HOUSE AMENDED
PRIOR PRINTER'S NOS. 398, 955, 969 PRINTER'S NO. 1040
No. 387 Session of 2003
INTRODUCED BY M. WHITE, MOWERY, WENGER, KUKOVICH, PILEGGI, DENT,
LAVALLE, MUSTO, ERICKSON, PUNT, CORMAN, SCHWARTZ, GREENLEAF,
RAFFERTY, ORIE, KASUNIC, PICCOLA, TARTAGLIONE, MADIGAN,
STACK, WONDERLING, WOZNIAK, RHOADES, THOMPSON AND BOSCOLA,
MARCH 3, 2003
AS REPORTED FROM COMMITTEE ON HEALTH AND HUMAN SERVICES, HOUSE
OF REPRESENTATIVES, AS AMENDED, JUNE 25, 2003
AN ACT
1 Amending the act of July 8, 1986 (P.L.408, No.89), entitled, as
2 reenacted and amended, "An act providing for the creation of
3 the Health Care Cost Containment Council, for its powers and
4 duties, for health care cost containment through the
5 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 membership of the council, its bylaws and terms of its <--
9 members, for powers and duties of the council, for data
10 submission and collection, for data dissemination and
11 publication, for access to council data and for enforcement
12 and penalties; requiring a certain report from the
13 Legislative Budget and Finance Committee; and extending the
14 sunset date of the act. FOR THE HEALTH CARE COST CONTAINMENT <--
15 COUNCIL, FOR POWERS AND DUTIES OF THE COUNCIL, FOR DATA
16 SUBMISSION AND COLLECTION, FOR ACCESS TO COUNCIL DATA, FOR
17 ENFORCEMENT AND PENALTY AND FOR EXPIRATION; AND PROVIDING FOR
18 PENALTIES.
19 The General Assembly of the Commonwealth of Pennsylvania
20 hereby enacts as follows:
21 Section 1. Sections 4(b), (d) and (f) and 5(b) and (d)(11) <--
22 of the act of July 8, 1986 (P.L.408, No.89), known as the Health
23 Care Cost Containment Act, reenacted and amended June 28, 1993
1 (P.L.146, No.34), are amended to read:
2 Section 4. Health Care Cost Containment Council.
3 * * *
4 (b) Composition.--The council shall consist of [21] 28
5 voting members, composed of and appointed in accordance with the
6 following:
7 (1) The Secretary of Health.
8 (2) The Secretary of Public Welfare.
9 (3) The Insurance Commissioner.
10 (3.1) Four members of the General Assembly, which shall
11 consist of the chairman and minority chairman of the Public
12 Health and Welfare Committee of the Senate and the chairman
13 and minority Chairman of the Health and Human Services
14 Committee of the House of Representatives. Members under this
15 paragraph may appoint a designee to act on behalf of the
16 member at meetings of the council and of committees, as
17 provided in subsection (f). Designees shall be counted for
18 purposes of determining a quorum.
19 (4) Six representatives of the business community, at
20 least one of whom represents small business, who are
21 purchasers of health care as defined in section 3, none of
22 which is primarily involved in the provision of health care
23 or health insurance, three of which shall be appointed by the
24 President pro tempore of the Senate and three of which shall
25 be appointed by the Speaker of the House of Representatives
26 from a list of twelve qualified persons recommended by the
27 Pennsylvania Chamber of Business and Industry. Three nominees
28 shall be representatives of small business.
29 (5) Six representatives of organized labor, three of
30 which shall be appointed by the President pro tempore of the
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1 Senate and three of which shall be appointed by the Speaker
2 of the House of Representatives from a list of twelve
3 qualified persons recommended by the Pennsylvania AFL-CIO.
4 (6) One representative of consumers who is not primarily
5 involved in the provision of health care or health care
6 insurance, appointed by the Governor from a list of three
7 qualified persons recommended jointly by the Speaker of the
8 House of Representatives and the President pro tempore of the
9 Senate.
10 (7) [One representative] Two representatives of
11 hospitals, one of which shall represent rural hospitals,
12 appointed by the Governor from a list of [three] five
13 qualified hospital representatives recommended by the
14 Hospital and Healthsystem Association of Pennsylvania. The
15 [representative] representatives under this paragraph may
16 each appoint two additional delegates to act for the
17 representative only at meetings of committees, as provided
18 for in subsection (f).
19 (8) [One representative] Two representatives of
20 physicians, appointed by the Governor from a list of [three]
21 five qualified physician representatives recommended jointly
22 by the Pennsylvania Medical Society and the Pennsylvania
23 Osteopathic Medical Society. The [representative]
24 representatives under this paragraph may each appoint two
25 additional delegates to act for the representative only at
26 meetings of committees, as provided for in subsection (f).
27 (8.1) One representative of nurses, appointed by the
28 Governor from a list of three qualified representatives
29 recommended by the Pennsylvania State Nurses Association.
30 (9) One representative of the Blue Cross and Blue Shield
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1 plans in Pennsylvania, appointed by the Governor from a list
2 of three qualified persons recommended jointly by the Blue
3 Cross and Blue Shield plans of Pennsylvania.
4 (10) One representative of commercial insurance
5 carriers, appointed by the Governor from a list of three
6 qualified persons recommended by the Insurance Federation of
7 Pennsylvania, Inc.
8 (11) One representative of health maintenance
9 organizations, appointed by the Governor from a list of three
10 qualified persons recommended by the [Pennsylvania
11 Association of Health Maintenance Organizations] Managed Care
12 Association of Pennsylvania.
13 (12) In the case of each appointment to be made from a
14 list supplied by a specified organization, it is incumbent
15 upon that organization to consult with and provide a list
16 which reflects the input of other equivalent organizations
17 representing similar interests. Each appointing authority
18 will have the discretion to request additions to the list
19 originally submitted. Additional names will be provided not
20 later than 15 days after such request. Appointments shall be
21 made by the appointing authority no later than 90 days after
22 receipt of the original list. If, for any reason, any
23 specified organization supplying a list should cease to
24 exist, then the respective appointing authority shall specify
25 a new equivalent organization to fulfill the responsibilities
26 of this act.
27 * * *
28 (d) Quorum.--[Eleven] Fifteen members, [a majority] six of
29 which in any combination shall be made up of representatives of
30 business and labor, shall constitute a quorum for the
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1 transaction of any business, and the act by the majority of the
2 members present at any meeting in which there is a quorum shall
3 be deemed to be the act of the council.
4 * * *
5 (f) Bylaws.--The council shall adopt bylaws, not
6 inconsistent with this act, and may appoint such committees or
7 elect such officers subordinate to those provided for in
8 subsection (c) as it deems advisable. The council shall provide
9 for the approval and participation of additional delegates
10 appointed under subsection [(b)(7)] (b)(3.1), (7) and (8) so
11 that each [organization] member represented by delegates under
12 those paragraphs shall not have more than one vote on any
13 committee to which they are appointed. The council shall also
14 appoint a technical advisory group which shall, on an ad hoc
15 basis, respond to issues presented to it by the council or
16 committees of the council and shall make recommendations to the
17 council. The technical advisory group shall include physicians,
18 researchers and biostatisticians. In appointing the technical
19 advisory group, the council shall consult with and take
20 nominations from the representatives of the Hospital Association
21 of Pennsylvania, the Pennsylvania Medical Society, the
22 Pennsylvania Osteopathic Medical Society or other like
23 organizations. At its discretion, nominations shall be approved
24 by the executive committee of the council. The Hospital and
25 Healthsystem Association of Pennsylvania and the Pennsylvania
26 Medical Society shall each be afforded one representative not
27 subject to executive committee approval. If the subject matter
28 of any project exceeds the expertise of the technical advisory
29 group, physicians in appropriate specialties who possess current
30 knowledge of the issue under study may be consulted. The
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1 technical advisory group shall also review the availability and
2 reliability of severity of illness measurements as they relate
3 to small hospitals and psychiatric, rehabilitation and
4 children's hospitals and shall make recommendations to the
5 council based upon this review.
6 * * *
7 Section 5. Powers and duties of the council.
8 * * *
9 (b) Rules and regulations.--The council [may, in a manner
10 provided by law,] shall promulgate rules and regulations in
11 accordance with the act of June 25, 1982 (P.L.633, No.181),
12 known as the Regulatory Review Act, necessary to carry out its
13 duties under this act.
14 * * *
15 (d) General duties and functions.--The council is hereby
16 authorized to and shall perform the following duties and
17 functions:
18 * * *
19 [(11) Adopt, within one year, a model patient itemized
20 statement for all providers, which itemizes all charges for
21 services, equipment, supplies and medicine, designed to be
22 more understandable than current patient bills. Each provider
23 shall be required to utilize said model patient itemized
24 statement for covered services within 90 days of adoption of
25 said form by the council. Such model patient itemized
26 statements shall be written in language that is
27 understandable to the average person and be presented to each
28 patient upon discharge from a health care facility or
29 provision of patient services or within a reasonable time
30 thereafter. Patients may request a copy of their Pennsylvania
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1 Uniform Claims and Billing Form, and, upon request, the
2 provider shall furnish this form to the patient within 30
3 days.]
4 * * *
5 Section 2. Section 6(a) and (d) of the act are amended and
6 the section is amended by adding a subsection to read:
7 Section 6. Data submission and collection.
8 (a) Submission of data.--
9 (1) The council is hereby authorized to collect and data
10 sources are hereby required to submit, upon request of the
11 council, all data required in this section, according to
12 uniform submission formats, coding systems and other
13 technical specifications necessary to render the incoming
14 data substantially valid, consistent, compatible and
15 manageable using electronic data processing according to data
16 submission schedules, such schedules to avoid, to the extent
17 possible, submission of identical data from more than one
18 data source, established and promulgated by the council in
19 regulations pursuant to its authority under section 5(b). If
20 payor data is requested by the council, it shall, to the
21 extent possible, be obtained from primary payor sources.
22 (2) Within 90 days of the effective date of this
23 paragraph, the council shall publish in the Pennsylvania
24 Bulletin a list of diseases, procedures or medical
25 conditions, not to exceed 75, for which data required under
26 subsections (c)(21) and (d) shall be required. The chosen
27 list shall not represent more than 50% of total hospital
28 admissions, based upon the previous year's data. Subsequent
29 to the publication of said list, any data submission
30 requirements under subsections (c)(21) and (d), previously in
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1 effect, will be null and void for any diseases, procedures or
2 medical conditions not contained on said list. All other data
3 elements shall continue to be required from data sources. The
4 council shall review this list at least once annually and may
5 adjust the list of diseases, procedures or medical
6 conditions, subject to the original limitation of 75
7 diseases, procedures or medical conditions and 50% of total
8 hospital admissions.
9 * * *
10 (d) [Provider quality] Quality and [provider] service
11 effectiveness data elements.--In carrying out its duty to
12 collect data on provider quality and provider service
13 effectiveness under section 5(d)(4) and subsection (c)(21), the
14 council shall define a methodology to measure provider service
15 effectiveness which may include additional data elements to be
16 specified by the council sufficient to carry out its
17 responsibilities under section 5(d)(4). The council may adopt a
18 nationally recognized methodology of quantifying and collecting
19 data on provider quality and provider service effectiveness
20 until such time as the council has the capability of developing
21 its own methodology and standard data elements. The council
22 shall include in the Pennsylvania Uniform Claims and Billing
23 Form a field consisting of the data elements required pursuant
24 to subsection (c)(21) to provide information on each provision
25 of covered services sufficient to permit analysis of provider
26 quality and provider service effectiveness within 180 days of
27 commencement of its operations pursuant to section 4. In
28 carrying out its responsibilities, the council may not require
29 health care insurers to report on additional data elements that
30 are not reported to nationally recognized accrediting
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1 organizations or to the Department of Health or the Insurance
2 Department in quarterly or annual reports. The council may not
3 require reporting by health care insurers in different formats
4 than are required for reporting to nationally recognized
5 accrediting organizations or on quarterly or annual reports
6 submitted to the Department of Health or the Insurance
7 Department as required by regulations of either department. The
8 council may adopt the quality findings as reported to nationally
9 recognized accrediting organizations.
10 * * *
11 (f.1) Review and correction of data.--The council shall
12 provide a reasonable period for data sources to review and
13 correct the data submitted by them under section 6 that the
14 council intends to prepare and issue in reports to the General
15 Assembly, to the general public or in special studies and
16 reports under section 11. When corrections are provided, the
17 council shall correct the appropriate data in its data files and
18 subsequent reports.
19 * * *
20 Section 3. Sections 7(a), 10(b)(5) and 12(b) of the act are
21 amended to read:
22 Section 7. Data dissemination and publication.
23 [(a) Public reports.--Subject to the restrictions on access
24 to council data set forth in section 10 and utilizing the data
25 collected under section 6 as well as other data, records and
26 matters of record available to it, the council shall prepare and
27 issue reports to the General Assembly and to the general public,
28 according to the following provisions:
29 (1) The council shall, for every provider within the
30 Commonwealth and within appropriate regions and subregions
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1 within the Commonwealth and for those inpatient and
2 outpatient services which, when ranked by order of frequency,
3 account for at least 65% of all covered services and which,
4 when ranked by order of total payments, account for at least
5 65% of total payments, prepare and issue reports that at
6 least provide information on the following:
7 (i) Comparisons among all providers of payments
8 received, charges, population-based admission or
9 incidence rates, and provider service effectiveness, such
10 comparisons to be grouped according to diagnosis and
11 severity, and to identify each provider by name and type
12 or specialty.
13 (ii) Comparisons among all providers, except
14 physicians, of inpatient and outpatient charges and
15 payments for room and board, ancillary services, drugs,
16 equipment and supplies and total services, such
17 comparisons to be grouped according to provider quality
18 and provider service effectiveness and according to
19 diagnosis and severity, and to identify each health care
20 facility by name and type.
21 (iii) Until and unless a methodology to measure
22 provider quality and provider service effectiveness
23 pursuant to sections 5(d)(4) and 6(c) and (d) is
24 available to the council, comparisons among all
25 providers, grouped according to diagnosis, procedure and
26 severity, which identify facilities by name and type and
27 physicians by name and specialty, of charges and payments
28 received, readmission rates, mortality rates, morbidity
29 rates and infection rates. Following adoption of the
30 methodology specified in sections 5(d)(4) and 6(c) and
20030S0387B1040 - 10 -
1 (d), the council may, at its discretion, discontinue
2 publication of this component of the report.
3 (iv) The incidence rate of selected medical or
4 surgical procedures, the provider service effectiveness
5 and the payments received for those providers, identified
6 by the name and type or specialty, for which these
7 elements vary significantly from the norms for all
8 providers.
9 (2) In preparing its reports under paragraph (1), the
10 council shall ensure that factors which have the effect of
11 either reducing provider revenue or increasing provider
12 costs, and other factors beyond a provider's control which
13 reduce provider competitiveness in the market place, are
14 explained in the reports. It shall also ensure that any
15 clarifications and dissents submitted by individual providers
16 under section 6(g) are noted in any reports that include
17 release of data on that individual provider.
18 (3) The council shall, for all providers within the
19 Commonwealth and within appropriate regions and subregions
20 within the Commonwealth, prepare and issue quarterly reports
21 that at least provide information on the number of
22 physicians, by speciality, on the staff of each hospital or
23 ambulatory service facility and those physicians on the staff
24 that accept Medicare assignment as full payment and that
25 accept Medical Assistance patients.
26 (4) The council shall publish all reports required in
27 this section in the Pennsylvania Bulletin and shall publish,
28 in at least one newspaper of general circulation in each
29 subregion within the Commonwealth, reports on the providers
30 in that subregion and subregions adjacent to it. In addition,
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1 the council shall advertise annually the availability of
2 these reports and the charge for duplication in the
3 Pennsylvania Bulletin and in at least one newspaper of
4 general circulation in each subregion within the Commonwealth
5 at least once in each calendar quarter.]
6 (a) Public reports.--Subject to the restrictions on access
7 to council data set forth in section 10 and utilizing the data
8 collected under section 6 as well as other data, records and
9 matters of record available to it, the council shall prepare and
10 issue reports to the General Assembly and to the general public,
11 according to the following provisions:
12 (1) The council shall, for every provider of both
13 inpatient and outpatient services within this Commonwealth
14 and within appropriate regions and subregions, prepare and
15 issue reports on provider quality and effectiveness on
16 diseases or procedures that, when ranked by volume, cost,
17 payment and high variation in outcome, represent the best
18 opportunity to improve overall provider quality, improve
19 patient safety and provide opportunities for cost reduction.
20 These reports shall provide comparative information on the
21 following:
22 (i) Differences in mortality rates; differences in
23 length of stay; differences in complication rates;
24 differences in readmission rates; differences in
25 infection rates; and other comparative outcome measures
26 the council may develop that will allow purchasers,
27 providers and consumers to make purchasing and quality
28 improvement decisions based upon quality patient care and
29 to restrain costs.
30 (ii) The incidence rate of selected medical or
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1 surgical procedures, the provider service effectiveness
2 and the payments received for those providers, identified
3 by the name and type or specialty, for which these
4 elements vary significantly from the norms for all
5 providers.
6 (2) In preparing its reports under paragraph (1), the
7 council shall ensure that factors which have the effect of
8 either reducing provider revenue or increasing provider costs
9 and other factors beyond a provider's control which reduce
10 provider competitiveness in the marketplace are explained in
11 the reports. The council shall also ensure that any
12 clarifications and dissents submitted by individual providers
13 under section 6(g) are noted in any reports that include
14 release of data on that individual provider.
15 * * *
16 Section 10. Access to council data.
17 * * *
18 (b) Limitations on access.--Unless specifically provided for
19 in this act, neither the council nor any contracting system
20 vendor shall release and no data source, person, member of the
21 public or other user of any data of the council shall gain
22 access to:
23 * * *
24 (5) Any raw data disclosing discounts or differentials
25 between payments accepted by providers for services and their
26 billed charges obtained by identified payors from identified
27 providers [unless comparable data on all other payors is also
28 released and the council determines that the release of such
29 information is not prejudicial or inequitable to any
30 individual payor or provider or group thereof. In making such
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1 determination the council shall consider that it is primarily
2 concerned with the analysis and dissemination of payments to
3 providers, not with discounts].
4 * * *
5 Section 12. Enforcement; penalty.
6 * * *
7 (b) Penalty.--
8 (1) Any person who fails to supply data pursuant to
9 section 6 [commits a misdemeanor of the third degree and
10 shall, upon conviction, be sentenced to pay a fine not to
11 exceed $1,000. Each day on which the required data is not
12 submitted constitutes a separate offense under this
13 paragraph.] may be assessed a civil penalty not to exceed
14 $1,000 for each day the data is not submitted.
15 (2) Any person who[, after being sentenced under
16 paragraph (1), fails to supply data] knowingly submits
17 inaccurate data pursuant to section 6 commits a misdemeanor
18 of the third degree and shall, upon conviction, be sentenced
19 to pay a fine of $10,000 or to imprisonment for not more than
20 five years, or both.
21 Section 4. The act is amended by adding a section to read:
22 Section 17.2. Legislative Budget and Finance Committee Report.
23 (a) General rule.--By December 31, 2006, the Legislative
24 Budget and Finance Committee shall complete a written report
25 evaluating the management, performance, visibility, awareness
26 and performance of the council and shall submit the report to
27 the Public Health and Welfare Committee of the Senate and the
28 Health and Human Services Committee of the House of
29 Representatives. The report shall determine whether the council
30 is:
20030S0387B1040 - 14 -
1 (1) Conducting authorized activities in a manner
2 consistent with accomplishing the objectives intended by the
3 General Assembly.
4 (2) Conducting activities and expending funds made
5 available in a faithful, efficient, economical and effective
6 manner.
7 (b) Contents of report.--The report shall include, but not
8 be limited to, discussion of the following criteria:
9 (1) Whether there is overlap or duplication of effort by
10 other agencies.
11 (2) Whether there is a more economical way of
12 accomplishing the objectives of the council.
13 (3) Whether there is a demonstrated need, based on
14 service to the public, for the continuing existence of the
15 council.
16 (4) Whether the operation of the council has been in the
17 public interest.
18 (5) Whether the council has encouraged public
19 participation in the making of its rules and decisions or
20 whether the council has permitted participation solely by the
21 persons its regulates.
22 (6) Whether there is an alternate, less restrictive
23 method of providing the same services to the public.
24 (7) Such other criteria as may be established by the
25 standing committees.
26 Section 5. Section 19 of the act is amended to read:
27 Section 19. Sunset.
28 This act shall expire June 30, [2003] 2009, unless reenacted
29 prior to [that date] March 31, 2009.
30 Section 6. This act shall take effect as follows:
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1 (1) The amendment of section 19 of the act shall take
2 effect immediately.
3 (2) This section shall take effect immediately.
4 (3) The remainder of this act shall take effect in 60
5 days.
6 SECTION 1. SECTIONS 4(B), (D), (F) AND (H) AND 5(B), (C) AND <--
7 (D)(4) AND (11) OF THE ACT OF JULY 8, 1986 (P.L.408, NO.89),
8 KNOWN AS THE HEALTH CARE COST CONTAINMENT ACT, REENACTED AND
9 AMENDED JUNE 28, 1993 (P.L.146, NO.34), ARE AMENDED TO READ:
10 SECTION 4. HEALTH CARE COST CONTAINMENT COUNCIL.
11 * * *
12 (B) COMPOSITION.--THE COUNCIL SHALL CONSIST OF [21] 24
13 VOTING MEMBERS, COMPOSED OF AND APPOINTED IN ACCORDANCE WITH THE
14 FOLLOWING:
15 (1) THE SECRETARY OF HEALTH.
16 (2) THE SECRETARY OF PUBLIC WELFARE.
17 (3) THE INSURANCE COMMISSIONER.
18 (4) SIX REPRESENTATIVES OF THE BUSINESS COMMUNITY, AT
19 LEAST ONE OF WHOM REPRESENTS SMALL BUSINESS, WHO ARE
20 PURCHASERS OF HEALTH CARE AS DEFINED IN SECTION 3, NONE OF
21 WHICH IS PRIMARILY INVOLVED IN THE PROVISION OF HEALTH CARE
22 OR HEALTH INSURANCE, THREE OF WHICH SHALL BE APPOINTED BY THE
23 PRESIDENT PRO TEMPORE OF THE SENATE AND THREE OF WHICH SHALL
24 BE APPOINTED BY THE SPEAKER OF THE HOUSE OF REPRESENTATIVES
25 FROM A LIST OF TWELVE QUALIFIED PERSONS RECOMMENDED BY THE
26 PENNSYLVANIA CHAMBER OF BUSINESS AND INDUSTRY. THREE NOMINEES
27 SHALL BE REPRESENTATIVES OF SMALL BUSINESS.
28 (5) SIX REPRESENTATIVES OF ORGANIZED LABOR, THREE OF
29 WHICH SHALL BE APPOINTED BY THE PRESIDENT PRO TEMPORE OF THE
30 SENATE AND THREE OF WHICH SHALL BE APPOINTED BY THE SPEAKER
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1 OF THE HOUSE OF REPRESENTATIVES FROM A LIST OF TWELVE
2 QUALIFIED PERSONS RECOMMENDED BY THE PENNSYLVANIA AFL-CIO.
3 (6) ONE REPRESENTATIVE OF CONSUMERS WHO IS NOT PRIMARILY
4 INVOLVED IN THE PROVISION OF HEALTH CARE OR HEALTH CARE
5 INSURANCE, APPOINTED BY THE GOVERNOR FROM A LIST OF THREE
6 QUALIFIED PERSONS RECOMMENDED JOINTLY BY THE SPEAKER OF THE
7 HOUSE OF REPRESENTATIVES AND THE PRESIDENT PRO TEMPORE OF THE
8 SENATE.
9 (7) [ONE REPRESENTATIVE] THREE REPRESENTATIVES OF
10 HOSPITALS, APPOINTED BY THE GOVERNOR FROM A LIST OF [THREE]
11 FIVE QUALIFIED HOSPITAL REPRESENTATIVES RECOMMENDED BY THE
12 HOSPITAL AND HEALTH SYSTEM ASSOCIATION OF PENNSYLVANIA.
13 REPRESENTATIVES UNDER THIS PARAGRAPH SHALL INCLUDE ONE
14 REPRESENTATIVE OF ACADEMIC TEACHING HOSPITALS AND ONE
15 REPRESENTATIVE OF RURAL HOSPITALS. [THE] EACH REPRESENTATIVE
16 UNDER THIS PARAGRAPH MAY APPOINT TWO ADDITIONAL DELEGATES TO
17 ACT FOR THE REPRESENTATIVE ONLY AT MEETINGS OF COMMITTEES, AS
18 PROVIDED FOR IN SUBSECTION (F).
19 (8) ONE REPRESENTATIVE OF PHYSICIANS, APPOINTED BY THE
20 GOVERNOR FROM A LIST OF THREE QUALIFIED PHYSICIAN
21 REPRESENTATIVES RECOMMENDED JOINTLY BY THE PENNSYLVANIA
22 MEDICAL SOCIETY AND THE PENNSYLVANIA OSTEOPATHIC MEDICAL
23 SOCIETY. THE REPRESENTATIVE UNDER THIS PARAGRAPH MAY APPOINT
24 TWO ADDITIONAL DELEGATES TO ACT FOR THE REPRESENTATIVE ONLY
25 AT MEETINGS OF COMMITTEES, AS PROVIDED FOR IN SUBSECTION (F).
26 (9) ONE REPRESENTATIVE OF NURSES, APPOINTED BY THE
27 GOVERNOR FROM A LIST OF THREE QUALIFIED REPRESENTATIVES
28 RECOMMENDED BY THE PENNSYLVANIA STATE NURSES ASSOCIATION.
29 [(9)] (10) ONE REPRESENTATIVE OF THE BLUE CROSS AND BLUE
30 SHIELD PLANS IN PENNSYLVANIA, APPOINTED BY THE GOVERNOR FROM
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1 A LIST OF THREE QUALIFIED PERSONS RECOMMENDED JOINTLY BY THE
2 BLUE CROSS AND BLUE SHIELD PLANS OF PENNSYLVANIA.
3 [(10)] (11) ONE REPRESENTATIVE OF COMMERCIAL INSURANCE
4 CARRIERS, APPOINTED BY THE GOVERNOR FROM A LIST OF THREE
5 QUALIFIED PERSONS RECOMMENDED BY THE INSURANCE FEDERATION OF
6 PENNSYLVANIA, INC.
7 [(11)] (12) ONE REPRESENTATIVE OF HEALTH MAINTENANCE
8 ORGANIZATIONS, APPOINTED BY THE GOVERNOR FROM A LIST OF THREE
9 QUALIFIED PERSONS RECOMMENDED BY THE [PENNSYLVANIA
10 ASSOCIATION OF HEALTH MAINTENANCE ORGANIZATIONS] MANAGED CARE
11 ASSOCIATION OF PENNSYLVANIA.
12 [(12)] (13) IN THE CASE OF EACH APPOINTMENT TO BE MADE
13 FROM A LIST SUPPLIED BY A SPECIFIED ORGANIZATION, IT IS
14 INCUMBENT UPON THAT ORGANIZATION TO CONSULT WITH AND PROVIDE
15 A LIST WHICH REFLECTS THE INPUT OF OTHER EQUIVALENT
16 ORGANIZATIONS REPRESENTING SIMILAR INTERESTS. EACH APPOINTING
17 AUTHORITY WILL HAVE THE DISCRETION TO REQUEST ADDITIONS TO
18 THE LIST ORIGINALLY SUBMITTED. ADDITIONAL NAMES WILL BE
19 PROVIDED NOT LATER THAN 15 DAYS AFTER SUCH REQUEST.
20 APPOINTMENTS SHALL BE MADE BY THE APPOINTING AUTHORITY NO
21 LATER THAN 90 DAYS AFTER RECEIPT OF THE ORIGINAL LIST. IF,
22 FOR ANY REASON, ANY SPECIFIED ORGANIZATION SUPPLYING A LIST
23 SHOULD CEASE TO EXIST, THEN THE RESPECTIVE APPOINTING
24 AUTHORITY SHALL SPECIFY A NEW EQUIVALENT ORGANIZATION TO
25 FULFILL THE RESPONSIBILITIES OF THIS ACT.
26 * * *
27 (D) QUORUM.--[ELEVEN] THIRTEEN MEMBERS, A MAJORITY OF WHICH
28 IN ANY COMBINATION SHALL BE MADE UP OF REPRESENTATIVES OF
29 BUSINESS AND LABOR, SHALL CONSTITUTE A QUORUM FOR THE
30 TRANSACTION OF ANY BUSINESS, AND THE ACT BY THE MAJORITY OF THE
20030S0387B1040 - 18 -
1 MEMBERS PRESENT AT ANY MEETING IN WHICH THERE IS A QUORUM SHALL
2 BE DEEMED TO BE THE ACT OF THE COUNCIL.
3 * * *
4 (F) BYLAWS.--THE COUNCIL SHALL ADOPT BYLAWS, NOT
5 INCONSISTENT WITH THIS ACT, AND MAY APPOINT SUCH COMMITTEES OR
6 ELECT SUCH OFFICERS SUBORDINATE TO THOSE PROVIDED FOR IN
7 SUBSECTION (C) AS IT DEEMS ADVISABLE. THE COUNCIL SHALL PROVIDE
8 FOR THE APPROVAL AND PARTICIPATION OF ADDITIONAL DELEGATES
9 APPOINTED UNDER SUBSECTION (B)(7) AND (8) SO THAT EACH
10 ORGANIZATION REPRESENTED BY DELEGATES UNDER THOSE PARAGRAPHS
11 SHALL NOT HAVE MORE THAN ONE VOTE ON ANY COMMITTEE TO WHICH THEY
12 ARE APPOINTED. THE COUNCIL SHALL ALSO APPOINT A TECHNICAL
13 ADVISORY GROUP WHICH SHALL, ON AN AD HOC BASIS, RESPOND TO
14 ISSUES PRESENTED TO IT BY THE COUNCIL OR COMMITTEES OF THE
15 COUNCIL AND SHALL MAKE RECOMMENDATIONS TO THE COUNCIL. THE
16 TECHNICAL ADVISORY GROUP SHALL INCLUDE [PHYSICIANS, RESEARCHERS
17 AND BIOSTATISTICIANS. IN APPOINTING THE TECHNICAL ADVISORY
18 GROUP, THE COUNCIL SHALL CONSULT WITH AND TAKE NOMINATIONS FROM
19 THE REPRESENTATIVES OF THE HOSPITAL ASSOCIATION OF PENNSYLVANIA,
20 THE PENNSYLVANIA MEDICAL SOCIETY, THE PENNSYLVANIA OSTEOPATHIC
21 MEDICAL SOCIETY OR OTHER LIKE ORGANIZATIONS.] AT A MINIMUM ONE
22 PHYSICIAN, ONE NURSE, ONE HEALTH RESEARCHER, ONE
23 BIOSTATISTICIAN, ONE HOSPITAL REPRESENTATIVE, ONE REPRESENTATIVE
24 OF A HEALTH CARE PLAN, ONE HEALTH ECONOMIST AND ONE
25 REPRESENTATIVE OF THE PUBLIC HEALTH SECTOR. AT ITS DISCRETION,
26 NOMINATIONS SHALL BE APPROVED BY THE EXECUTIVE COMMITTEE OF THE
27 COUNCIL. THE HOSPITAL AND HEALTHSYSTEM ASSOCIATION OF
28 PENNSYLVANIA AND THE PENNSYLVANIA MEDICAL SOCIETY SHALL EACH BE
29 AFFORDED ONE REPRESENTATIVE NOT SUBJECT TO EXECUTIVE COMMITTEE
30 APPROVAL. IF THE SUBJECT MATTER OF ANY PROJECT EXCEEDS THE
20030S0387B1040 - 19 -
1 EXPERTISE OF THE TECHNICAL ADVISORY GROUP, PHYSICIANS IN
2 APPROPRIATE SPECIALTIES WHO POSSESS CURRENT KNOWLEDGE OF THE
3 ISSUE UNDER STUDY MAY BE CONSULTED. THE TECHNICAL ADVISORY GROUP
4 SHALL ALSO REVIEW THE AVAILABILITY AND RELIABILITY OF SEVERITY
5 OF ILLNESS MEASUREMENTS AS THEY RELATE TO SMALL HOSPITALS AND
6 PSYCHIATRIC, REHABILITATION AND CHILDREN'S HOSPITALS AND SHALL
7 MAKE RECOMMENDATIONS TO THE COUNCIL BASED UPON THIS REVIEW.
8 * * *
9 (H) TERMS OF COUNCIL MEMBERS.--
10 (1) THE TERMS OF THE SECRETARY OF HEALTH, THE SECRETARY
11 OF PUBLIC WELFARE AND THE INSURANCE COMMISSIONER SHALL BE
12 CONCURRENT WITH THEIR HOLDING OF PUBLIC OFFICE. THE
13 [EIGHTEEN] TWENTY-ONE APPOINTED COUNCIL MEMBERS SHALL EACH
14 SERVE FOR A TERM OF [THREE] FOUR YEARS AND SHALL CONTINUE TO
15 SERVE THEREAFTER UNTIL THEIR SUCCESSOR IS APPOINTED, EXCEPT
16 THAT, OF THE MEMBERS FIRST APPOINTED:
17 (I) TWO EACH OF THE REPRESENTATIVES OF BUSINESS AND
18 ORGANIZED LABOR AND THE REPRESENTATIVE OF CONSUMERS SHALL
19 SERVE FOR A TERM TO EXPIRE ON JUNE 30 OF THE YEAR
20 FOLLOWING THEIR APPOINTMENT.
21 (II) TWO EACH OF THE REPRESENTATIVES OF BUSINESS AND
22 ORGANIZED LABOR AND THE REPRESENTATIVES OF THE BLUE CROSS
23 AND BLUE SHIELD PLANS OF PENNSYLVANIA AND THE COMMERCIAL
24 INSURANCE CARRIERS SHALL SERVE FOR A TERM TO EXPIRE ON
25 JUNE 30 OF THE SECOND YEAR FOLLOWING THEIR APPOINTMENT.
26 (III) TWO EACH OF THE REPRESENTATIVES OF BUSINESS
27 AND ORGANIZED LABOR AND THE REPRESENTATIVES OF HOSPITALS,
28 PHYSICIANS AND HEALTH MAINTENANCE ORGANIZATIONS SHALL
29 SERVE FOR A TERM TO EXPIRE ON JUNE 30 OF THE THIRD YEAR
30 FOLLOWING THEIR APPOINTMENT.
20030S0387B1040 - 20 -
1 (2) VACANCIES ON THE COUNCIL SHALL BE FILLED IN THE SAME
2 MANNER IN WHICH THEY WERE ORIGINALLY DESIGNATED UNDER
3 SUBSECTION (B), WITHIN 60 DAYS OF THE VACANCY, EXCEPT THAT
4 WHEN VACANCIES OCCUR AMONG THE REPRESENTATIVES OF BUSINESS OR
5 ORGANIZED LABOR, TWO NOMINATIONS SHALL BE SUBMITTED BY THE
6 ORGANIZATION SPECIFIED IN SUBSECTION (B) FOR EACH VACANCY ON
7 THE COUNCIL. IF THE OFFICER REQUIRED IN SUBSECTION (B) TO
8 MAKE APPOINTMENTS TO THE COUNCIL FAILS TO ACT WITHIN 60 DAYS
9 OF THE VACANCY, THE COUNCIL CHAIRPERSON MAY APPOINT ONE OF
10 THE PERSONS RECOMMENDED FOR THE VACANCY UNTIL THE APPOINTING
11 AUTHORITY MAKES THE APPOINTMENT.
12 (3) A MEMBER MAY BE REMOVED FOR JUST CAUSE BY THE
13 APPOINTING AUTHORITY AFTER RECOMMENDATION BY A VOTE OF AT
14 LEAST 14 MEMBERS OF THE COUNCIL.
15 (4) NO APPOINTED MEMBER SHALL BE ELIGIBLE TO SERVE MORE
16 THAN TWO FULL CONSECUTIVE TERMS OF FOUR YEARS BEGINNING ON
17 JULY 1, 2003.
18 * * *
19 SECTION 5. POWERS AND DUTIES OF THE COUNCIL.
20 * * *
21 (B) RULES AND REGULATIONS.--THE COUNCIL [MAY, IN A MANNER
22 PROVIDED BY LAW, PROMULGATE RULES AND REGULATIONS] SHALL
23 PROMULGATE RULES AND REGULATIONS IN ACCORDANCE WITH THE ACT OF
24 JUNE 25, 1982 (P.L.633, NO.181), KNOWN AS THE REGULATORY REVIEW
25 ACT, NECESSARY TO CARRY OUT ITS DUTIES UNDER THIS ACT.
26 (C) [AUDIT POWERS.--THE COUNCIL SHALL HAVE THE RIGHT TO
27 INDEPENDENTLY AUDIT ALL INFORMATION REQUIRED TO BE SUBMITTED BY
28 DATA SOURCES AS NEEDED TO CORROBORATE THE ACCURACY OF THE
29 SUBMITTED DATA, PURSUANT TO THE FOLLOWING:
30 (1) AUDITS OF INFORMATION SUBMITTED BY PROVIDERS OR
20030S0387B1040 - 21 -
1 HEALTH CARE INSURERS SHALL BE PERFORMED ON A SAMPLE AND
2 ISSUE-SPECIFIC BASIS, AS NEEDED BY THE COUNCIL, AND SHALL BE
3 COORDINATED, TO THE EXTENT PRACTICABLE, WITH AUDITS PERFORMED
4 BY THE COMMONWEALTH. ALL HEALTH CARE INSURERS AND PROVIDERS
5 ARE HEREBY REQUIRED TO MAKE THOSE BOOKS, RECORDS OF ACCOUNTS
6 AND ANY OTHER DATA NEEDED BY THE AUDITORS AVAILABLE TO THE
7 COUNCIL AT A CONVENIENT LOCATION WITHIN 30 DAYS OF A WRITTEN
8 NOTIFICATION BY THE COUNCIL.
9 (2) AUDITS OF INFORMATION SUBMITTED BY PURCHASERS SHALL
10 BE PERFORMED ON A SAMPLE BASIS, UNLESS THERE EXISTS
11 REASONABLE CAUSE TO AUDIT SPECIFIC PURCHASERS, BUT IN NO CASE
12 SHALL THE COUNCIL HAVE THE POWER TO AUDIT FINANCIAL
13 STATEMENTS OF PURCHASERS.
14 (3) ALL AUDITS PERFORMED BY THE COUNCIL SHALL BE
15 PERFORMED AT THE EXPENSE OF THE COUNCIL.]
16 VERIFICATION OF DATA.--THE COUNCIL SHALL REQUIRE ATTESTATION BY
17 DATA SOURCES AS TO THE ACCURACY OF THE SUBMITTED DATA. ANY
18 PERSON WHO SUBMITS INACCURATE DATA SHALL BE SUBJECT TO CIVIL
19 PENALTY UNDER THIS ACT.
20 (D) GENERAL DUTIES AND FUNCTIONS.--THE COUNCIL IS HEREBY
21 AUTHORIZED TO AND SHALL PERFORM THE FOLLOWING DUTIES AND
22 FUNCTIONS:
23 * * *
24 (4) ADOPT AND IMPLEMENT A METHODOLOGY TO [COLLECT AND]
25 DISSEMINATE DATA REFLECTING PROVIDER QUALITY AND PROVIDER
26 SERVICE EFFECTIVENESS PURSUANT TO SECTION 6 [AND TO
27 CONTINUOUSLY STUDY QUALITY OF CARE SYSTEMS].
28 * * *
29 [(11) ADOPT, WITHIN ONE YEAR, A MODEL PATIENT ITEMIZED
30 STATEMENT FOR ALL PROVIDERS, WHICH ITEMIZES ALL CHARGES FOR
20030S0387B1040 - 22 -
1 SERVICES, EQUIPMENT, SUPPLIES AND MEDICINE, DESIGNED TO BE
2 MORE UNDERSTANDABLE THAN CURRENT PATIENT BILLS. EACH PROVIDER
3 SHALL BE REQUIRED TO UTILIZE SAID MODEL PATIENT ITEMIZED
4 STATEMENT FOR COVERED SERVICES WITHIN 90 DAYS OF ADOPTION OF
5 SAID FORM BY THE COUNCIL. SUCH MODEL PATIENT ITEMIZED
6 STATEMENTS SHALL BE WRITTEN IN LANGUAGE THAT IS
7 UNDERSTANDABLE TO THE AVERAGE PERSON AND BE PRESENTED TO EACH
8 PATIENT UPON DISCHARGE FROM A HEALTH CARE FACILITY OR
9 PROVISION OF PATIENT SERVICES OR WITHIN A REASONABLE TIME
10 THEREAFTER. PATIENTS MAY REQUEST A COPY OF THEIR PENNSYLVANIA
11 UNIFORM CLAIMS AND BILLING FORM, AND, UPON REQUEST, THE
12 PROVIDER SHALL FURNISH THIS FORM TO THE PATIENT WITHIN 30
13 DAYS.]
14 * * *
15 SECTION 2. SECTION 6(A), (C)(19), (20) AND (21), (D) AND (F)
16 OF THE ACT ARE AMENDED AND THE SECTION IS AMENDED BY ADDING A
17 SUBSECTION TO READ:
18 SECTION 6. DATA SUBMISSION AND COLLECTION.
19 (A) (1) SUBMISSION OF DATA.--THE COUNCIL IS HEREBY
20 AUTHORIZED TO COLLECT AND DATA SOURCES ARE HEREBY REQUIRED TO
21 SUBMIT, UPON REQUEST OF THE COUNCIL, ALL DATA REQUIRED IN
22 THIS SECTION, ACCORDING TO UNIFORM SUBMISSION FORMATS, CODING
23 SYSTEMS AND OTHER TECHNICAL SPECIFICATIONS NECESSARY TO
24 RENDER THE INCOMING DATA SUBSTANTIALLY VALID, CONSISTENT,
25 COMPATIBLE AND MANAGEABLE USING ELECTRONIC DATA PROCESSING
26 ACCORDING TO DATA SUBMISSION SCHEDULES, SUCH SCHEDULES TO
27 AVOID, TO THE EXTENT POSSIBLE, SUBMISSION OF IDENTICAL DATA
28 FROM MORE THAN ONE DATA SOURCE, ESTABLISHED AND PROMULGATED
29 BY THE COUNCIL IN REGULATIONS PURSUANT TO ITS AUTHORITY UNDER
30 SECTION 5(B). IF PAYOR DATA IS REQUESTED BY THE COUNCIL, IT
20030S0387B1040 - 23 -
1 SHALL, TO THE EXTENT POSSIBLE, BE OBTAINED FROM PRIMARY PAYOR
2 SOURCES.
3 (2) ON AND AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH,
4 THE COUNCIL MAY ADD OTHER ADDITIONAL DATA ELEMENTS SO LONG AS
5 THEY ARE PROMULGATED AS REGULATIONS IN ACCORDANCE WITH
6 SECTION 5(B). PRIOR TO APPROVING REGULATIONS ADDING ANY SUCH
7 DATA ELEMENTS, THE INDEPENDENT REGULATORY REVIEW COMMISSION
8 SHALL CONSIDER THE FOLLOWING FACTORS:
9 (I) UTILIZATION OF SAMPLING TO THE MAXIMUM EXTENT
10 POSSIBLE;
11 (II) FEASIBILITY OF COLLECTING THE DATA ELEMENTS;
12 (III) COSTS AND BENEFITS OF COLLECTION AND
13 SUBMISSION OF DATA; AND
14 (IV) THE EXCHANGE OF DATA ELEMENTS AS OPPOSED TO THE
15 ADDITION OF DATA ELEMENTS.
16 (3) ADDITIONAL DATA REGARDING SPECIFIC CLINICAL
17 FINDINGS, FOR SPECIAL STUDIES AND REPORTS, MAY BE COLLECTED.
18 THESE ADDITIONAL DATA ELEMENTS SHALL BE REQUIRED ONLY WHEN
19 THE COUNCIL PUBLISHES REPORTS THAT IDENTIFY INDIVIDUAL
20 PHYSICIANS PROVIDING THE SERVICES INCLUDED IN THE REPORT OR
21 STUDY. THE COUNCIL SHALL DETERMINE THE SUBJECT OR SUBJECTS OF
22 THESE STUDIES AND REPORTS IN ADVANCE. THE COUNCIL SHALL ADD
23 NO MORE THAN A NET OF 15 DATA ELEMENTS DIRECTLY OR INDIRECTLY
24 TO THE HEALTH CARE FACILITY DATA SET OVER ANY FIVE-YEAR
25 PERIOD. ELEMENTS, IN THE CASE OF HEALTH CARE FACILITIES,
26 INCLUDED IN THE MANUAL DEVELOPED BY THE NATIONAL UNIFORM
27 BILLING COMMITTEE, SHALL BE EXEMPT FROM THE 15-ELEMENT NET
28 LIMIT.
29 * * *
30 (C) DATA ELEMENTS.--FOR EACH COVERED SERVICE PERFORMED IN
20030S0387B1040 - 24 -
1 PENNSYLVANIA, THE COUNCIL SHALL BE REQUIRED TO COLLECT THE
2 FOLLOWING DATA ELEMENTS:
3 * * *
4 (19) UNIFORM IDENTIFIER FOR PAYOR GROUP CONTRACT NUMBER;
5 AND
6 (20) PATIENT DISCHARGE STATUS[; AND].
7 [(21) PROVIDER SERVICE EFFECTIVENESS AND PROVIDER
8 QUALITY PURSUANT TO SECTION 5(D)(4) AND SUBSECTION (D).]
9 (D) [PROVIDER QUALITY AND PROVIDER SERVICE EFFECTIVENESS
10 DATA ELEMENTS.--IN CARRYING OUT ITS DUTY TO COLLECT DATA ON
11 PROVIDER QUALITY AND PROVIDER SERVICE EFFECTIVENESS UNDER
12 SECTION 5(D)(4) AND SUBSECTION (C)(21), THE COUNCIL SHALL DEFINE
13 A METHODOLOGY TO MEASURE PROVIDER SERVICE EFFECTIVENESS WHICH
14 MAY INCLUDE ADDITIONAL DATA ELEMENTS TO BE SPECIFIED BY THE
15 COUNCIL SUFFICIENT TO CARRY OUT ITS RESPONSIBILITIES UNDER
16 SECTION 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.] QUALITY AND SERVICE
27 EFFECTIVENESS DATA ELEMENTS.--EXCEPT AS PROVIDED IN SECTION 5
28 AND SUBSECTION (A)(2):
29 (1) THE COUNCIL MAY ADOPT A NATIONALLY RECOGNIZED
30 METHODOLOGY FOR INTERNAL USE BY THE STAFF OF THE COUNCIL TO
20030S0387B1040 - 25 -
1 ADJUST THE DATA SUBMITTED UNDER SUBSECTION (C) FOR SEVERITY
2 OF ILLNESS. EVERY THREE YEARS, THE COUNCIL SHALL SOLICIT BIDS
3 FROM THIRD-PARTY VENDORS TO ADJUST THE DATA SUBMITTED TO THE
4 COUNCIL. THE SOLICITATION SHALL BE IN ACCORDANCE WITH 62
5 PA.C.S. (RELATING TO PROCUREMENT). IN CARRYING OUT ITS
6 RESPONSIBILITIES, THE COUNCIL SHALL NOT REQUIRE HEALTH CARE
7 FACILITIES TO REPORT DATA ELEMENTS WHICH ARE NOT INCLUDED IN
8 THE MANUAL DEVELOPED BY THE NATIONAL UNIFORM BILLING
9 COMMITTEE.
10 (2) IN CARRYING OUT ITS RESPONSIBILITIES, THE COUNCIL
11 SHALL NOT REQUIRE HEALTH CARE INSURERS TO REPORT ON DATA
12 ELEMENTS THAT ARE NOT REPORTED TO NATIONALLY RECOGNIZED
13 ACCREDITING ORGANIZATIONS, TO THE DEPARTMENT OF HEALTH OR TO
14 THE INSURANCE DEPARTMENT IN QUARTERLY OR ANNUAL REPORTS. THE
15 COUNCIL SHALL NOT REQUIRE REPORTING BY HEALTH CARE INSURERS
16 IN DIFFERENT FORMATS THAN ARE REQUIRED FOR REPORTING TO
17 NATIONALLY RECOGNIZED ACCREDITING ORGANIZATIONS OR ON
18 QUARTERLY OR ANNUAL REPORTS SUBMITTED TO THE DEPARTMENT OF
19 HEALTH OR TO THE INSURANCE DEPARTMENT. THE COUNCIL MAY ADOPT
20 THE QUALITY FINDINGS AS REPORTED TO NATIONALLY RECOGNIZED
21 ACCREDITING ORGANIZATIONS.
22 * * *
23 (F) OTHER DATA REQUIRED TO BE SUBMITTED.--PROVIDERS [ARE
24 HEREBY] MAY BE REQUIRED TO SUBMIT AND THE COUNCIL IS HEREBY
25 AUTHORIZED TO COLLECT, IN ACCORDANCE WITH SUBMISSION DATES AND
26 SCHEDULES ESTABLISHED BY THE COUNCIL, THE FOLLOWING ADDITIONAL
27 DATA, PROVIDED SUCH DATA IS NOT AVAILABLE TO THE COUNCIL FROM
28 PUBLIC RECORDS:
29 (1) AUDITED ANNUAL FINANCIAL REPORTS OF ALL HOSPITALS
30 AND AMBULATORY SERVICE FACILITIES PROVIDING COVERED SERVICES
20030S0387B1040 - 26 -
1 AS DEFINED IN SECTION 3.
2 (2) THE MEDICARE COST REPORT (OMB FORM 2552 OR
3 EQUIVALENT FEDERAL FORM), OR THE AG-12 FORM FOR MEDICAL
4 ASSISTANCE OR SUCCESSOR FORMS, WHETHER COMPLETED OR PARTIALLY
5 COMPLETED, AND INCLUDING THE SETTLED MEDICARE COST REPORT AND
6 THE CERTIFIED AG-12 FORM.
7 [(3) ADDITIONAL DATA, INCLUDING, BUT NOT LIMITED TO,
8 DATA WHICH CAN BE USED TO PROVIDE AT LEAST THE FOLLOWING
9 INFORMATION:
10 (I) THE INCIDENCE OF MEDICAL AND SURGICAL PROCEDURES
11 IN THE POPULATION FOR INDIVIDUAL PROVIDERS;
12 (II) PHYSICIANS WHO PROVIDE COVERED SERVICES AND
13 ACCEPT MEDICAL ASSISTANCE PATIENTS;
14 (III) PHYSICIANS WHO PROVIDE COVERED SERVICES AND
15 ACCEPT MEDICARE ASSIGNMENT AS FULL PAYMENT;
16 (V) MORTALITY RATES FOR SPECIFIED DIAGNOSES AND
17 TREATMENTS, GROUPED BY SEVERITY, FOR INDIVIDUAL
18 PROVIDERS;
19 (VI) RATES OF INFECTION FOR SPECIFIED DIAGNOSES AND
20 TREATMENTS, GROUPED BY SEVERITY, FOR INDIVIDUAL
21 PROVIDERS;
22 (VII) MORBIDITY RATES FOR SPECIFIED DIAGNOSES AND
23 TREATMENTS, GROUPED BY SEVERITY, FOR INDIVIDUAL
24 PROVIDERS;
25 (VIII) READMISSION RATES FOR SPECIFIED DIAGNOSES AND
26 TREATMENTS, GROUPED BY SEVERITY, FOR INDIVIDUAL
27 PROVIDERS; AND
28 (IX) RATE OF INCIDENCE OF POSTDISCHARGE PROFESSIONAL
29 CARE FOR SELECTED DIAGNOSES AND PROCEDURES, GROUPED BY
30 SEVERITY, FOR INDIVIDUAL PROVIDERS.
20030S0387B1040 - 27 -
1 (4) ANY OTHER DATA THE COUNCIL REQUIRES TO CARRY OUT ITS
2 RESPONSIBILITIES PURSUANT TO SECTION 5(D).]
3 * * *
4 (G.1) REVIEW AND CORRECTION OF DATA.--THE COUNCIL SHALL
5 PROVIDE A REASONABLE PERIOD FOR DATA SOURCES TO REVIEW AND
6 CORRECT THE DATA SUBMITTED UNDER SECTION 6 WHICH THE COUNCIL
7 INTENDS TO PREPARE AND ISSUE IN REPORTS TO THE GENERAL ASSEMBLY,
8 TO THE GENERAL PUBLIC OR IN SPECIAL STUDIES AND REPORTS UNDER
9 SECTION 11. WHEN CORRECTIONS ARE PROVIDED, THE COUNCIL SHALL
10 CORRECT THE APPROPRIATE DATA IN ITS DATA FILES AND SUBSEQUENT
11 REPORTS.
12 * * *
13 SECTION 3. SECTIONS 7(A), 10(B)(5), 12(B) AND 19 OF THE ACT
14 ARE AMENDED TO READ:
15 SECTION 7. DATA DISSEMINATION AND PUBLICATION.
16 [(A) PUBLIC REPORTS.--SUBJECT TO THE RESTRICTIONS ON ACCESS
17 TO COUNCIL DATA SET FORTH IN SECTION 10 AND UTILIZING THE DATA
18 COLLECTED UNDER SECTION 6 AS WELL AS OTHER DATA, RECORDS AND
19 MATTERS OF RECORD AVAILABLE TO IT, THE COUNCIL SHALL PREPARE AND
20 ISSUE REPORTS TO THE GENERAL ASSEMBLY AND TO THE GENERAL PUBLIC,
21 ACCORDING TO THE FOLLOWING PROVISIONS:
22 (1) THE COUNCIL SHALL, FOR EVERY PROVIDER WITHIN THE
23 COMMONWEALTH AND WITHIN APPROPRIATE REGIONS AND SUBREGIONS
24 WITHIN THE COMMONWEALTH AND FOR THOSE INPATIENT AND
25 OUTPATIENT SERVICES WHICH, WHEN RANKED BY ORDER OF FREQUENCY,
26 ACCOUNT FOR AT LEAST 65% OF ALL COVERED SERVICES AND WHICH,
27 WHEN RANKED BY ORDER OF TOTAL PAYMENTS, ACCOUNT FOR AT LEAST
28 65% OF TOTAL PAYMENTS, PREPARE AND ISSUE REPORTS THAT AT
29 LEAST PROVIDE INFORMATION ON THE FOLLOWING:
30 (I) COMPARISONS AMONG ALL PROVIDERS OF PAYMENTS
20030S0387B1040 - 28 -
1 RECEIVED, CHARGES, POPULATION-BASED ADMISSION OR
2 INCIDENCE RATES, AND PROVIDER SERVICE EFFECTIVENESS, SUCH
3 COMPARISONS TO BE GROUPED ACCORDING TO DIAGNOSIS AND
4 SEVERITY, AND TO IDENTIFY EACH PROVIDER BY NAME AND TYPE
5 OR SPECIALTY.
6 (II) COMPARISONS AMONG ALL PROVIDERS, EXCEPT
7 PHYSICIANS, OF INPATIENT AND OUTPATIENT CHARGES AND
8 PAYMENTS FOR ROOM AND BOARD, ANCILLARY SERVICES, DRUGS,
9 EQUIPMENT AND SUPPLIES AND TOTAL SERVICES, SUCH
10 COMPARISONS TO BE GROUPED ACCORDING TO PROVIDER QUALITY
11 AND PROVIDER SERVICE EFFECTIVENESS AND ACCORDING TO
12 DIAGNOSIS AND SEVERITY, AND TO IDENTIFY EACH HEALTH CARE
13 FACILITY BY NAME AND TYPE.
14 (III) UNTIL AND UNLESS A METHODOLOGY TO MEASURE
15 PROVIDER QUALITY AND PROVIDER SERVICE EFFECTIVENESS
16 PURSUANT TO SECTIONS 5(D)(4) AND 6(C) AND (D) IS
17 AVAILABLE TO THE COUNCIL, COMPARISONS AMONG ALL
18 PROVIDERS, GROUPED ACCORDING TO DIAGNOSIS, PROCEDURE AND
19 SEVERITY, WHICH IDENTIFY FACILITIES BY NAME AND TYPE AND
20 PHYSICIANS BY NAME AND SPECIALTY, OF CHARGES AND PAYMENTS
21 RECEIVED, READMISSION RATES, MORTALITY RATES, MORBIDITY
22 RATES AND INFECTION RATES. FOLLOWING ADOPTION OF THE
23 METHODOLOGY SPECIFIED IN SECTIONS 5(D)(4) AND 6(C) AND
24 (D), THE COUNCIL MAY, AT ITS DISCRETION, DISCONTINUE
25 PUBLICATION OF THIS COMPONENT OF THE REPORT.
26 (IV) THE INCIDENCE RATE OF SELECTED MEDICAL OR
27 SURGICAL PROCEDURES, THE PROVIDER SERVICE EFFECTIVENESS
28 AND THE PAYMENTS RECEIVED FOR THOSE PROVIDERS, IDENTIFIED
29 BY THE NAME AND TYPE OR SPECIALTY, FOR WHICH THESE
30 ELEMENTS VARY SIGNIFICANTLY FROM THE NORMS FOR ALL
20030S0387B1040 - 29 -
1 PROVIDERS.
2 (2) IN PREPARING ITS REPORTS UNDER PARAGRAPH (1), THE
3 COUNCIL SHALL ENSURE THAT FACTORS WHICH HAVE THE EFFECT OF
4 EITHER REDUCING PROVIDER REVENUE OR INCREASING PROVIDER
5 COSTS, AND OTHER FACTORS BEYOND A PROVIDER'S CONTROL WHICH
6 REDUCE PROVIDER COMPETITIVENESS IN THE MARKET PLACE, ARE
7 EXPLAINED IN THE REPORTS. IT SHALL ALSO ENSURE THAT ANY
8 CLARIFICATIONS AND DISSENTS SUBMITTED BY INDIVIDUAL PROVIDERS
9 UNDER SECTION 6(G) ARE NOTED IN ANY REPORTS THAT INCLUDE
10 RELEASE OF DATA ON THAT INDIVIDUAL PROVIDER.
11 (3) THE COUNCIL SHALL, FOR ALL PROVIDERS WITHIN THE
12 COMMONWEALTH AND WITHIN APPROPRIATE REGIONS AND SUBREGIONS
13 WITHIN THE COMMONWEALTH, PREPARE AND ISSUE QUARTERLY REPORTS
14 THAT AT LEAST PROVIDE INFORMATION ON THE NUMBER OF
15 PHYSICIANS, BY SPECIALTY, ON THE STAFF OF EACH HOSPITAL OR
16 AMBULATORY SERVICE FACILITY AND THOSE PHYSICIANS ON THE STAFF
17 THAT ACCEPT MEDICARE ASSIGNMENT AS FULL PAYMENT AND THAT
18 ACCEPT MEDICAL ASSISTANCE PATIENTS.
19 (4) THE COUNCIL SHALL PUBLISH ALL REPORTS REQUIRED IN
20 THIS SECTION IN THE PENNSYLVANIA BULLETIN AND SHALL PUBLISH,
21 IN AT LEAST ONE NEWSPAPER OF GENERAL CIRCULATION IN EACH
22 SUBREGION WITHIN THE COMMONWEALTH, REPORTS ON THE PROVIDERS
23 IN THAT SUBREGION AND SUBREGIONS ADJACENT TO IT. IN ADDITION,
24 THE COUNCIL SHALL ADVERTISE ANNUALLY THE AVAILABILITY OF
25 THESE REPORTS AND THE CHARGE FOR DUPLICATION IN THE
26 PENNSYLVANIA BULLETIN AND IN AT LEAST ONE NEWSPAPER OF
27 GENERAL CIRCULATION IN EACH SUBREGION WITHIN THE COMMONWEALTH
28 AT LEAST ONCE IN EACH CALENDAR QUARTER.]
29 (A) PUBLIC REPORTS.--SUBJECT TO THE RESTRICTIONS ON ACCESS
30 TO COUNCIL DATA SET FORTH IN SECTION 10 AND UTILIZING THE DATA
20030S0387B1040 - 30 -
1 COLLECTED UNDER SECTION 6 AS WELL AS OTHER DATA, RECORDS AND
2 MATTERS OF RECORD AVAILABLE TO IT, THE COUNCIL SHALL PREPARE AND
3 ISSUE REPORTS TO THE GENERAL ASSEMBLY AND TO THE GENERAL PUBLIC,
4 ACCORDING TO THE FOLLOWING PROVISIONS:
5 (1) THE COUNCIL SHALL, FOR EVERY PROVIDER OF BOTH
6 INPATIENT AND OUTPATIENT SERVICES WITHIN THIS COMMONWEALTH
7 AND WITHIN APPROPRIATE REGIONS AND SUBREGIONS, PREPARE AND
8 ISSUE REPORTS ON PROVIDER QUALITY AND SERVICE EFFECTIVENESS
9 ON DISEASES OR PROCEDURES THAT, WHEN RANKED BY VOLUME, COST,
10 PAYMENT AND HIGH VARIATION IN OUTCOME, REPRESENT THE BEST
11 OPPORTUNITY TO IMPROVE OVERALL PROVIDER QUALITY, IMPROVE
12 PATIENT SAFETY AND PROVIDE OPPORTUNITIES FOR COST REDUCTION.
13 THESE REPORTS SHALL PROVIDE COMPARATIVE INFORMATION ON THE
14 FOLLOWING:
15 (I) DIFFERENCES IN MORTALITY RATES; DIFFERENCES IN
16 LENGTH OF STAY; DIFFERENCES IN COMPLICATION RATES;
17 DIFFERENCES IN READMISSION RATES; DIFFERENCES IN
18 INFECTION RATES; AND OTHER COMPARATIVE OUTCOME MEASURES
19 THE COUNCIL MAY DEVELOP THAT WILL ALLOW PURCHASERS,
20 PROVIDERS AND CONSUMERS TO MAKE PURCHASING AND QUALITY
21 IMPROVEMENT DECISIONS BASED UPON QUALITY PATIENT CARE AND
22 TO RESTRAIN COSTS.
23 (II) THE INCIDENCE RATE OF SELECTED MEDICAL OR
24 SURGICAL PROCEDURES, THE QUALITY AND SERVICE
25 EFFECTIVENESS AND THE PAYMENTS RECEIVED FOR THOSE
26 PROVIDERS, IDENTIFIED BY THE NAME AND TYPE OR SPECIALTY,
27 FOR WHICH THESE ELEMENTS VARY SIGNIFICANTLY FROM THE
28 NORMS FOR ALL PROVIDERS.
29 (2) IN PREPARING ITS REPORTS UNDER PARAGRAPH (1), THE
30 COUNCIL SHALL ENSURE THAT FACTORS WHICH HAVE THE EFFECT OF
20030S0387B1040 - 31 -
1 EITHER REDUCING PROVIDER REVENUE OR INCREASING PROVIDER COSTS
2 AND OTHER FACTORS BEYOND A PROVIDER'S CONTROL WHICH REDUCE
3 PROVIDER COMPETITIVENESS IN THE MARKETPLACE ARE EXPLAINED IN
4 THE REPORTS. THE COUNCIL SHALL ALSO ENSURE THAT ANY
5 CLARIFICATIONS AND DISSENTS SUBMITTED BY INDIVIDUAL PROVIDERS
6 UNDER SECTION 6(G) ARE NOTED IN ANY REPORTS THAT INCLUDE
7 RELEASE OF DATA ON THAT INDIVIDUAL PROVIDER.
8 * * *
9 SECTION 10. ACCESS TO COUNCIL DATA.
10 * * *
11 (B) LIMITATIONS ON ACCESS.--UNLESS SPECIFICALLY PROVIDED FOR
12 IN THIS ACT, NEITHER THE COUNCIL NOR ANY CONTRACTING SYSTEM
13 VENDOR SHALL RELEASE AND NO DATA SOURCE, PERSON, MEMBER OF THE
14 PUBLIC OR OTHER USER OF ANY DATA OF THE COUNCIL SHALL GAIN
15 ACCESS TO:
16 * * *
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 [COMPARABLE DATA ON ALL OTHER PAYORS IS ALSO
21 RELEASED] THE DATA IS RELEASED IN A STATEWIDE, AGGREGATE
22 FORMAT THAT DOES NOT IDENTIFY ANY INDIVIDUAL PAYOR OR CLASS
23 OF PAYORS AND THE COUNCIL [DETERMINES] ASSURES THAT THE
24 RELEASE OF SUCH INFORMATION IS NOT PREJUDICIAL OR INEQUITABLE
25 TO ANY INDIVIDUAL PAYOR OR PROVIDER OR GROUP THEREOF. [IN
26 MAKING SUCH DETERMINATION THE COUNCIL SHALL CONSIDER THAT IT
27 IS PRIMARILY CONCERNED WITH THE ANALYSIS AND DISSEMINATION OF
28 PAYMENTS TO PROVIDERS, NOT WITH DISCOUNTS.]
29 * * *
30 SECTION 12. ENFORCEMENT; PENALTY.
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1 * * *
2 (B) PENALTY.--
3 (1) ANY PERSON WHO FAILS TO SUPPLY DATA PURSUANT TO
4 SECTION 6 [COMMITS A MISDEMEANOR OF THE THIRD DEGREE AND
5 SHALL, UPON CONVICTION, BE SENTENCED TO PAY A FINE NOT TO
6 EXCEED $1,000. EACH DAY ON WHICH THE REQUIRED DATA IS NOT
7 SUBMITTED CONSTITUTES A SEPARATE OFFENSE UNDER THIS
8 PARAGRAPH.] MAY BE ASSESSED A CIVIL PENALTY NOT TO EXCEED
9 $1,000 FOR EACH DAY THE DATA IS NOT SUBMITTED.
10 (2) [ANY PERSON WHO, AFTER BEING SENTENCED UNDER
11 PARAGRAPH (1), FAILS TO SUPPLY DATA PURSUANT TO SECTION 6
12 COMMITS A MISDEMEANOR OF THE THIRD DEGREE AND SHALL, UPON
13 CONVICTION, BE SENTENCED TO PAY A FINE OF $10,000 OR TO
14 IMPRISONMENT FOR NOT MORE THAN FIVE YEARS, OR BOTH.] ANY
15 PERSON WHO KNOWINGLY SUBMITS INACCURATE DATA COMMITS A
16 MISDEMEANOR OF THE THIRD DEGREE AND SHALL, UPON CONVICTION,
17 BE SENTENCED TO PAY A FINE OF $10,000 OR TO IMPRISONMENT FOR
18 NOT MORE THAN FIVE YEARS, OR BOTH.
19 SECTION 19. SUNSET.
20 THIS ACT SHALL EXPIRE JUNE 30, [2003] 2009, UNLESS REENACTED
21 PRIOR TO [THAT DATE.] SEPTEMBER 1, 2008. BY MARCH 1, 2008, A
22 WRITTEN REPORT BY THE LEGISLATIVE BUDGET AND FINANCE COMMITTEE
23 EVALUATING THE MANAGEMENT, VISIBILITY, AWARENESS AND PERFORMANCE
24 OF THE COUNCIL SHALL BE PROVIDED TO THE PUBLIC HEALTH AND
25 WELFARE COMMITTEE OF THE SENATE AND THE HEALTH AND HUMAN
26 SERVICES COMMITTEE OF THE HOUSE OF REPRESENTATIVES. THE REPORT
27 SHALL INCLUDE A REVIEW OF THE COUNCIL'S PROCEDURES AND POLICIES,
28 THE AVAILABILITY AND QUALITY OF DATA FOR COMPLETING REPORTS TO
29 HOSPITALS AND OUTSIDE VENDOR PURCHASERS; THE ABILITY OF THE
30 COUNCIL TO BECOME SELF-SUFFICIENT BY SELLING DATA TO OUTSIDE
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1 PURCHASERS; WHETHER THERE IS A MORE COST-EFFICIENT WAY OF
2 ACCOMPLISHING THE OBJECTIVES OF THE COUNCIL AND THE NEED FOR
3 REAUTHORIZATION OF THE COUNCIL.
4 SECTION 4. THIS ACT SHALL TAKE EFFECT IMMEDIATELY.
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