will allow. Any such provision of special reports or
computer-to-computer access by the council shall be made only
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subject to the restrictions on access to raw data set forth in
section 10(b) and only after payment for costs of preparation or
duplication pursuant to section 10(f) or (g).
Section 8. Health care for the medically indigent.
(a) Declaration of policy.--The General Assembly finds that
every person in this Commonwealth should receive timely and
appropriate health care services from any provider operating in
this Commonwealth; that, as a continuing condition of licensure,
each provider should offer and provide medically necessary,
lifesaving and emergency health care services to every person in
this Commonwealth, regardless of financial status or ability to
pay; and that health care facilities may transfer patients only
in instances where the facility lacks the staff or facilities to
properly render definitive treatment.
(b) Studies on indigent care.--To reduce the undue burden on
the several providers that disproportionately treat medically
indigent people on an uncompensated basis, to contain the long-
term costs generated by untreated or delayed treatment of
illness and disease and to determine the most appropriate means
of treating and financing the treatment of medically indigent
persons, the council, at the request of the Governor or the
General Assembly, may undertake studies and utilize its current
data base to:
(1) Study and analyze the medically indigent population,
the magnitude of uncompensated care for the medically
indigent, the degree of access to and the result of any lack
of access by the medically indigent to appropriate care, the
types of providers and the settings in which they provide
indigent care and the cost of the provision of that care
pursuant to subsection (c).
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(2) Determine, from studies undertaken under paragraph
(1), a definition of the medically indigent population and
the most appropriate method for the delivery of timely and
appropriate health care services to the medically indigent.
(c) Studies.--The council shall conduct studies pursuant to
subsection (b)(1) and thereafter report to the Governor and the
General Assembly the results of the studies and its
recommendations. The council may contract with an independent
vendor to conduct the study in accordance with the provisions
for selecting vendors in section 16. The study shall include,
but not be limited to, the following:
(1) the number and characteristics of the medically
indigent population, including such factors as income,
employment status, health status, patterns of health care
utilization, type of health care needed and utilized,
eligibility for health care insurance, distribution of this
population on a geographic basis and by age, sex and racial
or linguistic characteristics, and the changes in these
characteristics, including the following:
(i) the needs and problems of indigent persons in
urban areas;
(ii) the needs and problems of indigent persons in
rural areas;
(iii) the needs and problems of indigent persons who
are members of racial or linguistic minorities;
(iv) the needs and problems of indigent persons in
areas of high unemployment; and
(v) the needs and problems of the underinsured;
(2) the degree of and any change in access of this
population to sources of health care, including hospitals,
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physicians and other providers;
(3) the distribution and means of financing indigent
care between and among providers, insurers, government,
purchasers and consumers, and the effect of that distribution
on each;
(4) the major types of care rendered to the indigent,
the setting in which each type of care is rendered and the
need for additional care of each type by the indigent;
(5) the likely impact of changes in the health delivery
system, including managed care entities, and the effects of
cost containment in the Commonwealth on the access to,
availability of and financing of needed care for the
indigent, including the impact on providers which provide a
disproportionate amount of care to the indigent;
(6) the distribution of delivered care and actual cost
to render such care by provider, region and subregion;
(7) the provision of care to the indigent through
improvements in the primary health care system, including the
management of needed hospital care by primary care providers;
(8) innovative means to finance and deliver care to the
medically indigent; and
(9) reduction in the dependence of indigent persons on
hospital services through improvements in preventive health
measures.
Section 9. Mandated health benefits.
In relation to current law or proposed legislation, the
council shall, upon the request of the appropriate committee
chairman in the Senate and in the House of Representatives or
upon the request of the Secretary of Health, provide information
on the proposed mandated health benefit pursuant to the
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following:
(1) The General Assembly hereby declares that proposals
for mandated health benefits or mandated health insurance
coverage should be accompanied by adequate, independently
certified documentation defining the social and financial
impact and medical efficacy of the proposal. To that end the
council, upon receipt of such requests, is hereby authorized
to conduct a preliminary review of the material submitted by
both proponents and opponents concerning the proposed
mandated benefit. If, after this preliminary review, the
council is satisfied that both proponents and opponents have
submitted sufficient documentation necessary for a review
pursuant to paragraphs (3) and (4), the council is directed
to contract with individuals, pursuant to the selection
procedures for vendors set forth in section 16, who will
constitute a Mandated Benefits Review Panel to review
mandated benefits proposals and provide independently
certified documentation, as provided for in this section.
(2) The panel shall consist of senior researchers, each
of whom shall be a recognized expert:
(i) one in health research;
(ii) one in biostatistics;
(iii) one in economic research;
(iv) one, a physician, in the appropriate specialty
with current knowledge of the subject being proposed as a
mandated benefit; and
(v) one with experience in insurance or actuarial
research.
(3) The Mandated Benefits Review Panel shall have the
following duties and responsibilities:
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(i) To review documentation submitted by persons
proposing or opposing mandated benefits within 90 days of
submission of said documentation to the panel.
(ii) To report to the council, pursuant to its
review in subparagraph (i), the following:
(A) Whether or not the documentation is complete
as defined in paragraph (4).
(B) Whether or not the research cited in the
documentation meets professional standards.
(C) Whether or not all relevant research
respecting the proposed mandated benefit has been
cited in the documentation.
(D) Whether or not the conclusions and
interpretations in the documentation are consistent
with the data submitted.
(4) To provide the Mandated Benefits Review Panel with
sufficient information to carry out its duties and
responsibilities pursuant to paragraph (3), persons proposing
or opposing legislation mandating benefits coverage should
submit documentation to the council, pursuant to the
procedure established in paragraph (5), which demonstrates
the following:
(i) The extent to which the proposed benefit and the
services it would provide are needed by, available to and
utilized by the population of the Commonwealth.
(ii) The extent to which insurance coverage for the
proposed benefit already exists, or if no such coverage
exists, the extent to which this lack of coverage results
in inadequate health care or financial hardship for the
population of the Commonwealth.
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(iii) The demand for the proposed benefit from the
public and the source and extent of opposition to
mandating the benefit.
(iv) All relevant findings bearing on the social
impact of the lack of the proposed benefit.
(v) Where the proposed benefit would mandate
coverage of a particular therapy, the results of at least
one professionally accepted, controlled trial comparing
the medical consequences of the proposed therapy,
alternative therapies and no therapy.
(vi) Where the proposed benefit would mandate
coverage of an additional class of practitioners, the
results of at least one professionally accepted,
controlled trial comparing the medical results achieved
by the additional class of practitioners and those
practitioners already covered by benefits.
(vii) The results of any other relevant research.
(viii) Evidence of the financial impact of the
proposed legislation, including at least:
(A) The extent to which the proposed benefit
would increase or decrease cost for treatment or
service.
(B) The extent to which similar mandated
benefits in other states have affected charges, costs
and payments for services.
(C) The extent to which the proposed benefit
would increase the appropriate use of the treatment
or service.
(D) The impact of the proposed benefit on
administrative expenses of health care insurers.
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(E) The impact of the proposed benefits on
benefits costs of purchasers.
(F) The impact of the proposed benefits on the
total cost of health care within the Commonwealth.
(5) The procedure for review of documentation is as
follows:
(i) Any person wishing to submit information on
proposed legislation mandating insurance benefits for
review by the panel should submit the documentation
specified in paragraph (4) to the council.
(ii) The council shall, within 30 days of receipt of
the documentation:
(A) Publish in the Pennsylvania Bulletin notice
of receipt of the documentation, a description of the
proposed legislation, provision for a period of 60
days for public comment and the time and place at
which any person may examine the documentation.
(B) Submit copies of the documentation to the
Secretary of Health and the Insurance Commissioner,
who shall review and submit comments to the council
on the proposed legislation within 30 days.
(C) Submit copies of the documentation to the
panel, which shall review the documentation and issue
their findings, pursuant to paragraph (3), within 90
days.
(iii) Upon receipt of the comments of the Secretary
of Health and the Insurance Commissioner and of the
findings of the panel, pursuant to subparagraph (ii), but
no later than 120 days following the publication required
in subparagraph (ii), the council shall submit said
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comments and findings, together with its recommendations
respecting the proposed legislation, to the Governor, the
President pro tempore of the Senate, the Speaker of the
House of Representatives, the Secretary of Health, the
Insurance Commissioner and the person who submitted the
information pursuant to subparagraph (i).
Section 10. Right-to-Know Law and access to council data.
(a) Public access.--The information and data received by the
council shall be utilized by the council for the benefit of the
public and public officials. Subject to the specific limitations
set forth in this section and section 3101.1 of the act of
February 14, 2008 (P.L.6, No.3), known as the Right-to-Know Law,
the council shall make determinations on requests for
information in favor of access. Payor discounts and allowances
are considered confidential proprietary information and, as
such, are not records subject to the requirements for public
access established under the Right-to-Know Law.
(a.1) Outreach programs.--The council shall develop and
implement outreach programs designed to make its information
understandable and usable to purchasers, providers, other
Commonwealth agencies and the general public. The programs shall
include efforts to educate through pamphlets, booklets, seminars
and other appropriate measures and to facilitate making more
informed health care choices.
(b) Limitations on access.--Unless specifically provided for
in this act, neither the council nor any contracting system
vendor shall release and no data source, person, member of the
public or other user of any data of the council shall gain
access to:
(1) Any raw data of the council that does not
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simultaneously disclose payment, as well as provider quality
and provider service effectiveness pursuant to sections 5(d)
(4) and 6(d) or 7(a)(1)(iii).
(2) Any raw data of the council which could reasonably
be expected to reveal the identity of an individual patient.
(3) Any raw data of the council which could reasonably
be expected to reveal the identity of any purchaser, as
defined in section 3, other than a purchaser requesting data
on its own group or an entity entitled to said purchaser's
data pursuant to subsection (f).
(4) Any raw data of the council relating to actual
payments to any identified provider made by any purchaser,
except that this provision shall not apply to access by a
purchaser requesting data on the group for which it purchases
or otherwise provides covered services or to access to that
same data by an entity entitled to the purchaser's data
pursuant to subsection (f).
(5) Any raw data disclosing discounts or allowances
between identified payors and providers unless the data is
released in a Statewide, aggregate format that does not
identify any individual payor or class of payors, directly or
indirectly through the use of a market share, and unless the
council assures that the release of such information is not
prejudicial or inequitable to any individual payor or
provider or group thereof. Payor data shall be released to
individual providers for purposes of verification and
validation prior to inclusion in a public report. An
individual provider shall verify and validate the payor data
within 30 days of its release to that specific individual
provider.
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(c) Unauthorized use of data.--Any person who knowingly
releases council data violating the patient confidentiality,
actual payments, discount data or raw data safeguards set forth
in this section to an unauthorized person commits a misdemeanor
of the first degree and shall, upon conviction, be sentenced to
pay a fine of $10,000 or to imprisonment for not more than five
years, or both. An unauthorized person who knowingly receives or
possesses such data commits a misdemeanor of the first degree.
(d) Unauthorized access to data.--Should any person
inadvertently or by council error gain access to data that
violates the safeguards set forth in this section, the data must
immediately be returned, without duplication, to the council
with proper notification.
(e) Public access to records.--All public reports prepared
by the council shall be public records and shall be available to
the public for a reasonable fee, and copies shall be provided,
upon request of the chair, to the Public Health and Welfare
Committee of the Senate and the Health and Welfare Committee of
the House of Representatives.
(f) Access to raw council data by purchasers.--Pursuant to
sections 5(d)(5) and 7(b) and subject to the limitations on
access set forth in subsection (b), the council shall provide
access to its raw data to purchasers in accordance with the
following procedure:
(1) Special reports derived from raw data of the council
shall be provided by the council to any purchaser requesting
such reports.
(2) A means to enable computer-to-computer access by any
purchaser to raw data of the council as defined in section 3
shall be developed, adopted and implemented by the council,
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and the council shall provide such access to its raw data to
any purchaser upon request.
(3) In the event that any employer obtains from the
council, pursuant to paragraph (1) or (2), data pertaining to
its employees and their dependents for whom said employer
purchases or otherwise provides covered services as defined
in section 3 and who are represented by a certified
collective bargaining representative, said collective
bargaining representative shall be entitled to that same
data, after payment of fees as specified in paragraph (4).
Likewise, should a certified collective bargaining
representative obtain from the council, pursuant to paragraph
(1) or (2), data pertaining to its members and their
dependents who are employed by and for whom covered services
are purchased or otherwise provided by any employer, said
employer shall be entitled to that same data, after payment
of fees as specified in paragraph (4).
(4) In providing for access to its raw data, the council
shall charge the purchasers which originally obtained such
access a fee sufficient to cover its costs to prepare and
provide special reports requested pursuant to paragraph (1)
or to provide computer-to-computer access to its raw data
requested pursuant to paragraph (2). Should a second or
subsequent party or parties request this same information
pursuant to paragraph (3), the council shall charge said
party a reasonable fee.
(g) Access to raw council data by other parties.--Subject to
the limitations on access to raw council data set forth in
subsection (b), the council may, at its discretion, provide
special reports derived from its raw data or computer-to-
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computer access to parties other than purchasers. The council
shall publish regulations that set forth the criteria and the
procedure it shall use in making determinations on such access,
pursuant to the powers vested in the council in section 4. In
providing such access, the council shall charge the party
requesting the access a reasonable fee.
Section 4. Section 11 of the act is reenacted and amended to
read:
Section 11. Special studies and reports.
(a) Special studies.--Any Commonwealth agency may publish or
contract for publication of special studies. Any special study
so published shall become a public document.
(b) Special reports.--
(1) Any Commonwealth agency may study and issue a report
on the special medical needs, demographic characteristics,
access or lack thereof to health care services and need for
financing of health care services of:
(i) Senior citizens, particularly low-income senior
citizens, senior citizens who are members of minority
groups and senior citizens residing in low-income urban
or rural areas.
(ii) Low-income urban or rural areas.
(iii) Minority communities.
(iv) Women.
(v) Children.
(vi) Unemployed workers.
(vii) Veterans.
The reports shall include information on the current
availability of services to these targeted parts of the
population, and whether access to such services has increased
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or decreased over the past [ten] 10 years, and specific
recommendations for the improvement of their primary care and
health delivery systems, including disease prevention and
comprehensive health care services. The department may also
study and report on the effects of using prepaid, capitated
or HMO health delivery systems as ways to promote the
delivery of primary health care services to the underserved
segments of the population enumerated above.
(2) The department may study and report on the short-
term and long-term fiscal and programmatic impact on the
health care consumer of changes in ownership of hospitals
from nonprofit to profit, whether through purchase, merger or
the like. The department may also study and report on factors
which have the effect of either reducing provider revenue or
increasing provider cost, and other factors beyond a
provider's control which reduce provider competitiveness in
the marketplace, are explained in the reports.
Section 5. Section 12, 13, 14, 15, 16, 17.1, 17.2 and 18 of
the act are reenacted to read:
Section 12. Enforcement; penalty.
(a) Compliance enforcement.--The council shall have standing
to bring an action in law or in equity through private counsel
in any court of common pleas to enforce compliance with any
provision of this act, except section 11, or any requirement or
appropriate request of the council made pursuant to this act. In
addition, the Attorney General is authorized and shall bring any
such enforcement action in aid of the council in any court of
common pleas at the request of the council in the name of the
Commonwealth.
(b) Penalty.--
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(1) Any person who fails to supply data pursuant to
section 6 may be assessed a civil penalty not to exceed
$1,000 for each day the data is not submitted.
(2) Any person who knowingly submits inaccurate data
under section 6 commits a misdemeanor of the third degree and
shall, upon conviction, be sentenced to pay a fine of $1,000
or to imprisonment for not more than one year, or both.
Section 13. Research and demonstration projects.
The council shall actively encourage research and
demonstrations to design and test improved methods of assessing
provider quality, provider service effectiveness and efficiency.
To that end, provided that no data submission requirements in a
mandated demonstration may exceed the current reserve field on
the Pennsylvania Uniform Claims and Billing Form, the council
may:
(1) Authorize contractors engaged in health services
research selected by the council, pursuant to the provisions
of section 16, to have access to the council's raw data
files, providing such entities assume any contractual
obligations imposed by the council to assure patient identity
confidentiality.
(2) Place data sources participating in research and
demonstrations on different data submission requirements from
other data sources in this Commonwealth.
(3) Require data source participation in research and
demonstration projects when this is the only testing method
the council determines is promising.
Section 14. Grievances and grievance procedures.
(a) Procedures and requirements.--Pursuant to its powers to
publish regulations under section 5(b) and with the requirements
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of this section, the council is hereby authorized and directed
to establish procedures and requirements for the filing, hearing
and adjudication of grievances against the council of any data
source. Such procedures and requirements shall be published in
the Pennsylvania Bulletin pursuant to law.
(b) Claims; hearings.--Grievance claims of any data source
shall be submitted to the council or to a third party designated
by the council, and the council or the designated third party
shall convene a hearing, if requested, and adjudicate the
grievance.
Section 15. Antitrust provisions.
Persons or entities required to submit data or information
under this act or receiving data or information from the council
in accordance with this act are declared to be acting pursuant
to State requirements embodied in this act and shall be exempt
from antitrust claims or actions grounded upon submission or
receipt of such data or information.
Section 16. Contracts with vendors.
Any contract with any vendor other than a sole source vendor
for purchase of services or for purchase or lease of supplies
and equipment related to the council's powers and duties shall
be let only after a public bidding process and only in
accordance with the following provisions, and no contract shall
be let by the council that does not conform to these provisions:
(1) The council shall prepare specifications fully
describing the services to be rendered or equipment or
supplies to be provided by a vendor and shall make these
specifications available for inspection by any person at the
council's offices during normal working hours and at such
other places and such other times as the council deems
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advisable.
(2) The council shall publish notice of invitations to
bid in the Pennsylvania Bulletin. The council shall also
publish such notice in at least four newspapers in general
circulation in the Commonwealth on at least three occasions
at intervals of not less than three days. Said notice shall
include at least the following:
(i) The deadline for submission of bids by
prospective vendors, which shall be no sooner than 30
days following the latest publication of the notice as
prescribed in this paragraph.
(ii) The locations, dates and times during which
prospective vendors can examine the specifications
required in paragraph (1).
(iii) The date, time and place of the meeting or
meetings of the council at which bids will be opened and
accepted.
(iv) A statement to the effect that any person is
eligible to bid.
(3) Bids shall be accepted as follows:
(i) No council member who is affiliated in any way
with any bidder shall vote on the awarding of any
contract for which said bidder has submitted a bid, and
any council member who has an affiliation with a bidder
shall state the nature of the affiliation prior to any
vote of the council.
(ii) Bids shall be opened and reviewed by the
appropriate council committee, which shall make
recommendations to the council on approval. Bids shall be
accepted and such acceptance shall be announced only at a
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public meeting of the council as defined in section 4(e),
and no bids shall be accepted at an executive session of
the council.
(iii) The council may require that a certified
check, in an amount determined by the council, accompany
every bid, and, when so required, no bid shall be
accepted unless so accompanied.
(4) In order to prevent any party from deliberately
underbidding contracts in order to gain or prevent access to
council data, the council may award any contract at its
discretion, regardless of the amount of the bid, pursuant to
the following:
(i) Any bid accepted must reasonably reflect the
actual cost of services provided.
(ii) Any vendor so selected by the council shall be
found by the council to be of such character and such
integrity as to assure, to the maximum extent possible,
adherence to all the provisions of this act in the
provision of contracted services.
(iii) The council may require the selected vendor to
furnish, within 20 days after the contract has been
awarded, a bond with suitable and reasonable requirements
guaranteeing the services to be performed with sufficient
surety in an amount determined by the council, and upon
failure to furnish such bond within the time specified,
the previous award shall be void.
(5) The council shall make efforts to assure that its
vendors have established affirmative action plans to assure
equal opportunity policies for hiring and promoting
employees.
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Section 17.1. Reporting.
The council shall provide an annual report of its financial
expenditures to the Appropriations Committee of the Senate and
the Appropriations Committee of the House of Representatives.
Section 17.2. Health Care Cost Containment Council Act Review
Committee.
(a) Establishment.--There is established an independent
committee to be known as the Health Care Cost Containment
Council Act Review Committee.
(b) Composition.--The committee shall consist of the
following voting members composed of and appointed as follows:
(1) One member appointed by the Governor.
(2) Four members appointed by the General Assembly, one
of whom appointed by each of the following:
(i) one by the President pro tempore of the Senate;
(ii) one by the Minority Leader of the Senate;
(iii) one by the Majority Leader of the House of
Representatives; and
(iv) one by the Minority Leader of the House of
Representatives.
(3) Two representatives of the business community, at
least one of whom represents small business, and neither of
whom is primarily involved in the provision of health care or
health insurance, one of whom appointed by the President pro
tempore of the Senate and one of whom appointed by the
Speaker of the House of Representatives from a list of four
qualified persons recommended by the Pennsylvania Chamber of
Business and Industry.
(4) Two representatives of organized labor, one of whom
appointed by the President pro tempore of the Senate and one
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of whom appointed by the Speaker of the House of
Representatives from a list of four qualified persons
recommended by the Pennsylvania AFL-CIO.
(5) One representative of consumers who is not primarily
involved in the provision of health care or health care
insurance, appointed by the Governor from a list of three
qualified persons recommended jointly by the President pro
tempore of the Senate and the Speaker of the House of
Representatives.
(6) One representative of a health care facility,
appointed by the Governor from a list of three qualified
hospital representatives recommended by the Hospital and
Health System Association of Pennsylvania.
(7) One representative of physicians, appointed by the
Governor from a list of three qualified physician
representatives recommended jointly by the Pennsylvania
Medical Society and the Pennsylvania Osteopathic Medical
Society.
(8) One representative of nurses, appointed by the
Governor from a list of three qualified representatives
recommended by the Pennsylvania State Nurses Association.
(9) One representative of the Blue Cross and Blue Shield
plans in Pennsylvania, pursuant to 40 Pa.C.S. Ch. 61
(relating to Hospital Plan Corporations), appointed by the
Governor from a list of three qualified persons recommended
jointly by the Blue Cross and Blue Shield plans of
Pennsylvania.
(10) One representative of commercial insurance
carriers, appointed by the Governor from a list of three
qualified persons recommended by the Insurance Federation of
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Pennsylvania, Inc.
(c) Chairperson.--The appointment made by the Governor under
subsection (b)(1) shall serve as chairman of the committee.
(d) Quorum.--Eleven members shall constitute a quorum for
the transaction of any business, and action by the majority of
the members present at any meeting in which there is a quorum
shall be deemed to be action of the committee.
(e) Meetings.--
(1) All meetings of the committee shall be advertised
and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating to open
meetings).
(2) All action taken by the committee shall be taken in
open public session, and action of the committee shall not be
taken except upon the affirmative vote of a majority of the
members of the committee present during meetings at which a
quorum is present.
(f) Compensation and expenses.--The members of the committee
shall not receive a salary or per diem allowance for serving as
members of the committee but shall be reimbursed for actual and
necessary expenses incurred in the performance of their duties.
Expenses may include reimbursement of travel and living expenses
while engaged in committee business.
(g) Commencement of committee.--
(1) Within 15 days after the effective date of this
section, each organization or individual required to submit a
list of recommended persons to the Governor, the President
pro tempore of the Senate or the Speaker of the House of
Representatives under subsection (b) shall submit the list.
(2) Within 30 days of the effective date of this
section, the Governor, the President pro tempore of the
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Senate and the Speaker of the House of Representatives shall
make the appointments called for in subsection (b), and the
committee shall begin operations immediately following the
appointments.
(h) Responsibilities of the committee.--The committee shall
have the following powers and duties:
(1) To study, review and recommend changes to this act.
(2) To accept and review suggested changes to this act
submitted by members of the committee.
(3) To approve, by a majority vote of the members of the
committee, a report recommending statutory changes to this
act. The report shall include, at a minimum, the following:
(i) The establishment of an Internet database for
the general public showing Medicare reimbursement rates
for common covered services and treatment.
(ii) In consultation with experts in the fields of
quality data and outcome measures, the definition and
implementation of:
(A) A methodology by provider type for the
council to risk-adjust quality data.
(B) A methodology for the council to collect and
disseminate data reflecting provider quality and
provider service effectiveness.
(4) To submit the report approved under paragraph (3) to
the President pro tempore of the Senate and the Speaker of
the House of Representatives within six months after the
effective date of this section.
(i) Committee support.--The council shall offer staff and
administrative support from the council or its work groups
necessary for the committee to carry out its duties under this
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section.
Section 18. Severability.
The provisions of this act are severable. If any provision of
this act or its application to any person or circumstance is
held invalid, the invalidity shall not affect other provisions
or applications of this act which can be given effect without
the invalid provision or application.
Section 6. Section 19 of the act is reenacted and amended to
read:
Section 19. [Sunset] Expiration.
This act shall expire June 30, [2014] 2019, unless reenacted
prior to that date. [By September 1, 2013, a written report by
the Legislative Budget and Finance Committee evaluating the
management, visibility, awareness and performance of the council
shall be provided to the Public Health and Welfare Committee of
the Senate and the Health and Human Services Committee of the
House of Representatives. The report shall include a review of
the council's procedures and policies, the availability and
quality of data for completing reports , whether there is a more
cost-efficient way of accomplishing the objectives of the
council and the need for reauthorization of the council.]
Section 7. Section 20 of the act is reenacted to read:
Section 20. Effective date.
This act shall take effect immediately.
Section 8. This act shall be retroactive to June 29, 2014.
Section 9. This act shall take effect immediately.
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