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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY EACHUS, FEBRUARY 2, 2009 |
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| REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 2, 2009 |
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| AN ACT |
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1 | Amending the act of July 8, 1986 (P.L.408, No.89), entitled, as |
2 | reenacted, "An act providing for the creation of the Health |
3 | Care Cost Containment Council, for its powers and duties, for |
4 | health care cost containment through the collection and |
5 | dissemination of data, for public accountability of health |
6 | care costs and for health care for the indigent; and making |
7 | an appropriation," further providing for definitions, for the |
8 | council and its powers and duties, for data submission, |
9 | collection, dissemination and publication, for health care |
10 | for the medically indigent, for mandated health benefits, for |
11 | access to council data, for special studies and reports, |
12 | enforcement and penalties, for research and demonstration |
13 | projects, for grievances and grievance procedures, for |
14 | antitrust, for contracts with vendors and for reporting; |
15 | providing for establishment of a health care cost containment |
16 | council act review committee; and further providing for |
17 | severability and for sunset. |
18 | The General Assembly of the Commonwealth of Pennsylvania |
19 | hereby enacts as follows: |
20 | Section 1. The title and sections 1 and 2 of the act of July |
21 | 8, 1986 (P.L.408, No.89), known as the Health Care Cost |
22 | Containment Act, reenacted and amended July 17, 2003 (P.L.31, |
23 | No.14), are reenacted to read: |
24 | AN ACT |
25 | Providing for the creation of the Health Care Cost Containment |
26 | Council, for its powers and duties, for health care cost |
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1 | containment through the collection and dissemination of data, |
2 | for public accountability of health care costs and for health |
3 | care for the indigent; and making an appropriation. |
4 | Section 1. Short title. |
5 | This act shall be known and may be cited as the Health Care |
6 | Cost Containment Act. |
7 | Section 2. Legislative finding and declaration. |
8 | The General Assembly finds that there exists in this |
9 | Commonwealth a major crisis because of the continuing escalation |
10 | of costs for health care services. Because of the continuing |
11 | escalation of costs, an increasingly large number of |
12 | Pennsylvania citizens have severely limited access to |
13 | appropriate and timely health care. Increasing costs are also |
14 | undermining the quality of health care services currently being |
15 | provided. Further, the continuing escalation is negatively |
16 | affecting the economy of this Commonwealth, is restricting new |
17 | economic growth and is impeding the creation of new job |
18 | opportunities in this Commonwealth. |
19 | The continuing escalation of health care costs is |
20 | attributable to a number of interrelated causes, including: |
21 | (1) Inefficiency in the present configuration of health |
22 | care service systems and in their operation. |
23 | (2) The present system of health care cost payments by |
24 | third parties. |
25 | (3) The increasing burden of indigent care which |
26 | encourages cost shifting. |
27 | (4) The absence of a concentrated and continuous effort |
28 | in all segments of the health care industry to contain health |
29 | care costs. |
30 | Therefore, it is hereby declared to be the policy of the |
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1 | Commonwealth of Pennsylvania to promote health care cost |
2 | containment and to identify appropriate utilization practices by |
3 | creating an independent council to be known as the Health Care |
4 | Cost Containment Council. |
5 | It is the purpose of this legislation to promote the public |
6 | interest by encouraging the development of competitive health |
7 | care services in which health care costs are contained and to |
8 | assure that all citizens have reasonable access to quality |
9 | health care. |
10 | It is further the intent of this act to facilitate the |
11 | continuing provision of quality, cost-effective health services |
12 | throughout the Commonwealth by providing current, accurate data |
13 | and information to the purchasers and consumers of health care |
14 | on both cost and quality of health care services and to public |
15 | officials for the purpose of determining health-related programs |
16 | and policies and to assure access to health care services. |
17 | Nothing in this act shall prohibit a purchaser from obtaining |
18 | from its third-party insurer, carrier or administrator, nor |
19 | relieve said third-party insurer, carrier or administrator from |
20 | the obligation of providing, on terms consistent with past |
21 | practices, data previously provided to a purchaser pursuant to |
22 | any existing or future arrangement, agreement or understanding. |
23 | Section 2. Sections 3, 4, 5 and 6 of the act are reenacted |
24 | and amended to read: |
25 | Section 3. Definitions. |
26 | The following words and phrases when used in this act shall |
27 | have the meanings given to them in this section unless the |
28 | context clearly indicates otherwise: |
29 | "Ambulatory service facility." A facility licensed in this |
30 | Commonwealth, not part of a hospital, which provides medical, |
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1 | diagnostic or surgical treatment to patients not requiring |
2 | hospitalization, including ambulatory surgical facilities, |
3 | ambulatory imaging or diagnostic centers, birthing centers, |
4 | freestanding emergency rooms and any other facilities providing |
5 | ambulatory care which charge a separate facility charge. This |
6 | term does not include the offices of private physicians or |
7 | dentists, whether for individual or group practices. |
8 | "Charge" or "rate." The amount billed by a provider for |
9 | specific goods or services provided to a patient, prior to any |
10 | adjustment for contractual allowances. |
11 | "Committee." The Health Care Cost Containment Council Act |
12 | Review Committee. |
13 | "Council." The Health Care Cost Containment Council. |
14 | "Covered services." Any health care services or procedures |
15 | connected with episodes of illness that require either inpatient |
16 | hospital care or major ambulatory service such as surgical, |
17 | medical or major radiological procedures, including any initial |
18 | and follow-up outpatient services associated with the episode of |
19 | illness before, during or after inpatient hospital care or major |
20 | ambulatory service. The term does not include routine outpatient |
21 | services connected with episodes of illness that do not require |
22 | hospitalization or major ambulatory service. |
23 | "Data source." A hospital; ambulatory service facility; |
24 | physician; health maintenance organization as defined in the act |
25 | of December 29, 1972 (P.L.1701, No.364), known as the Health |
26 | Maintenance Organization Act; hospital, medical or health |
27 | service plan with a certificate of authority issued by the |
28 | Insurance Department, including, but not limited to, hospital |
29 | plan corporations as defined in 40 Pa.C.S. Ch. 61 (relating to |
30 | hospital plan corporations) and professional health services |
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1 | plan corporations as defined in 40 Pa.C.S. Ch. 63 (relating to |
2 | professional health services plan corporations); commercial |
3 | insurer with a certificate of authority issued by the Insurance |
4 | Department providing health or accident insurance; self-insured |
5 | employer providing health or accident coverage or benefits for |
6 | employees employed in the Commonwealth; administrator of a self- |
7 | insured or partially self-insured health or accident plan |
8 | providing covered services in the Commonwealth; any health and |
9 | welfare fund that provides health or accident benefits or |
10 | insurance pertaining to covered service in the Commonwealth; the |
11 | Department of Public Welfare for those covered services it |
12 | purchases or provides through the medical assistance program |
13 | under the act of June 13, 1967 (P.L.31, No.21), known as the |
14 | Public Welfare Code, and any other payor for covered services in |
15 | the Commonwealth other than an individual. |
16 | "Health care facility." A general or special hospital, |
17 | including tuberculosis and psychiatric hospitals, kidney disease |
18 | treatment centers, including freestanding hemodialysis units, |
19 | and ambulatory service facilities as defined in this section, |
20 | and hospices, both profit and nonprofit, and including those |
21 | operated by an agency of State or local government. |
22 | "Health care insurer." Any person, corporation or other |
23 | entity that offers administrative, indemnity or payment services |
24 | for health care in exchange for a premium or service charge |
25 | under a program of health care benefits, including, but not |
26 | limited to, an insurance company, association or exchange |
27 | issuing health insurance policies in this Commonwealth; hospital |
28 | plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to |
29 | hospital plan corporations); professional health services plan |
30 | corporation as defined in 40 Pa.C.S. Ch. 63 (relating to |
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1 | professional health services plan corporations); health |
2 | maintenance organization; preferred provider organization; |
3 | fraternal benefit societies; beneficial societies; and third- |
4 | party administrators; but excluding employers, labor unions or |
5 | health and welfare funds jointly or separately administered by |
6 | employers or labor unions that purchase or self-fund a program |
7 | of health care benefits for their employees or members and their |
8 | dependents. |
9 | "Health maintenance organization." An organized system which |
10 | combines the delivery and financing of health care and which |
11 | provides basic health services to voluntarily enrolled |
12 | subscribers for a fixed prepaid fee, as defined in the act of |
13 | December 29, 1972 (P.L.1701, No.364), known as the Health |
14 | Maintenance Organization Act. |
15 | "Hospital." An institution, licensed in this Commonwealth, |
16 | which is a general, tuberculosis, mental, chronic disease or |
17 | other type of hospital, or kidney disease treatment center, |
18 | whether profit or nonprofit, and including those operated by an |
19 | agency of State or local government. |
20 | "Indigent care." The actual costs, as determined by the |
21 | council, for the provision of appropriate health care, on an |
22 | inpatient or outpatient basis, given to individuals who cannot |
23 | pay for their care because they are above the medical assistance |
24 | eligibility levels and have no health insurance or other |
25 | financial resources which can cover their health care. |
26 | "Major ambulatory service." Surgical or medical procedures, |
27 | including diagnostic and therapeutic radiological procedures, |
28 | commonly performed in hospitals or ambulatory service |
29 | facilities, which are not of a type commonly performed or which |
30 | cannot be safely performed in physicians' offices and which |
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1 | require special facilities such as operating rooms or suites or |
2 | special equipment such as fluoroscopic equipment or computed |
3 | tomographic scanners, or a postprocedure recovery room or short- |
4 | term convalescent room. |
5 | "Medical procedure incidence variations." The variation in |
6 | the incidence in the population of specific medical, surgical |
7 | and radiological procedures in any given year, expressed as a |
8 | deviation from the norm, as these terms are defined in the |
9 | classical statistical definition of "variation," "incidence," |
10 | "deviation" and "norm." |
11 | "Medically indigent" or "indigent." The status of a person |
12 | as described in the definition of indigent care. |
13 | "Payment." The payments that providers actually accept for |
14 | their services, exclusive of charity care, rather than the |
15 | charges they bill. |
16 | "Payor." Any person or entity, including, but not limited |
17 | to, health care insurers and purchasers, that make direct |
18 | payments to providers for covered services. |
19 | "Physician." An individual licensed under the laws of this |
20 | Commonwealth to practice medicine and surgery within the scope |
21 | of the act of October 5, 1978 (P.L.1109, No.261), known as the |
22 | Osteopathic Medical Practice Act, or the act of December 20, |
23 | 1985 (P.L.457, No.112), known as the Medical Practice Act of |
24 | 1985. |
25 | "Preferred provider organization." Any arrangement between a |
26 | health care insurer and providers of health care services which |
27 | specifies rates of payment to such providers which differ from |
28 | their usual and customary charges to the general public and |
29 | which encourage enrollees to receive health services from such |
30 | providers. |
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1 | "Provider." A hospital, an ambulatory service facility or a |
2 | physician. |
3 | "Provider quality." The extent to which a provider renders |
4 | care that, within the capabilities of modern medicine, obtains |
5 | for patients medically acceptable health outcomes and prognoses, |
6 | adjusted for patient severity, and treats patients |
7 | compassionately and responsively. |
8 | "Provider service effectiveness." The effectiveness of |
9 | services rendered by a provider, determined by measurement of |
10 | the medical outcome of patients grouped by severity receiving |
11 | those services. |
12 | "Purchaser." All corporations, labor organizations and other |
13 | entities that purchase benefits which provide covered services |
14 | for their employees or members, either through a health care |
15 | insurer or by means of a self-funded program of benefits, and a |
16 | certified bargaining representative that represents a group or |
17 | groups of employees for whom employers purchase a program of |
18 | benefits which provide covered services, but excluding entities |
19 | defined in this section as "health care insurers." |
20 | "Raw data" or "data." Data collected by the council under |
21 | section 6 in the form initially received. No data shall be |
22 | released by the council except as provided for in section 11. |
23 | "Severity." In any patient, the measureable degree of the |
24 | potential for failure of one or more vital organs. |
25 | Section 4. Health Care Cost Containment Council. |
26 | (a) Establishment.--The General Assembly hereby establishes |
27 | an independent council to be known as the Health Care Cost |
28 | Containment Council. |
29 | (b) Composition.--The council shall consist of voting |
30 | members, composed of and appointed in accordance with the |
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1 | following: |
2 | (1) The Secretary of Health. |
3 | (2) The Secretary of Public Welfare. |
4 | (3) The Insurance Commissioner. |
5 | (4) Six representatives of the business community, at |
6 | least one of whom represents small business, who are |
7 | purchasers of health care as defined in section 3, none of |
8 | which is primarily involved in the provision of health care |
9 | or health insurance, three of which shall be appointed by the |
10 | President pro tempore of the Senate and three of which shall |
11 | be appointed by the Speaker of the House of Representatives |
12 | from a list of twelve qualified persons recommended by the |
13 | Pennsylvania Chamber of Business and Industry. Three nominees |
14 | shall be representatives of small business. |
15 | (5) Six representatives of organized labor, three of |
16 | which shall be appointed by the President pro tempore of the |
17 | Senate and three of which shall be appointed by the Speaker |
18 | of the House of Representatives from a list of twelve |
19 | qualified persons recommended by the Pennsylvania AFL-CIO. |
20 | (6) One representative of consumers who is not primarily |
21 | involved in the provision of health care or health care |
22 | insurance, appointed by the Governor from a list of three |
23 | qualified persons recommended jointly by the Speaker of the |
24 | House of Representatives and the President pro tempore of the |
25 | Senate. |
26 | (7) Two representatives of hospitals, appointed by the |
27 | Governor from a list of five qualified hospital |
28 | representatives recommended by the Hospital and Health System |
29 | Association of Pennsylvania one of whom shall be a |
30 | representative of rural hospitals. Each representative under |
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1 | this paragraph may appoint two additional delegates to act |
2 | for the representative only at meetings of committees, as |
3 | provided for in subsection (f). |
4 | (8) Two representatives of physicians, appointed by the |
5 | Governor from a list of five qualified physician |
6 | representatives recommended jointly by the Pennsylvania |
7 | Medical Society and the Pennsylvania Osteopathic Medical |
8 | Society. The representative under this paragraph may appoint |
9 | two additional delegates to act for the representative only |
10 | at meetings of committees, as provided for in subsection (f). |
11 | (8.1) An individual appointed by the Governor who has |
12 | expertise in the application of continuous quality |
13 | improvement methods in hospitals. |
14 | (8.2) One representative of nurses, appointed by the |
15 | Governor from a list of three qualified representatives |
16 | recommended by the Pennsylvania State Nurses Association. |
17 | (9) One representative of the Blue Cross and Blue Shield |
18 | plans in Pennsylvania, appointed by the Governor from a list |
19 | of three qualified persons recommended jointly by the Blue |
20 | Cross and Blue Shield plans of Pennsylvania. |
21 | (10) One representative of commercial insurance |
22 | carriers, appointed by the Governor from a list of three |
23 | qualified persons recommended by the Insurance Federation of |
24 | Pennsylvania, Inc. |
25 | (11) One representative of health maintenance |
26 | organizations, appointed by the Governor [from a list of |
27 | three qualified persons recommended by the Managed Care |
28 | Association of Pennsylvania]. |
29 | (12) In the case of each appointment to be made from a |
30 | list supplied by a specified organization, it is incumbent |
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1 | upon that organization to consult with and provide a list |
2 | which reflects the input of other equivalent organizations |
3 | representing similar interests. Each appointing authority |
4 | will have the discretion to request additions to the list |
5 | originally submitted. Additional names will be provided not |
6 | later than 15 days after such request. Appointments shall be |
7 | made by the appointing authority no later than 90 days after |
8 | receipt of the original list. If, for any reason, any |
9 | specified organization supplying a list should cease to |
10 | exist, then the respective appointing authority shall specify |
11 | a new equivalent organization to fulfill the responsibilities |
12 | of this act. |
13 | (c) Chairperson and vice chairperson.--The members shall |
14 | annually elect, by a majority vote of the members, a chairperson |
15 | and a vice chairperson of the council from among the business |
16 | and labor representatives on the council. |
17 | (d) Quorum.--Thirteen members, at least six of whom must be |
18 | made up of representatives of business and labor, shall |
19 | constitute a quorum for the transaction of any business, and the |
20 | act by the majority of the members present at any meeting in |
21 | which there is a quorum shall be deemed to be the act of the |
22 | council. |
23 | (e) Meetings.--All meetings of the council shall be |
24 | advertised and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating |
25 | to open meetings), unless otherwise provided in this section. |
26 | (1) The council shall meet at least once every two |
27 | months, and may provide for special meetings as it deems |
28 | necessary. Meeting dates shall be set by a majority vote of |
29 | the members of the council or by the call of the chairperson |
30 | upon seven days' notice to all council members. |
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1 | (2) All meetings of the council shall be publicly |
2 | advertised, as provided for in this subsection, and shall be |
3 | open to the public, except that the council, through its |
4 | bylaws, may provide for executive sessions of the council on |
5 | subjects permitted to be discussed in such sessions under 65 |
6 | Pa.C.S. Ch. 7. No act of the council shall be taken in an |
7 | executive session. |
8 | (3) The council shall publish a schedule of its meetings |
9 | in the Pennsylvania Bulletin and in at least one newspaper in |
10 | general circulation in the Commonwealth. Such notice shall be |
11 | published at least once in each calendar quarter and shall |
12 | list the schedule of meetings of the council to be held in |
13 | the subsequent calendar quarter. Such notice shall specify |
14 | the date, time and place of the meeting and shall state that |
15 | the council's meetings are open to the general public, except |
16 | that no such notice shall be required for executive sessions |
17 | of the council. |
18 | (4) All action taken by the council shall be taken in |
19 | open public session, and action of the council shall not be |
20 | taken except upon the affirmative vote of a majority of the |
21 | members of the council present during meetings at which a |
22 | quorum is present. |
23 | (f) Bylaws.--The council shall adopt bylaws, not |
24 | inconsistent with this act, and may appoint such committees or |
25 | elect such officers subordinate to those provided for in |
26 | subsection (c) as it deems advisable. The council shall provide |
27 | for the approval and participation of additional delegates |
28 | appointed under subsection (b)(7) and (8) so that each |
29 | organization represented by delegates under those paragraphs |
30 | shall not have more than one vote on any committee to which they |
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1 | are appointed. The council shall also appoint a technical |
2 | advisory group which shall, on an ad hoc basis, respond to |
3 | issues presented to it by the council or committees of the |
4 | council and shall make recommendations to the council. The |
5 | technical advisory group shall include physicians, researchers, |
6 | biostatisticians, one representative of the Hospital and |
7 | Healthsystem Association of Pennsylvania and one representative |
8 | of the Pennsylvania Medical Society. The Hospital and |
9 | Healthsystem Association of Pennsylvania and the Pennsylvania |
10 | Medical Society representatives shall not be subject to |
11 | executive committee approval. In appointing other physicians, |
12 | researchers and biostatisticians to the technical advisory |
13 | group, the council shall consult with and take nominations from |
14 | the representatives of the Hospital Association of Pennsylvania, |
15 | the Pennsylvania Medical Society, the Pennsylvania Osteopathic |
16 | Medical Society or other like organizations. At its discretion |
17 | and in accordance with this section, nominations shall be |
18 | approved by the executive committee of the council. If the |
19 | subject matter of any project exceeds the expertise of the |
20 | technical advisory group, physicians in appropriate specialties |
21 | who possess current knowledge of the issue under study may be |
22 | consulted. The technical advisory group shall also review the |
23 | availability and reliability of severity of illness measurements |
24 | as they relate to small hospitals and psychiatric, |
25 | rehabilitation and children's hospitals and shall make |
26 | recommendations to the council based upon this review. Meetings |
27 | of the technical advisory group shall be open to the general |
28 | public. |
29 | (g) Compensation and expenses.--The members of the council |
30 | shall not receive a salary or per diem allowance for serving as |
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1 | members of the council but shall be reimbursed for actual and |
2 | necessary expenses incurred in the performance of their duties. |
3 | Said expenses may include reimbursement of travel and living |
4 | expenses while engaged in council business. |
5 | (h) Terms of council members.-- |
6 | (1) The terms of the Secretary of Health, the Secretary |
7 | of Public Welfare and the Insurance Commissioner shall be |
8 | concurrent with their holding of public office. The council |
9 | members under subsection (b)(4) through (11) shall each serve |
10 | for a term of four years and shall continue to serve |
11 | thereafter until their successor is appointed. |
12 | (2) Vacancies on the council shall be filled in the |
13 | manner designated under subsection (b), within 60 days of the |
14 | vacancy, except that when vacancies occur among the |
15 | representatives of business or organized labor, two |
16 | nominations shall be submitted by the organization specified |
17 | in subsection (b) for each vacancy on the council. If the |
18 | officer required in subsection (b) to make appointments to |
19 | the council fails to act within 60 days of the vacancy, the |
20 | council chairperson may appoint one of the persons |
21 | recommended for the vacancy until the appointing authority |
22 | makes the appointment. |
23 | (3) A member may be removed for just cause by the |
24 | appointing authority after recommendation by a vote of at |
25 | least 14 members of the council. |
26 | (4) No appointed member under subsection (b)(4) through |
27 | (11) shall be eligible to serve more than two full |
28 | consecutive terms of four years beginning on the effective |
29 | date of this paragraph. |
30 | (j) Subsequent appointments.--Submission of lists of |
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1 | recommended persons and appointments of council members for |
2 | succeeding terms shall be made in the same manner as prescribed |
3 | in subsection (b), except that: |
4 | (1) Organizations required under subsection (b) to |
5 | submit lists of recommended persons shall do so at least 60 |
6 | days prior to expiration of the council members' terms. |
7 | (2) The officer required under subsection (b) to make |
8 | appointments to the council shall make said appointments at |
9 | least 30 days prior to expiration of the council members' |
10 | terms. If the appointments are not made within the specified |
11 | time, the council chairperson may make interim appointments |
12 | from the lists of recommended individuals. An interim |
13 | appointment shall be valid only until the appropriate officer |
14 | under subsection (b) makes the required appointment. Whether |
15 | the appointment is by the required officer or by the |
16 | chairperson of the council, the appointment shall become |
17 | effective immediately upon expiration of the incumbent |
18 | member's term. |
19 | Section 5. Powers and duties of the council. |
20 | (a) General powers.--The council shall exercise all powers |
21 | necessary and appropriate to carry out its duties, including the |
22 | following: |
23 | (1) To employ an executive director, investigators and |
24 | other staff necessary to comply with the provisions of this |
25 | act and regulations promulgated thereunder, to employ or |
26 | retain legal counsel and to engage professional consultants, |
27 | as it deems necessary to the performance of its duties. Any |
28 | consultants, other than sole source consultants, engaged by |
29 | the council shall be selected in accordance with the |
30 | provisions for contracting with vendors set forth in section |
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1 | 16. |
2 | (2) To fix the compensation of all employees and to |
3 | prescribe their duties. Notwithstanding the independence of |
4 | the council under section 4(a), employees under this |
5 | paragraph shall be deemed employees of the Commonwealth for |
6 | the purposes of participation in the Pennsylvania Employee |
7 | Benefit Trust Fund. |
8 | (3) To make and execute contracts and other instruments, |
9 | including those for purchase of services and purchase or |
10 | leasing of equipment and supplies, necessary or convenient to |
11 | the exercise of the powers of the council. Any such contract |
12 | shall be let only in accordance with the provision for |
13 | contracting with vendors set forth in section 16. |
14 | (4) To conduct examinations and investigations, to |
15 | conduct audits, pursuant to the provisions of subsection (c), |
16 | and to hear testimony and take proof, under oath or |
17 | affirmation, at public or private hearings, on any matter |
18 | necessary to its duties. |
19 | (4.1) To provide hospitals with individualized data on |
20 | patient safety indicators pursuant to section 6(c)(7). The |
21 | data shall be risk adjusted and made available to hospitals |
22 | electronically and free of charge on a quarterly basis within |
23 | 45 days of receipt of the corrected quarterly data from the |
24 | hospitals. The data is intended to provide the patient safety |
25 | committee of each hospital with information necessary to |
26 | assist in conducting patient safety analysis. |
27 | (5) To do all things necessary to carry out its duties |
28 | under the provisions of this act. |
29 | (b) Rules and regulations.--The council shall promulgate |
30 | rules and regulations in accordance with the act of June 25, |
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1 | 1982 (P.L.633, No.181), known as the Regulatory Review Act, |
2 | necessary to carry out its duties under this act. This |
3 | subsection shall not apply to regulations in effect on June 30, |
4 | [2003] 2008. |
5 | (c) Audit powers.--The council shall have the right to |
6 | independently audit all information required to be submitted by |
7 | data sources as needed to corroborate the accuracy of the |
8 | submitted data, pursuant to the following: |
9 | (1) Audits of information submitted by providers or |
10 | health care insurers shall be performed on a sample and |
11 | issue-specific basis, as needed by the council, and shall be |
12 | coordinated, to the extent practicable, with audits performed |
13 | by the Commonwealth. All health care insurers and providers |
14 | are hereby required to make those books, records of accounts |
15 | and any other data needed by the auditors available to the |
16 | council at a convenient location within 30 days of a written |
17 | notification by the council. |
18 | (2) Audits of information submitted by purchasers shall |
19 | be performed on a sample basis, unless there exists |
20 | reasonable cause to audit specific purchasers, but in no case |
21 | shall the council have the power to audit financial |
22 | statements of purchasers. |
23 | (3) All audits performed by the council shall be |
24 | performed at the expense of the council. |
25 | (4) The results of audits of providers or health care |
26 | insurers shall be provided to the audited providers and |
27 | health care insurers on a timely basis, not to exceed 30 days |
28 | beyond presentation of audit findings to the council. |
29 | (d) General duties and functions.--The council is hereby |
30 | authorized to and shall perform the following duties and |
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1 | functions: |
2 | (1) Develop a computerized system for the collection, |
3 | analysis and dissemination of data. The council may contract |
4 | with a vendor who will provide such data processing services. |
5 | The council shall assure that the system will be capable of |
6 | processing all data required to be collected under this act. |
7 | Any vendor selected by the council shall be selected in |
8 | accordance with the provisions of section 16, and said vendor |
9 | shall relinquish any and all proprietary rights or claims to |
10 | the data base created as a result of implementation of the |
11 | data processing system. |
12 | (2) Establish a Pennsylvania Uniform Claims and Billing |
13 | Form for all data sources and all providers which shall be |
14 | utilized and maintained by all data sources and all providers |
15 | for all services covered under this act. |
16 | (3) Collect and disseminate data, as specified in |
17 | section 6, and other information from data sources to which |
18 | the council is entitled, prepared according to formats, time |
19 | frames and confidentiality provisions as specified in |
20 | sections 6 and 10, and by the council. |
21 | (4) Adopt and implement a methodology to collect and |
22 | disseminate data reflecting provider quality and provider |
23 | service effectiveness pursuant to section 6. |
24 | (5) Subject to the restrictions on access to raw data |
25 | set forth in section 10, issue special reports and make |
26 | available raw data as defined in section 3 to any purchaser |
27 | requesting it. Sale by any recipient or exchange or |
28 | publication by a recipient, other than a purchaser, of raw |
29 | council data to other parties without the express written |
30 | consent of, and under terms approved by, the council shall be |
|
1 | unauthorized use of data pursuant to section 10(c). |
2 | (6) On an annual basis, publish in the Pennsylvania |
3 | Bulletin a list of all the raw data reports it has prepared |
4 | under section 10(f) and a description of the data obtained |
5 | through each computer-to-computer access it has provided |
6 | under section 10(f) and of the names of the parties to whom |
7 | the council provided the reports or the computer-to-computer |
8 | access during the previous month. |
9 | (7) Promote competition in the health care and health |
10 | insurance markets. |
11 | (8) Assure that the use of council data does not raise |
12 | access barriers to care. |
13 | (10) Make annual reports to the General Assembly on the |
14 | rate of increase in the cost of health care in the |
15 | Commonwealth and the effectiveness of the council in carrying |
16 | out the legislative intent of this act. In addition, the |
17 | council may make recommendations on the need for further |
18 | health care cost containment legislation. The council shall |
19 | also make annual reports to the General Assembly on the |
20 | quality and effectiveness of health care and access to health |
21 | care for all citizens of the Commonwealth. |
22 | (12) Conduct studies and publish reports thereon |
23 | analyzing the effects that noninpatient, alternative health |
24 | care delivery systems have on health care costs. These |
25 | systems shall include, but not be limited to: HMO's; PPO's; |
26 | primary health care facilities; home health care; attendant |
27 | care; ambulatory service facilities; freestanding emergency |
28 | centers; birthing centers; and hospice care. These reports |
29 | shall be submitted to the General Assembly and shall be made |
30 | available to the public. |
|
1 | (13) Conduct studies and make reports concerning the |
2 | utilization of experimental and nonexperimental transplant |
3 | surgery and other highly technical and experimental |
4 | procedures, including costs and mortality rates. |
5 | [(14) In order to ensure that the council adopts and |
6 | maintains both scientifically credible and cost-effective |
7 | methodology to collect and disseminate data reflecting |
8 | provider quality and effectiveness, the council shall, within |
9 | one year of the effective date of this paragraph, utilizing |
10 | current Commonwealth agency guidelines and procedures, issue |
11 | a request for information from any vendor that wishes to |
12 | provide data collection or risk adjustment methodology to the |
13 | council to help meet the requirements of this subsection and |
14 | section 6. The council shall establish an independent Request |
15 | for Information Review Committee to review and rank all |
16 | responses and to make a final recommendation to the council. |
17 | The Request for Information Review Committee shall consist of |
18 | the following members appointed by the Governor: |
19 | (i) One representative of the Hospital and |
20 | Healthsystem Association of Pennsylvania. |
21 | (ii) One representative of the Pennsylvania Medical |
22 | Society. |
23 | (iii) One representative of insurance. |
24 | (iv) One representative of labor. |
25 | (v) One representative of business. |
26 | (vi) Two representatives of the general public. |
27 | (15) The council shall execute a request for proposals |
28 | with third-party vendors for the purpose of demonstrating a |
29 | methodology for the collection, analysis and reporting of |
30 | hospital-specific complication rates. The results of this |
|
1 | demonstration shall be provided to the chairman and minority |
2 | chairman of the Public Health and Welfare Committee of the |
3 | Senate and the chairman and minority chairman of the Health |
4 | and Human Services Committee of the House of Representatives. |
5 | This methodology may be utilized by the council for public |
6 | reporting on comparative hospital complication rates.] |
7 | Section 6. Data submission and collection. |
8 | (a) [(1)] 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. The |
22 | council shall not require any data sources to contract with |
23 | any specific vendor for submission of any specific data |
24 | elements to the council. |
25 | (1.1) Any data source shall comply with data submission |
26 | guidelines established in the report submitted under section |
27 | 17.2. The council shall maintain a vendor list of at least |
28 | two vendors that may be chosen by any data source for |
29 | submission of any specific data elements. |
30 | (2) Except as provided in this section, the council may |
|
1 | adopt any nationally recognized methodology to adjust data |
2 | submitted under subsection (c) for severity of illness. Every |
3 | three years after the effective date of this paragraph, the |
4 | council shall solicit bids from third-party vendors to adjust |
5 | the data. The solicitation shall be in accordance with 62 |
6 | Pa.C.S. (relating to procurement). Except as provided in |
7 | subparagraph (i), in carrying out its responsibilities, the |
8 | council shall not require health care facilities to report |
9 | data elements which are not included in the manual developed |
10 | by the national uniform billing committee. The [following |
11 | apply: |
12 | (i) Within 60 days of the effective date of this |
13 | paragraph, the] council shall publish in the Pennsylvania |
14 | Bulletin a list of diseases, procedures and medical |
15 | conditions, not to exceed 35, for which data under |
16 | subsections (c)(21) and (d) shall be required. The chosen |
17 | list shall not represent more than 50% of total hospital |
18 | discharges, based upon the previous year's hospital |
19 | discharge data. Subsequent to the publication of the |
20 | list, any data submission requirements under subsections |
21 | (c)(21) and (d) previously in effect shall be null and |
22 | void for diseases, procedures and medical conditions not |
23 | found on the list. All other data elements pursuant to |
24 | subsection (c) shall continue to be required from data |
25 | sources. The council shall review the list and may add no |
26 | more than a net of three diseases, procedures or medical |
27 | conditions per year over a five-year period starting on |
28 | the effective date of this subparagraph. The adjusted |
29 | list of diseases, procedures and medical conditions shall |
30 | at no time be more than 50% of total hospital discharges. |
|
1 | [(ii) If the current data vendor is unable to |
2 | achieve, on a per-chart basis, savings of at least 40% in |
3 | the cost of hospital compliance with the data abstracting |
4 | and submission requirements of this act by June 30, 2004, |
5 | as compared to June 30, 2003, then the council shall |
6 | disqualify the current vendor and reopen the bidding |
7 | process. The independent auditor shall determine the |
8 | extent and validity of the savings. In determining any |
9 | demonstrated cost savings, surveys of all hospitals in |
10 | this Commonwealth shall be conducted and consideration |
11 | shall be given at a minimum to: |
12 | (A) new costs, in terms of making the |
13 | methodology operational, associated with laboratory, |
14 | pharmacy and other information systems a hospital is |
15 | required to purchase in order to reduce hospital |
16 | compliance costs, including the cost of electronic |
17 | transfer of required data; and |
18 | (B) the audited direct personnel and related |
19 | costs of data abstracting and submission required. |
20 | (iii) Review by the independent auditor shall |
21 | commence by March 1, 2004, and shall conclude with a |
22 | report of findings by July 31, 2004. The report shall be |
23 | delivered to the council, the Governor, the Health and |
24 | Human Services Committee of the House of Representatives |
25 | and the Public Health and Welfare Committee of the |
26 | Senate. |
27 | (a.1) Abstraction and technology work group.-- |
28 | (1) The council shall establish a data abstraction and |
29 | technology work group to produce recommendations for |
30 | improving and refining the data required by the council and |
|
1 | reducing, through innovative direct data collection |
2 | techniques, the cost of collecting required data. The work |
3 | group shall consist of the following members appointed by the |
4 | council: |
5 | (i) one member representing the Office of Health |
6 | Care Reform; |
7 | (ii) one member representing the business community; |
8 | (iii) one member representing labor; |
9 | (iv) one member representing consumers; |
10 | (v) two members representing physicians; |
11 | (vi) two members representing nurses; |
12 | (vii) two members representing hospitals; |
13 | (viii) one member representing health underwriters; |
14 | and |
15 | (ix) one member representing commercial insurance |
16 | carriers. |
17 | (2) The work group, with approval of the council, may |
18 | hire an independent auditor to determine the value of various |
19 | data sets. The work group shall have no more than one year to |
20 | study current data requirements and methods of collecting and |
21 | transferring data and to make recommendations for changes to |
22 | produce a 50% overall reduction in the cost of collecting and |
23 | reporting required data to the council while maintaining the |
24 | scientific credibility of the council's analysis and |
25 | reporting. The work group recommendations shall be presented |
26 | to the council for a vote.] |
27 | (b) Pennsylvania Uniform Claims and Billing Form.--The |
28 | council shall [adopt, within 180 days of the commencement of its |
29 | operations pursuant to section 4(i),] maintain a Pennsylvania |
30 | Uniform Claims and Billing Form format. The council shall |
|
1 | furnish said claims and billing form format to all data sources, |
2 | and said claims and billing form shall be utilized and |
3 | maintained by all data sources for all services covered by this |
4 | act. The Pennsylvania Uniform Claims and Billing Form shall |
5 | consist of the Uniform Hospital Billing Form UB-82/HCFA-1450, |
6 | and the HCFA-1500, or their successors, as developed by the |
7 | National Uniform Billing Committee, with additional fields as |
8 | necessary to provide all of the data set forth in subsections |
9 | (c) and (d). |
10 | (c) Data elements.--For each covered service performed in |
11 | Pennsylvania, the council shall be required to collect the |
12 | following data elements: |
13 | (1) uniform patient identifier, continuous across |
14 | multiple episodes and providers; |
15 | (2) patient date of birth; |
16 | (3) patient sex; |
17 | (3.1) patient race, consistent with the method of |
18 | collection of race/ethnicity data by the United States Bureau |
19 | of the Census and the United States Standard Certificates of |
20 | Live Birth and Death; |
21 | (4) patient ZIP Code number; |
22 | (5) date of admission; |
23 | (6) date of discharge; |
24 | (7) principal and secondary diagnoses by standard code, |
25 | including external cause of injury, complication, infection |
26 | and childbirth; |
27 | (8) principal procedure by council-specified standard |
28 | code and date; |
29 | (9) up to three secondary procedures by council- |
30 | specified standard codes and dates; |
|
1 | (10) uniform health care facility identifier, continuous |
2 | across episodes, patients and providers; |
3 | (11) uniform identifier of admitting physician, by |
4 | unique physician identification number established by the |
5 | council, continuous across episodes, patients and providers; |
6 | (12) uniform identifier of consulting physicians, by |
7 | unique physician identification number established by the |
8 | council, continuous across episodes, patients and providers; |
9 | (13) total charges of health care facility, segregated |
10 | into major categories, including, but not limited to, room |
11 | and board, radiology, laboratory, operating room, drugs, |
12 | medical supplies and other goods and services according to |
13 | guidelines specified by the council; |
14 | (14) actual payments to health care facility, |
15 | segregated, if available, according to the categories |
16 | specified in paragraph (13); |
17 | (15) charges of each physician or professional rendering |
18 | service relating to an incident of hospitalization or |
19 | treatment in an ambulatory service facility; |
20 | (16) actual payments to each physician or professional |
21 | rendering service pursuant to paragraph (15); |
22 | (17) uniform identifier of primary payor; |
23 | (18) ZIP Code number of facility where health care |
24 | service is rendered; |
25 | (19) uniform identifier for payor group contract number; |
26 | (20) patient discharge status; and |
27 | (21) provider service effectiveness and provider quality |
28 | pursuant to section 5(d)(4) and subsection (d). |
29 | (d) Provider quality and provider service effectiveness data |
30 | elements.--In carrying out its duty to collect data on provider |
|
1 | quality and provider service effectiveness under section 5(d)(4) |
2 | and subsection (c)(21), the council shall define a methodology |
3 | to measure provider service effectiveness which may include |
4 | additional data elements to be specified by the council |
5 | sufficient to carry out its responsibilities under section 5(d) |
6 | (4). The council may adopt a nationally recognized methodology |
7 | of quantifying and collecting data on provider quality and |
8 | provider service effectiveness until such time as the council |
9 | has the capability of developing its own methodology and |
10 | standard data elements. The council shall include in the |
11 | Pennsylvania Uniform Claims and Billing Form a field consisting |
12 | of the data elements required pursuant to subsection (c)(21) to |
13 | provide information on each provision of covered services |
14 | sufficient to permit analysis of provider quality and provider |
15 | service effectiveness within 180 days of commencement of its |
16 | operations pursuant to section 4. In carrying out its |
17 | responsibilities, the council shall not require health care |
18 | insurers to report on data elements that are not reported to |
19 | nationally recognized accrediting organizations, to the |
20 | Department of Health or to the Insurance Department in quarterly |
21 | or annual reports. The council shall not require reporting by |
22 | health care insurers in different formats than are required for |
23 | reporting to nationally recognized accrediting organizations or |
24 | on quarterly or annual reports submitted to the Department of |
25 | Health or to the Insurance Department. The council may adopt the |
26 | quality findings as reported to nationally recognized |
27 | accrediting organizations. Additional quality data elements must |
28 | be defined and released for public comment prior to the |
29 | promulgation of regulations under section 5(b). The public |
30 | comment period shall be no less than 30 days from the release of |
|
1 | these elements. |
2 | (e) Reserve field utilization and addition or deletion of |
3 | data elements.--The council shall include in the Pennsylvania |
4 | Uniform Claims and Billing Form a reserve field. The council may |
5 | utilize the reserve field by adding other data elements beyond |
6 | those required to carry out its responsibilities under section |
7 | 5(d)(3) and (4) and subsections (c) and (d), or the council may |
8 | delete data elements from the Pennsylvania Uniform Claims and |
9 | Billing Form only by a majority vote of the council and only |
10 | pursuant to the following procedure: |
11 | (1) The council shall obtain a cost-benefit analysis of |
12 | the proposed addition or deletion which shall include the |
13 | cost to data sources of any proposed additions. |
14 | (2) The council shall publish notice of the proposed |
15 | addition or deletion, along with a copy or summary of the |
16 | cost-benefit analysis, in the Pennsylvania Bulletin, and such |
17 | notice shall include provision for a 60-day comment period. |
18 | (3) The council may hold additional hearings or request |
19 | such other reports as it deems necessary and shall consider |
20 | the comments received during the 60-day comment period and |
21 | any additional information gained through such hearings or |
22 | other reports in making a final determination on the proposed |
23 | addition or deletion. |
24 | (f) Other data required to be submitted.--Providers are |
25 | hereby required to submit and the council is hereby authorized |
26 | to collect, in accordance with submission dates and schedules |
27 | established by the council, the following additional data, |
28 | provided such data is not available to the council from public |
29 | records: |
30 | (1) Audited annual financial reports of all hospitals |
|
1 | and ambulatory service facilities providing covered services |
2 | as defined in section 3. |
3 | (2) The Medicare cost report (OMB Form 2552 or |
4 | equivalent Federal form), or the AG-12 form for Medical |
5 | Assistance or successor forms, whether completed or partially |
6 | completed, and including the settled Medicare cost report and |
7 | the certified AG-12 form. |
8 | (3) Additional data, including, but not limited to, data |
9 | which can be used to provide at least the following |
10 | information: |
11 | (i) the incidence of medical and surgical procedures |
12 | in the population for individual providers; |
13 | (ii) physicians who provide covered services and |
14 | accept medical assistance patients; |
15 | (iii) physicians who provide covered services and |
16 | accept Medicare assignment as full payment; |
17 | (v) mortality rates for specified diagnoses and |
18 | treatments, grouped by severity, for individual |
19 | providers; |
20 | (vi) rates of infection for specified diagnoses and |
21 | treatments, grouped by severity, for individual |
22 | providers; |
23 | (vii) morbidity rates for specified diagnoses and |
24 | treatments, grouped by severity, for individual |
25 | providers; |
26 | (viii) readmission rates for specified diagnoses and |
27 | treatments, grouped by severity, for individual |
28 | providers; and |
29 | (ix) rate of incidence of postdischarge professional |
30 | care for selected diagnoses and procedures, grouped by |
|
1 | severity, for individual providers. |
2 | (4) Any other data the council requires to carry out its |
3 | responsibilities pursuant to section 5(d). |
4 | (f.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 | (g) Allowance for clarification or dissents.--The council |
13 | shall maintain a file of written statements submitted by data |
14 | sources who wish to provide an explanation of data that they |
15 | feel might be misleading or misinterpreted. The council shall |
16 | provide access to such file to any person and shall, where |
17 | practical, in its reports and data files indicate the |
18 | availability of such statements. When the council agrees with |
19 | such statements, it shall correct the appropriate data and |
20 | comments in its data files and subsequent reports. |
21 | (g.1) Allowance for correction.--The council shall verify |
22 | the patient safety indicator data submitted by hospitals |
23 | pursuant to subsection (c)(7) within 60 days of receipt. The |
24 | council may allow hospitals to make changes to the data |
25 | submitted during the verification period. After the verification |
26 | period, but within 45 days of receipt of the adjusted hospital |
27 | data, the council shall risk adjust the information and provide |
28 | reports to the patient safety committee of the relevant |
29 | hospital. |
30 | (h) Availability of data.--Nothing in this act shall |
|
1 | prohibit a purchaser from obtaining from its health care |
2 | insurer, nor relieve said health care insurer from the |
3 | obligation of providing said purchaser, on terms consistent with |
4 | past practices, data previously provided or additional data not |
5 | currently provided to said purchaser by said health care insurer |
6 | pursuant to any existing or future arrangement, agreement or |
7 | understanding. |
8 | Section 3. Sections 7, 8 and 9 of the act are reenacted to |
9 | read: |
10 | Section 7. Data dissemination and publication. |
11 | (a) Public reports.--Subject to the restrictions on access |
12 | to council data set forth in section 10 and utilizing the data |
13 | collected under section 6 as well as other data, records and |
14 | matters of record available to it, the council shall prepare and |
15 | issue reports to the General Assembly and to the general public |
16 | according to the following provisions: |
17 | (1) The council shall, for every provider of both |
18 | inpatient and outpatient services within this Commonwealth |
19 | and within appropriate regions and subregions, prepare and |
20 | issue reports on provider quality and service effectiveness |
21 | on diseases or procedures that, when ranked by volume, cost, |
22 | payment and high variation in outcome, represent the best |
23 | opportunity to improve overall provider quality, improve |
24 | patient safety and provide opportunities for cost reduction. |
25 | These reports shall provide comparative information on the |
26 | following: |
27 | (i) Differences in mortality rates; differences in |
28 | length of stay; differences in complication rates; |
29 | differences in readmission rates; differences in |
30 | infection rates; and other comparative outcome measures |
|
1 | the council may develop that will allow purchasers, |
2 | providers and consumers to make purchasing and quality |
3 | improvement decisions based upon quality patient care and |
4 | to restrain costs. |
5 | (ii) The incidence rate of selected medical or |
6 | surgical procedures, the quality and service |
7 | effectiveness and the payments received for those |
8 | providers, identified by the name and type or specialty, |
9 | for which these elements vary significantly from the |
10 | norms for all providers. |
11 | (2) In preparing its reports under paragraph (1), the |
12 | council shall ensure that factors which have the effect of |
13 | either reducing provider revenue or increasing provider costs |
14 | and other factors beyond a provider's control which reduce |
15 | provider competitiveness in the marketplace are explained in |
16 | the reports. The council shall also ensure that any |
17 | clarifications and dissents submitted by individual providers |
18 | under section 6(g) are noted in any reports that include |
19 | release of data on that individual provider. |
20 | (b) Raw data reports and computer access to council data.-- |
21 | The council shall provide special reports derived from raw data |
22 | and a means for computer-to-computer access to its raw data to |
23 | any purchaser, pursuant to section 10(f). The council shall |
24 | provide such reports and computer-to-computer access, at its |
25 | discretion, to other parties, pursuant to section 10(g). The |
26 | council shall provide these special reports and computer-to- |
27 | computer access in as timely a fashion as the council's |
28 | responsibilities to publish the public reports required in this |
29 | section will allow. Any such provision of special reports or |
30 | computer-to-computer access by the council shall be made only |
|
1 | subject to the restrictions on access to raw data set forth in |
2 | section 10(b) and only after payment for costs of preparation or |
3 | duplication pursuant to section 10(f) or (g). |
4 | Section 8. Health care for the medically indigent. |
5 | (a) Declaration of policy.--The General Assembly finds that |
6 | every person in this Commonwealth should receive timely and |
7 | appropriate health care services from any provider operating in |
8 | this Commonwealth; that, as a continuing condition of licensure, |
9 | each provider should offer and provide medically necessary, |
10 | lifesaving and emergency health care services to every person in |
11 | this Commonwealth, regardless of financial status or ability to |
12 | pay; and that health care facilities may transfer patients only |
13 | in instances where the facility lacks the staff or facilities to |
14 | properly render definitive treatment. |
15 | (b) Studies on indigent care.--To reduce the undue burden on |
16 | the several providers that disproportionately treat medically |
17 | indigent people on an uncompensated basis, to contain the long- |
18 | term costs generated by untreated or delayed treatment of |
19 | illness and disease and to determine the most appropriate means |
20 | of treating and financing the treatment of medically indigent |
21 | persons, the council, at the request of the Governor or the |
22 | General Assembly, may undertake studies and utilize its current |
23 | data base to: |
24 | (1) Study and analyze the medically indigent population, |
25 | the magnitude of uncompensated care for the medically |
26 | indigent, the degree of access to and the result of any lack |
27 | of access by the medically indigent to appropriate care, the |
28 | types of providers and the settings in which they provide |
29 | indigent care and the cost of the provision of that care |
30 | pursuant to subsection (c). |
|
1 | (2) Determine, from studies undertaken under paragraph |
2 | (1), a definition of the medically indigent population and |
3 | the most appropriate method for the delivery of timely and |
4 | appropriate health care services to the medically indigent. |
5 | (c) Studies.--The council shall conduct studies pursuant to |
6 | subsection (b)(1) and thereafter report to the Governor and the |
7 | General Assembly the results of the studies and its |
8 | recommendations. The council may contract with an independent |
9 | vendor to conduct the study in accordance with the provisions |
10 | for selecting vendors in section 16. The study shall include, |
11 | but not be limited to, the following: |
12 | (1) the number and characteristics of the medically |
13 | indigent population, including such factors as income, |
14 | employment status, health status, patterns of health care |
15 | utilization, type of health care needed and utilized, |
16 | eligibility for health care insurance, distribution of this |
17 | population on a geographic basis and by age, sex and racial |
18 | or linguistic characteristics, and the changes in these |
19 | characteristics, including the following: |
20 | (i) the needs and problems of indigent persons in |
21 | urban areas; |
22 | (ii) the needs and problems of indigent persons in |
23 | rural areas; |
24 | (iii) the needs and problems of indigent persons who |
25 | are members of racial or linguistic minorities; |
26 | (iv) the needs and problems of indigent persons in |
27 | areas of high unemployment; and |
28 | (v) the needs and problems of the underinsured; |
29 | (2) the degree of and any change in access of this |
30 | population to sources of health care, including hospitals, |
|
1 | physicians and other providers; |
2 | (3) the distribution and means of financing indigent |
3 | care between and among providers, insurers, government, |
4 | purchasers and consumers, and the effect of that distribution |
5 | on each; |
6 | (4) the major types of care rendered to the indigent, |
7 | the setting in which each type of care is rendered and the |
8 | need for additional care of each type by the indigent; |
9 | (5) the likely impact of changes in the health delivery |
10 | system, including managed care entities, and the effects of |
11 | cost containment in the Commonwealth on the access to, |
12 | availability of and financing of needed care for the |
13 | indigent, including the impact on providers which provide a |
14 | disproportionate amount of care to the indigent; |
15 | (6) the distribution of delivered care and actual cost |
16 | to render such care by provider, region and subregion; |
17 | (7) the provision of care to the indigent through |
18 | improvements in the primary health care system, including the |
19 | management of needed hospital care by primary care providers; |
20 | (8) innovative means to finance and deliver care to the |
21 | medically indigent; and |
22 | (9) reduction in the dependence of indigent persons on |
23 | hospital services through improvements in preventive health |
24 | measures. |
25 | Section 9. Mandated health benefits. |
26 | In relation to current law or proposed legislation, the |
27 | council shall, upon the request of the appropriate committee |
28 | chairman in the Senate and in the House of Representatives or |
29 | upon the request of the Secretary of Health, provide information |
30 | on the proposed mandated health benefit pursuant to the |
|
1 | following: |
2 | (1) The General Assembly hereby declares that proposals |
3 | for mandated health benefits or mandated health insurance |
4 | coverage should be accompanied by adequate, independently |
5 | certified documentation defining the social and financial |
6 | impact and medical efficacy of the proposal. To that end the |
7 | council, upon receipt of such requests, is hereby authorized |
8 | to conduct a preliminary review of the material submitted by |
9 | both proponents and opponents concerning the proposed |
10 | mandated benefit. If, after this preliminary review, the |
11 | council is satisfied that both proponents and opponents have |
12 | submitted sufficient documentation necessary for a review |
13 | pursuant to paragraphs (3) and (4), the council is directed |
14 | to contract with individuals, pursuant to the selection |
15 | procedures for vendors set forth in section 16, who will |
16 | constitute a Mandated Benefits Review Panel to review |
17 | mandated benefits proposals and provide independently |
18 | certified documentation, as provided for in this section. |
19 | (2) The panel shall consist of senior researchers, each |
20 | of whom shall be a recognized expert: |
21 | (i) one in health research; |
22 | (ii) one in biostatistics; |
23 | (iii) one in economic research; |
24 | (iv) one, a physician, in the appropriate specialty |
25 | with current knowledge of the subject being proposed as a |
26 | mandated benefit; and |
27 | (v) one with experience in insurance or actuarial |
28 | research. |
29 | (3) The Mandated Benefits Review Panel shall have the |
30 | following duties and responsibilities: |
|
1 | (i) To review documentation submitted by persons |
2 | proposing or opposing mandated benefits within 90 days of |
3 | submission of said documentation to the panel. |
4 | (ii) To report to the council, pursuant to its |
5 | review in subparagraph (i), the following: |
6 | (A) Whether or not the documentation is complete |
7 | as defined in paragraph (4). |
8 | (B) Whether or not the research cited in the |
9 | documentation meets professional standards. |
10 | (C) Whether or not all relevant research |
11 | respecting the proposed mandated benefit has been |
12 | cited in the documentation. |
13 | (D) Whether or not the conclusions and |
14 | interpretations in the documentation are consistent |
15 | with the data submitted. |
16 | (4) To provide the Mandated Benefits Review Panel with |
17 | sufficient information to carry out its duties and |
18 | responsibilities pursuant to paragraph (3), persons proposing |
19 | or opposing legislation mandating benefits coverage should |
20 | submit documentation to the council, pursuant to the |
21 | procedure established in paragraph (5), which demonstrates |
22 | the following: |
23 | (i) The extent to which the proposed benefit and the |
24 | services it would provide are needed by, available to and |
25 | utilized by the population of the Commonwealth. |
26 | (ii) The extent to which insurance coverage for the |
27 | proposed benefit already exists, or if no such coverage |
28 | exists, the extent to which this lack of coverage results |
29 | in inadequate health care or financial hardship for the |
30 | population of the Commonwealth. |
|
1 | (iii) The demand for the proposed benefit from the |
2 | public and the source and extent of opposition to |
3 | mandating the benefit. |
4 | (iv) All relevant findings bearing on the social |
5 | impact of the lack of the proposed benefit. |
6 | (v) Where the proposed benefit would mandate |
7 | coverage of a particular therapy, the results of at least |
8 | one professionally accepted, controlled trial comparing |
9 | the medical consequences of the proposed therapy, |
10 | alternative therapies and no therapy. |
11 | (vi) Where the proposed benefit would mandate |
12 | coverage of an additional class of practitioners, the |
13 | results of at least one professionally accepted, |
14 | controlled trial comparing the medical results achieved |
15 | by the additional class of practitioners and those |
16 | practitioners already covered by benefits. |
17 | (vii) The results of any other relevant research. |
18 | (viii) Evidence of the financial impact of the |
19 | proposed legislation, including at least: |
20 | (A) The extent to which the proposed benefit |
21 | would increase or decrease cost for treatment or |
22 | service. |
23 | (B) The extent to which similar mandated |
24 | benefits in other states have affected charges, costs |
25 | and payments for services. |
26 | (C) The extent to which the proposed benefit |
27 | would increase the appropriate use of the treatment |
28 | or service. |
29 | (D) The impact of the proposed benefit on |
30 | administrative expenses of health care insurers. |
|
1 | (E) The impact of the proposed benefits on |
2 | benefits costs of purchasers. |
3 | (F) The impact of the proposed benefits on the |
4 | total cost of health care within the Commonwealth. |
5 | (5) The procedure for review of documentation is as |
6 | follows: |
7 | (i) Any person wishing to submit information on |
8 | proposed legislation mandating insurance benefits for |
9 | review by the panel should submit the documentation |
10 | specified in paragraph (4) to the council. |
11 | (ii) The council shall, within 30 days of receipt of |
12 | the documentation: |
13 | (A) Publish in the Pennsylvania Bulletin notice |
14 | of receipt of the documentation, a description of the |
15 | proposed legislation, provision for a period of 60 |
16 | days for public comment and the time and place at |
17 | which any person may examine the documentation. |
18 | (B) Submit copies of the documentation to the |
19 | Secretary of Health and the Insurance Commissioner, |
20 | who shall review and submit comments to the council |
21 | on the proposed legislation within 30 days. |
22 | (C) Submit copies of the documentation to the |
23 | panel, which shall review the documentation and issue |
24 | their findings, pursuant to paragraph (3), within 90 |
25 | days. |
26 | (iii) Upon receipt of the comments of the Secretary |
27 | of Health and the Insurance Commissioner and of the |
28 | findings of the panel, pursuant to subparagraph (ii), but |
29 | no later than 120 days following the publication required |
30 | in subparagraph (ii), the council shall submit said |
|
1 | comments and findings, together with its recommendations |
2 | respecting the proposed legislation, to the Governor, the |
3 | President pro tempore of the Senate, the Speaker of the |
4 | House of Representatives, the Secretary of Health, the |
5 | Insurance Commissioner and the person who submitted the |
6 | information pursuant to subparagraph (i). |
7 | Section 4. Section 10 of the act is reenacted and amended to |
8 | read: |
9 | Section 10. Access to council data. |
10 | (a) Public access.--The information and data received by the |
11 | council shall be utilized by the council for the benefit of the |
12 | public and public officials. Subject to the specific limitations |
13 | set forth in this section, the council shall make determinations |
14 | on requests for information in favor of access. |
15 | (a.1) Outreach programs.--The council shall develop and |
16 | implement outreach programs designed to make its information |
17 | understandable and usable to purchasers, providers, other |
18 | Commonwealth agencies and the general public. The programs shall |
19 | include efforts to educate through pamphlets, booklets, seminars |
20 | and other appropriate measures and to facilitate making more |
21 | informed health care choices. |
22 | (b) Limitations on access.--Unless specifically provided for |
23 | in this act, neither the council nor any contracting system |
24 | vendor shall release and no data source, person, member of the |
25 | public or other user of any data of the council shall gain |
26 | access to: |
27 | (1) Any raw data of the council that does not |
28 | simultaneously disclose payment, as well as provider quality |
29 | and provider service effectiveness pursuant to sections 5(d) |
30 | (4) and 6(d) or 7(a)(1)(iii). |
|
1 | (2) Any raw data of the council which could reasonably |
2 | be expected to reveal the identity of an individual patient. |
3 | (3) Any raw data of the council which could reasonably |
4 | be expected to reveal the identity of any purchaser, as |
5 | defined in section 3, other than a purchaser requesting data |
6 | on its own group or an entity entitled to said purchaser's |
7 | data pursuant to subsection (f). |
8 | (4) Any raw data of the council relating to actual |
9 | payments to any identified provider made by any purchaser, |
10 | except that this provision shall not apply to access by a |
11 | purchaser requesting data on the group for which it purchases |
12 | or otherwise provides covered services or to access to that |
13 | same data by an entity entitled to the purchaser's data |
14 | pursuant to subsection (f). |
15 | (5) Any raw data disclosing discounts or differentials |
16 | between payments accepted by providers for services and their |
17 | billed charges obtained by identified payors from identified |
18 | providers unless the data is released in a Statewide, |
19 | aggregate format that does not identify any individual payor |
20 | or class of payors and the council assures that the release |
21 | of such information is not prejudicial or inequitable to any |
22 | individual payor or provider or group thereof. Payor data |
23 | shall be released to individual providers for purposes of |
24 | verification and validation prior to inclusion in a public |
25 | report. An individual provider shall verify and validate the |
26 | payor data within 30 days of its release to that specific |
27 | individual provider. |
28 | (c) Unauthorized use of data.--Any person who knowingly |
29 | releases council data violating the patient confidentiality, |
30 | actual payments, discount data or raw data safeguards set forth |
|
1 | in this section to an unauthorized person commits a misdemeanor |
2 | of the first degree and shall, upon conviction, be sentenced to |
3 | pay a fine of $10,000 or to imprisonment for not more than five |
4 | years, or both. An unauthorized person who knowingly receives or |
5 | possesses such data commits a misdemeanor of the first degree. |
6 | (d) Unauthorized access to data.--Should any person |
7 | inadvertently or by council error gain access to data that |
8 | violates the safeguards set forth in this section, the data must |
9 | immediately be returned, without duplication, to the council |
10 | with proper notification. |
11 | (e) Public access to records.--All public reports prepared |
12 | by the council shall be public records and shall be available to |
13 | the public for a reasonable fee, and copies shall be provided, |
14 | upon request of the chair, to the Public Health and Welfare |
15 | Committee of the Senate and the Health and Welfare Committee of |
16 | the House of Representatives. |
17 | (f) Access to raw council data by purchasers.--Pursuant to |
18 | sections 5(d)(5) and 7(b) and subject to the limitations on |
19 | access set forth in subsection (b), the council shall provide |
20 | access to its raw data to purchasers in accordance with the |
21 | following procedure: |
22 | (1) Special reports derived from raw data of the council |
23 | shall be provided by the council to any purchaser requesting |
24 | such reports. |
25 | (2) A means to enable computer-to-computer access by any |
26 | purchaser to raw data of the council as defined in section 3 |
27 | shall be developed, adopted and implemented by the council, |
28 | and the council shall provide such access to its raw data to |
29 | any purchaser upon request. |
30 | (3) In the event that any employer obtains from the |
|
1 | council, pursuant to paragraph (1) or (2), data pertaining to |
2 | its employees and their dependents for whom said employer |
3 | purchases or otherwise provides covered services as defined |
4 | in section 3 and who are represented by a certified |
5 | collective bargaining representative, said collective |
6 | bargaining representative shall be entitled to that same |
7 | data, after payment of fees as specified in paragraph (4). |
8 | Likewise, should a certified collective bargaining |
9 | representative obtain from the council, pursuant to paragraph |
10 | (1) or (2), data pertaining to its members and their |
11 | dependents who are employed by and for whom covered services |
12 | are purchased or otherwise provided by any employer, said |
13 | employer shall be entitled to that same data, after payment |
14 | of fees as specified in paragraph (4). |
15 | (4) In providing for access to its raw data, the council |
16 | shall charge the purchasers which originally obtained such |
17 | access a fee sufficient to cover its costs to prepare and |
18 | provide special reports requested pursuant to paragraph (1) |
19 | or to provide computer-to-computer access to its raw data |
20 | requested pursuant to paragraph (2). Should a second or |
21 | subsequent party or parties request this same information |
22 | pursuant to paragraph (3), the council shall charge said |
23 | party a reasonable fee. |
24 | (g) Access to raw council data by other parties.--Subject to |
25 | the limitations on access to raw council data set forth in |
26 | subsection (b), the council may, at its discretion, provide |
27 | special reports derived from its raw data or computer-to- |
28 | computer access to parties other than purchasers. The council |
29 | shall publish regulations that set forth the criteria and the |
30 | procedure it shall use in making determinations on such access, |
|
1 | pursuant to the powers vested in the council in section 4. In |
2 | providing such access, the council shall charge the party |
3 | requesting the access a reasonable fee. |
4 | Section 5. Sections 11, 12, 13, 14, 15, 16 and 17.1 of the |
5 | act are reenacted to read: |
6 | Section 11. Special studies and reports. |
7 | (a) Special studies.--Any Commonwealth agency may publish or |
8 | contract for publication of special studies. Any special study |
9 | so published shall become a public document. |
10 | (b) Special reports.-- |
11 | (1) Any Commonwealth agency may study and issue a report |
12 | on the special medical needs, demographic characteristics, |
13 | access or lack thereof to health care services and need for |
14 | financing of health care services of: |
15 | (i) Senior citizens, particularly low-income senior |
16 | citizens, senior citizens who are members of minority |
17 | groups and senior citizens residing in low-income urban |
18 | or rural areas. |
19 | (ii) Low-income urban or rural areas. |
20 | (iii) Minority communities. |
21 | (iv) Women. |
22 | (v) Children |
23 | (vi) Unemployed workers. |
24 | (vii) Veterans. |
25 | The reports shall include information on the current |
26 | availability of services to these targeted parts of the |
27 | population, and whether access to such services has increased |
28 | or decreased over the past ten years, and specific |
29 | recommendations for the improvement of their primary care and |
30 | health delivery systems, including disease prevention and |
|
1 | comprehensive health care services. The department may also |
2 | study and report on the effects of using prepaid, capitated |
3 | or HMO health delivery systems as ways to promote the |
4 | delivery of primary health care services to the underserved |
5 | segments of the population enumerated above. |
6 | (2) The department may study and report on the short- |
7 | term and long-term fiscal and programmatic impact on the |
8 | health care consumer of changes in ownership of hospitals |
9 | from nonprofit to profit, whether through purchase, merger or |
10 | the like. The department may also study and report on factors |
11 | which have the effect of either reducing provider revenue or |
12 | increasing provider cost, and other factors beyond a |
13 | provider's control which reduce provider competitiveness in |
14 | the marketplace, are explained in the reports. |
15 | Section 12. Enforcement; penalty. |
16 | (a) Compliance enforcement.--The council shall have standing |
17 | to bring an action in law or in equity through private counsel |
18 | in any court of common pleas to enforce compliance with any |
19 | provision of this act, except section 11, or any requirement or |
20 | appropriate request of the council made pursuant to this act. In |
21 | addition, the Attorney General is authorized and shall bring any |
22 | such enforcement action in aid of the council in any court of |
23 | common pleas at the request of the council in the name of the |
24 | Commonwealth. |
25 | (b) Penalty.-- |
26 | (1) Any person who fails to supply data pursuant to |
27 | section 6 may be assessed a civil penalty not to exceed |
28 | $1,000 for each day the data is not submitted. |
29 | (2) Any person who knowingly submits inaccurate data |
30 | under section 6 commits a misdemeanor of the third degree and |
|
1 | shall, upon conviction, be sentenced to pay a fine of $1,000 |
2 | or to imprisonment for not more than one year, or both. |
3 | Section 13. Research and demonstration projects. |
4 | The council shall actively encourage research and |
5 | demonstrations to design and test improved methods of assessing |
6 | provider quality, provider service effectiveness and efficiency. |
7 | To that end, provided that no data submission requirements in a |
8 | mandated demonstration may exceed the current reserve field on |
9 | the Pennsylvania Uniform Claims and Billing Form, the council |
10 | may: |
11 | (1) Authorize contractors engaged in health services |
12 | research selected by the council, pursuant to the provisions |
13 | of section 16, to have access to the council's raw data |
14 | files, providing such entities assume any contractual |
15 | obligations imposed by the council to assure patient identity |
16 | confidentiality. |
17 | (2) Place data sources participating in research and |
18 | demonstrations on different data submission requirements from |
19 | other data sources in this Commonwealth. |
20 | (3) Require data source participation in research and |
21 | demonstration projects when this is the only testing method |
22 | the council determines is promising. |
23 | Section 14. Grievances and grievance procedures. |
24 | (a) Procedures and requirements.--Pursuant to its powers to |
25 | publish regulations under section 5(b) and with the requirements |
26 | of this section, the council is hereby authorized and directed |
27 | to establish procedures and requirements for the filing, hearing |
28 | and adjudication of grievances against the council of any data |
29 | source. Such procedures and requirements shall be published in |
30 | the Pennsylvania Bulletin pursuant to law. |
|
1 | (b) Claims; hearings.--Grievance claims of any data source |
2 | shall be submitted to the council or to a third party designated |
3 | by the council, and the council or the designated third party |
4 | shall convene a hearing, if requested, and adjudicate the |
5 | grievance. |
6 | Section 15. Antitrust provisions. |
7 | Persons or entities required to submit data or information |
8 | under this act or receiving data or information from the council |
9 | in accordance with this act are declared to be acting pursuant |
10 | to State requirements embodied in this act and shall be exempt |
11 | from antitrust claims or actions grounded upon submission or |
12 | receipt of such data or information. |
13 | Section 16. Contracts with vendors. |
14 | Any contract with any vendor other than a sole source vendor |
15 | for purchase of services or for purchase or lease of supplies |
16 | and equipment related to the council's powers and duties shall |
17 | be let only after a public bidding process and only in |
18 | accordance with the following provisions, and no contract shall |
19 | be let by the council that does not conform to these provisions: |
20 | (1) The council shall prepare specifications fully |
21 | describing the services to be rendered or equipment or |
22 | supplies to be provided by a vendor and shall make these |
23 | specifications available for inspection by any person at the |
24 | council's offices during normal working hours and at such |
25 | other places and such other times as the council deems |
26 | advisable. |
27 | (2) The council shall publish notice of invitations to |
28 | bid in the Pennsylvania Bulletin. The council shall also |
29 | publish such notice in at least four newspapers in general |
30 | circulation in the Commonwealth on at least three occasions |
|
1 | at intervals of not less than three days. Said notice shall |
2 | include at least the following: |
3 | (i) The deadline for submission of bids by |
4 | prospective vendors, which shall be no sooner than 30 |
5 | days following the latest publication of the notice as |
6 | prescribed in this paragraph. |
7 | (ii) The locations, dates and times during which |
8 | prospective vendors can examine the specifications |
9 | required in paragraph (1). |
10 | (iii) The date, time and place of the meeting or |
11 | meetings of the council at which bids will be opened and |
12 | accepted. |
13 | (iv) A statement to the effect that any person is |
14 | eligible to bid. |
15 | (3) Bids shall be accepted as follows: |
16 | (i) No council member who is affiliated in any way |
17 | with any bidder shall vote on the awarding of any |
18 | contract for which said bidder has submitted a bid, and |
19 | any council member who has an affiliation with a bidder |
20 | shall state the nature of the affiliation prior to any |
21 | vote of the council. |
22 | (ii) Bids shall be opened and reviewed by the |
23 | appropriate council committee, which shall make |
24 | recommendations to the council on approval. Bids shall be |
25 | accepted and such acceptance shall be announced only at a |
26 | public meeting of the council as defined in section 4(e), |
27 | and no bids shall be accepted at an executive session of |
28 | the council. |
29 | (iii) The council may require that a certified |
30 | check, in an amount determined by the council, accompany |
|
1 | every bid, and, when so required, no bid shall be |
2 | accepted unless so accompanied. |
3 | (4) In order to prevent any party from deliberately |
4 | underbidding contracts in order to gain or prevent access to |
5 | council data, the council may award any contract at its |
6 | discretion, regardless of the amount of the bid, pursuant to |
7 | the following: |
8 | (i) Any bid accepted must reasonably reflect the |
9 | actual cost of services provided. |
10 | (ii) Any vendor so selected by the council shall be |
11 | found by the council to be of such character and such |
12 | integrity as to assure, to the maximum extent possible, |
13 | adherence to all the provisions of this act in the |
14 | provision of contracted services. |
15 | (iii) The council may require the selected vendor to |
16 | furnish, within 20 days after the contract has been |
17 | awarded, a bond with suitable and reasonable requirements |
18 | guaranteeing the services to be performed with sufficient |
19 | surety in an amount determined by the council, and upon |
20 | failure to furnish such bond within the time specified, |
21 | the previous award shall be void. |
22 | (5) The council shall make efforts to assure that its |
23 | vendors have established affirmative action plans to assure |
24 | equal opportunity policies for hiring and promoting |
25 | employees. |
26 | Section 17.1. Reporting. |
27 | The council shall provide an annual report of its financial |
28 | expenditures to the Appropriations Committee of the Senate and |
29 | the Appropriations Committee of the House of Representatives. |
30 | Section 6. The act is amended by adding a section to read: |
|
1 | Section 17.2. Health Care Cost Containment Council Act Review |
2 | Committee. |
3 | (a) Establishment.--There is hereby established an |
4 | independent committee to be known as the Health Care Cost |
5 | Containment Council Act Review Committee. |
6 | (b) Composition.--The committee shall consist of the |
7 | following voting members composed of and appointed as follows: |
8 | (1) One member appointed by the Governor. |
9 | (2) Four members appointed by the General Assembly, one |
10 | of whom shall be appointed by each of the following: |
11 | (i) one by the President pro tempore of the Senate; |
12 | (ii) one by the Minority Leader of the Senate; |
13 | (iii) one by the Majority Leader of the House of |
14 | Representatives; and |
15 | (iv) one by the Minority Leader of the House of |
16 | Representatives. |
17 | (3) Two representatives of the business community, at |
18 | least one of whom represents small business, and neither of |
19 | whom is primarily involved in the provision of health care or |
20 | health insurance, one of whom shall be appointed by the |
21 | President pro tempore of the Senate and one of whom shall be |
22 | appointed by the Speaker of the House of Representatives from |
23 | a list of four qualified persons recommended by the |
24 | Pennsylvania Chamber of Business and Industry. |
25 | (4) Two representatives of organized labor, one of whom |
26 | shall be appointed by the President pro tempore of the Senate |
27 | and one of whom shall be appointed by the Speaker of the |
28 | House of Representatives from a list of four qualified |
29 | persons recommended by the Pennsylvania AFL-CIO. |
30 | (5) One representative of consumers who is not primarily |
|
1 | involved in the provision of health care or health care |
2 | insurance, appointed by the Governor from a list of three |
3 | qualified persons recommended jointly by the President pro |
4 | tempore of the Senate and the Speaker of the House of |
5 | Representatives. |
6 | (6) One representative of hospitals, appointed by the |
7 | Governor from a list of three qualified hospital |
8 | representatives recommended by the Hospital and Health System |
9 | Association of Pennsylvania. |
10 | (7) One representative of physicians, appointed by the |
11 | Governor from a list of three qualified physician |
12 | representatives recommended jointly by the Pennsylvania |
13 | Medical Society and the Pennsylvania Osteopathic Medical |
14 | Society. |
15 | (8) One representative of nurses, appointed by the |
16 | Governor from a list of three qualified representatives |
17 | recommended by the Pennsylvania State Nurses Association. |
18 | (9) One representative of the Blue Cross and Blue Shield |
19 | plans in Pennsylvania, appointed by the Governor from a list |
20 | of three qualified persons recommended jointly by the Blue |
21 | Cross and Blue Shield plans of Pennsylvania. |
22 | (10) One representative of commercial insurance |
23 | carriers, appointed by the Governor from a list of three |
24 | qualified persons recommended by the Insurance Federation of |
25 | Pennsylvania, Inc. |
26 | (c) Chairperson.--The appointment made by the Governor under |
27 | subsection (b)(1) shall serve as chairman of the committee. |
28 | (d) Quorum.--Eleven members shall constitute a quorum for |
29 | the transaction of any business, and the act by the majority of |
30 | the members present at any meeting in which there is a quorum |
|
1 | shall be deemed to be the act of the committee. |
2 | (e) Meetings.-- |
3 | (1) All meetings of the committee shall be advertised |
4 | and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating to open |
5 | meetings). |
6 | (2) All action taken by the committee shall be taken in |
7 | open public session, and action of the committee shall not be |
8 | taken except upon the affirmative vote of a majority of the |
9 | members of the committee present during meetings at which a |
10 | quorum is present. |
11 | (f) Compensation and expenses.--The members of the committee |
12 | shall not receive a salary or per diem allowance for serving as |
13 | members of the committee but shall be reimbursed for actual and |
14 | necessary expenses incurred in the performance of their duties. |
15 | Expenses may include reimbursement of travel and living expenses |
16 | while engaged in committee business. |
17 | (g) Commencement of committee.-- |
18 | (1) Within 15 days after the effective date of this |
19 | section, each organization or individual required to submit a |
20 | list of recommended persons to the Governor, the President |
21 | pro tempore of the Senate or the Speaker of the House of |
22 | Representatives under subsection (b) shall submit the list. |
23 | (2) Within 30 days of the effective date of this |
24 | section, the Governor, the President pro tempore of the |
25 | Senate and the Speaker of the House of Representatives shall |
26 | make the appointments called for in subsection (b), and the |
27 | committee shall begin operations immediately following the |
28 | appointments. |
29 | (h) Responsibilities of the committee.--The committee shall |
30 | have the following powers and duties: |
|
1 | (1) To study, review and recommend changes to this act. |
2 | (2) To accept and review suggested changes to this act |
3 | submitted by members of the committee. |
4 | (3) To approve, by a majority vote of the members of the |
5 | committee, a report recommending statutory changes to this |
6 | act. The report shall include, at a minimum, the following: |
7 | (i) The establishment of an Internet database for |
8 | the general public showing Medicare reimbursement rates |
9 | for common covered services and treatment. |
10 | (ii) In consultation with experts in the fields of |
11 | quality data and outcome measures, the definition and |
12 | implementation of: |
13 | (A) A methodology by provider type for the |
14 | council to risk adjust quality data. |
15 | (B) A methodology for the council to collect and |
16 | disseminate data reflecting provider quality and |
17 | provider service effectiveness. |
18 | (4) To submit the report approved under paragraph (3) to |
19 | the President pro tempore of the Senate and the Speaker of |
20 | the House of Representatives by March 1, 2010. |
21 | (i) Committee support.--The council shall offer staff and |
22 | administrative support from the council or its work groups |
23 | necessary for the committee to carry out its duties under this |
24 | section. |
25 | Section 7. Section 18 of the act is reenacted to read: |
26 | Section 18. Severability. |
27 | The provisions of this act are severable. If any provision of |
28 | this act or its application to any person or circumstance is |
29 | held invalid, the invalidity shall not affect other provisions |
30 | or applications of this act which can be given effect without |
|
1 | the invalid provision or application. |
2 | Section 8. Section 19 of the act is reenacted and amended to |
3 | read: |
4 | Section 19. Sunset. |
5 | This act shall expire [June 30, 2008] December 31, 2014, |
6 | unless reenacted prior to that date. By [September 1, 2007] |
7 | December 31, 2013, a written report by the Legislative Budget |
8 | and Finance Committee evaluating the management, visibility, |
9 | awareness and performance of the council shall be provided to |
10 | the Public Health and Welfare Committee of the Senate and the |
11 | Health and Human Services Committee of the House of |
12 | Representatives. The report shall include a review of the |
13 | council's procedures and policies, the availability and quality |
14 | of data for completing reports [to hospitals and outside vendor |
15 | purchasers, the ability of the council to become self-sufficient |
16 | by selling data to outside purchasers], whether there is a more |
17 | cost-efficient way of accomplishing the objectives of the |
18 | council and the need for reauthorization of the council. |
19 | Section 9. Section 20 of the act is reenacted to read: |
20 | Section 20. Effective date. |
21 | This act shall take effect immediately. |
22 | Section 10. In accordance with section 11 of this act, the |
23 | following apply to the period from June 29, 2008, to the |
24 | effective date of this section: |
25 | (1) There is no lapse in membership on the Health Care |
26 | Cost Containment Council. |
27 | (2) Eleven members constitute a quorum. |
28 | (3) Any action taken by the council is validated. |
29 | (4) There shall be no lapse in the employment |
30 | relationship for employees of the council. This paragraph |
|
1 | includes salary, seniority, benefits and retirement |
2 | eligibility of the employees. |
3 | Section 11. This act shall apply as follows: |
4 | (1) Except as set forth in paragraph (2), this act shall |
5 | apply retroactively to June 29, 2008. |
6 | (2) The reenactment of section 6 of the act shall apply |
7 | retroactively under paragraph (1), but the amendment of |
8 | section 6 of the act shall apply from the effective date of |
9 | the amendment under section 12(1) of this act. |
10 | Section 12. This act shall take effect as follows: |
11 | (1) The amendment of section 6 of the act shall take |
12 | effect June 30, 2011. |
13 | (2) The remainder of this act shall take effect |
14 | immediately. |
|