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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| SENATE BILL |
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| INTRODUCED BY VANCE, FONTANA, ERICKSON, SCARNATI, PILEGGI, ALLOWAY, BAKER, BOSCOLA, BROWNE, CORMAN, COSTA, EARLL, FARNESE, FERLO, GORDNER, GREENLEAF, HUGHES, KASUNIC, LEACH, LOGAN, MELLOW, O'PAKE, ORIE, PICCOLA, PIPPY, RAFFERTY, ROBBINS, STACK, STOUT, TARTAGLIONE, WASHINGTON, WAUGH AND YAW, JANUARY 29, 2009 |
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| REFERRED TO PUBLIC HEALTH AND WELFARE, JANUARY 29, 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," defining "committee"; further providing |
8 | for the Health Care Cost Containment Council and its powers |
9 | and duties, for data submission and collection and for access |
10 | to council data; and providing for the establishment of a |
11 | Health Care Cost Containment Council Act Review Committee and |
12 | for sunset of act. |
13 | The General Assembly of the Commonwealth of Pennsylvania |
14 | hereby enacts as follows: |
15 | Section 1. Section 3 of the act of July 8, 1986 (P.L.408, |
16 | No.89), known as the Health Care Cost Containment Act, reenacted |
17 | and amended July 17, 2003 (P.L.31, No.14), is amended by adding |
18 | a definition to read: |
19 | Section 3. Definitions. |
20 | The following words and phrases when used in this act shall |
21 | have the meanings given to them in this section unless the |
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1 | context clearly indicates otherwise: |
2 | * * * |
3 | "Committee." The Health Care Cost Containment Council Act |
4 | Review Committee. |
5 | * * * |
6 | Section 2. Sections 4(f), 5(c) and (d), 6(a) and (d) and |
7 | 10(b)(5) of the act are amended to read: |
8 | Section 4. Health Care Cost Containment Council. |
9 | * * * |
10 | (f) Bylaws.--The council shall adopt bylaws, not |
11 | inconsistent with this act, and may appoint such committees or |
12 | elect such officers subordinate to those provided for in |
13 | subsection (c) as it deems advisable. The council shall provide |
14 | for the approval and participation of additional delegates |
15 | appointed under subsection (b)(7) and (8) so that each |
16 | organization represented by delegates under those paragraphs |
17 | shall not have more than one vote on any committee to which they |
18 | are appointed. The council shall also appoint a technical |
19 | advisory group which shall, on an ad hoc basis, respond to |
20 | issues presented to it by the council or committees of the |
21 | council and shall make recommendations to the council. The |
22 | technical advisory group shall include physicians, researchers, |
23 | biostatisticians, one representative of the Hospital and |
24 | Healthsystem Association of Pennsylvania and one representative |
25 | of the Pennsylvania Medical Society. The Hospital and |
26 | Healthsystem Association of Pennsylvania and the Pennsylvania |
27 | Medical Society representatives shall not be subject to |
28 | executive committee approval. In appointing other physicians, |
29 | researchers and biostatisticians to the technical advisory |
30 | group, the council shall consult with and take nominations from |
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1 | the representatives of the Hospital Association of Pennsylvania, |
2 | the Pennsylvania Medical Society, the Pennsylvania Osteopathic |
3 | Medical Society or other like organizations. At its discretion |
4 | and in accordance with this section, nominations shall be |
5 | approved by the executive committee of the council. If the |
6 | subject matter of any project exceeds the expertise of the |
7 | technical advisory group, physicians in appropriate specialties |
8 | who possess current knowledge of the issue under study may be |
9 | consulted. The technical advisory group shall also review the |
10 | availability and reliability of severity of illness measurements |
11 | as they relate to small hospitals and psychiatric, |
12 | rehabilitation and children's hospitals and shall make |
13 | recommendations to the council based upon this review. Meetings |
14 | of the technical advisory group shall be open to the general |
15 | public. |
16 | * * * |
17 | Section 5. Powers and duties of the council. |
18 | * * * |
19 | (c) Audit powers.--The council shall have the right to |
20 | independently audit all information required to be submitted by |
21 | data sources as needed to corroborate the accuracy of the |
22 | submitted data, pursuant to the following: |
23 | (1) Audits of information submitted by providers or |
24 | health care insurers shall be performed on a sample and |
25 | issue-specific basis, as needed by the council, and shall be |
26 | coordinated, to the extent practicable, with audits performed |
27 | by the Commonwealth. All health care insurers and providers |
28 | are hereby required to make those books, records of accounts |
29 | and any other data needed by the auditors available to the |
30 | council at a convenient location within 30 days of a written |
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1 | notification by the council. |
2 | (2) Audits of information submitted by purchasers shall |
3 | be performed on a sample basis, unless there exists |
4 | reasonable cause to audit specific purchasers, but in no case |
5 | shall the council have the power to audit financial |
6 | statements of purchasers. |
7 | (3) All audits performed by the council shall be |
8 | performed at the expense of the council. |
9 | (4) The results of audits of providers or health care |
10 | insurers shall be provided to the audited providers and |
11 | health care insurers on a timely basis, not to exceed 30 days |
12 | beyond presentation of audit findings to the council. |
13 | (d) General duties and functions.--The council is hereby |
14 | authorized to and shall perform the following duties and |
15 | functions: |
16 | (1) Develop a computerized system for the collection, |
17 | analysis and dissemination of data. The council may contract |
18 | with a vendor who will provide such data processing services. |
19 | The council shall assure that the system will be capable of |
20 | processing all data required to be collected under this act. |
21 | Any vendor selected by the council shall be selected in |
22 | accordance with the provisions of section 16, and said vendor |
23 | shall relinquish any and all proprietary rights or claims to |
24 | the data base created as a result of implementation of the |
25 | data processing system. |
26 | (2) Establish a Pennsylvania Uniform Claims and Billing |
27 | Form for all data sources and all providers which shall be |
28 | utilized and maintained by all data sources and all providers |
29 | for all services covered under this act. |
30 | (3) Collect and disseminate data, as specified in |
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1 | section 6, and other information from data sources to which |
2 | the council is entitled, prepared according to formats, time |
3 | frames and confidentiality provisions as specified in |
4 | sections 6 and 10, and by the council. |
5 | (4) Adopt and implement a methodology to collect and |
6 | disseminate data reflecting provider quality and provider |
7 | service effectiveness pursuant to section 6. |
8 | (5) Subject to the restrictions on access to raw data |
9 | set forth in section 10, issue special reports and make |
10 | available raw data as defined in section 3 to any purchaser |
11 | requesting it. Sale by any recipient or exchange or |
12 | publication by a recipient, other than a purchaser, of raw |
13 | council data to other parties without the express written |
14 | consent of, and under terms approved by, the council shall be |
15 | unauthorized use of data pursuant to section 10(c). |
16 | (6) On an annual basis, publish in the Pennsylvania |
17 | Bulletin a list of all the raw data reports it has prepared |
18 | under section 10(f) and a description of the data obtained |
19 | through each computer-to-computer access it has provided |
20 | under section 10(f) and of the names of the parties to whom |
21 | the council provided the reports or the computer-to-computer |
22 | access during the previous month. |
23 | (7) Promote competition in the health care and health |
24 | insurance markets. |
25 | (8) Assure that the use of council data does not raise |
26 | access barriers to care. |
27 | (10) Make annual reports to the General Assembly on the |
28 | rate of increase in the cost of health care in the |
29 | Commonwealth and the effectiveness of the council in carrying |
30 | out the legislative intent of this act. In addition, the |
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1 | council may make recommendations on the need for further |
2 | health care cost containment legislation. The council shall |
3 | also make annual reports to the General Assembly on the |
4 | quality and effectiveness of health care and access to health |
5 | care for all citizens of the Commonwealth. |
6 | (12) Conduct studies and publish reports thereon |
7 | analyzing the effects that noninpatient, alternative health |
8 | care delivery systems have on health care costs. These |
9 | systems shall include, but not be limited to: HMO's; PPO's; |
10 | primary health care facilities; home health care; attendant |
11 | care; ambulatory service facilities; freestanding emergency |
12 | centers; birthing centers; and hospice care. These reports |
13 | shall be submitted to the General Assembly and shall be made |
14 | available to the public. |
15 | (13) Conduct studies and make reports concerning the |
16 | utilization of experimental and nonexperimental transplant |
17 | surgery and other highly technical and experimental |
18 | procedures, including costs and mortality rates. |
19 | (14) In order to ensure that the council adopts and |
20 | maintains both scientifically credible and cost-effective |
21 | methodology to collect and disseminate data reflecting |
22 | provider quality and service effectiveness, the council |
23 | shall, within one year of the effective date of this |
24 | paragraph, utilizing current Commonwealth agency guidelines |
25 | and procedures, issue a request for information from any |
26 | vendor that wishes to provide data collection or risk |
27 | adjustment methodology to the council to help meet the |
28 | requirements of this subsection and section 6. The council |
29 | shall establish an independent Request for Information Review |
30 | Committee to review and rank all responses and to make a |
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1 | final recommendation to the council. The Request for |
2 | Information Review Committee shall consist of the following |
3 | members appointed by the Governor: |
4 | (i) One representative of the Hospital and |
5 | Healthsystem Association of Pennsylvania. |
6 | (ii) One representative of the Pennsylvania Medical |
7 | Society. |
8 | (iii) One representative of insurance. |
9 | (iv) One representative of labor. |
10 | (v) One representative of business. |
11 | (vi) Two representatives of the general public. |
12 | (15) The council shall execute a request for proposals |
13 | with third-party vendors for the purpose of demonstrating a |
14 | methodology for the collection, analysis and reporting of |
15 | hospital-specific complication rates. The results of this |
16 | demonstration shall be provided to the chairman and minority |
17 | chairman of the Public Health and Welfare Committee of the |
18 | Senate and the chairman and minority chairman of the Health |
19 | and Human Services Committee of the House of Representatives. |
20 | This methodology may be utilized by the council for public |
21 | reporting on comparative hospital complication rates. |
22 | Section 6. Data submission and collection. |
23 | (a) (1) Submission of data.--The council is hereby |
24 | authorized to collect and data sources are hereby required to |
25 | submit, upon request of the council, all data required in |
26 | this section, according to uniform submission formats, coding |
27 | systems and other technical specifications necessary to |
28 | render the incoming data substantially valid, consistent, |
29 | compatible and manageable using electronic data processing |
30 | according to data submission schedules, such schedules to |
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1 | avoid, to the extent possible, submission of identical data |
2 | from more than one data source, established and promulgated |
3 | by the council in regulations pursuant to its authority under |
4 | section 5(b). If payor data is requested by the council, it |
5 | shall, to the extent possible, be obtained from primary payor |
6 | sources. The council shall not require any data sources to |
7 | contract with any specific vendor for submission of any |
8 | specific data elements to the council. |
9 | (1.1) Any vendor shall comply with data submission |
10 | guidelines established in the report submitted under section |
11 | 17.2. The council shall maintain a vendor list of at least |
12 | two vendors that may be chosen by any data source for |
13 | submission of any specific data elements. |
14 | (2) Except as provided in this section, the council may |
15 | adopt any nationally recognized methodology to adjust data |
16 | submitted under subsection (c) for severity of illness. Every |
17 | three years after the effective date of this paragraph, the |
18 | council shall solicit bids from third-party vendors to adjust |
19 | the data. The solicitation shall be in accordance with 62 |
20 | Pa.C.S. (relating to procurement). Except as provided in |
21 | subparagraph (i), in carrying out its responsibilities, the |
22 | council shall not require health care facilities to report |
23 | data elements which are not included in the manual developed |
24 | by the national uniform billing committee. The following |
25 | apply: |
26 | (i) Within 60 days of the effective date of this |
27 | paragraph, the council shall publish in the Pennsylvania |
28 | Bulletin a list of diseases, procedures and medical |
29 | conditions, not to exceed 35, for which data under |
30 | subsections (c)(21) and (d) shall be required. The chosen |
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1 | list shall not represent more than 50% of total hospital |
2 | discharges, based upon the previous year's hospital |
3 | discharge data. Subsequent to the publication of the |
4 | list, any data submission requirements under subsections |
5 | (c)(21) and (d) previously in effect shall be null and |
6 | void for diseases, procedures and medical conditions not |
7 | found on the list. All other data elements pursuant to |
8 | subsection (c) shall continue to be required from data |
9 | sources. The council shall review the list and may add no |
10 | more than a net of three diseases, procedures or medical |
11 | conditions per year over a five-year period starting on |
12 | the effective date of this subparagraph. The adjusted |
13 | list of diseases, procedures and medical conditions shall |
14 | at no time be more than 50% of total hospital discharges. |
15 | (ii) If the current data vendor is unable to |
16 | achieve, on a per-chart basis, savings of at least 40% in |
17 | the cost of hospital compliance with the data abstracting |
18 | and submission requirements of this act by June 30, 2004, |
19 | as compared to June 30, 2003, then the council shall |
20 | disqualify the current vendor and reopen the bidding |
21 | process. The independent auditor shall determine the |
22 | extent and validity of the savings. In determining any |
23 | demonstrated cost savings, surveys of all hospitals in |
24 | this Commonwealth shall be conducted and consideration |
25 | shall be given at a minimum to: |
26 | (A) new costs, in terms of making the |
27 | methodology operational, associated with laboratory, |
28 | pharmacy and other information systems a hospital is |
29 | required to purchase in order to reduce hospital |
30 | compliance costs, including the cost of electronic |
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1 | transfer of required data; and |
2 | (B) the audited direct personnel and related |
3 | costs of data abstracting and submission required. |
4 | (iii) Review by the independent auditor shall |
5 | commence by March 1, 2004, and shall conclude with a |
6 | report of findings by July 31, 2004. The report shall be |
7 | delivered to the council, the Governor, the Health and |
8 | Human Services Committee of the House of Representatives |
9 | and the Public Health and Welfare Committee of the |
10 | Senate. |
11 | * * * |
12 | (d) Provider quality and provider service effectiveness data |
13 | elements.--In carrying out its duty to collect data on provider |
14 | quality and provider service effectiveness under section 5(d)(4) |
15 | and subsection (c)(21), the council shall define a methodology |
16 | to measure provider service effectiveness which may include |
17 | additional data elements to be specified by the council |
18 | sufficient to carry out its responsibilities under section 5(d) |
19 | (4). The council may adopt a nationally recognized methodology |
20 | of quantifying and collecting data on provider quality and |
21 | provider service effectiveness until such time as the council |
22 | has the capability of developing its own methodology and |
23 | standard data elements. The council shall include in the |
24 | Pennsylvania Uniform Claims and Billing Form a field consisting |
25 | of the data elements required pursuant to subsection (c)(21) to |
26 | provide information on each provision of covered services |
27 | sufficient to permit analysis of provider quality and provider |
28 | service effectiveness within 180 days of commencement of its |
29 | operations pursuant to section 4. In carrying out its |
30 | responsibilities, the council shall not require health care |
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1 | insurers to report on data elements that are not reported to |
2 | nationally recognized accrediting organizations, to the |
3 | Department of Health or to the Insurance Department in quarterly |
4 | or annual reports. The council shall not require reporting by |
5 | health care insurers in different formats than are required for |
6 | reporting to nationally recognized accrediting organizations or |
7 | on quarterly or annual reports submitted to the Department of |
8 | Health or to the Insurance Department. The council may adopt the |
9 | quality findings as reported to nationally recognized |
10 | accrediting organizations. Additional quality data elements must |
11 | be defined and released for public comment prior to the |
12 | promulgation of regulations pursuant to section 5(b). The public |
13 | comment period shall be no less than 30 days from the release of |
14 | these elements. |
15 | * * * |
16 | Section 10. Access to council data. |
17 | * * * |
18 | (b) Limitations on access.--Unless specifically provided for |
19 | in this act, neither the council nor any contracting system |
20 | vendor shall release and no data source, person, member of the |
21 | public or other user of any data of the council shall gain |
22 | access to: |
23 | * * * |
24 | (5) Any raw data disclosing discounts or differentials |
25 | between payments accepted by providers for services and their |
26 | billed charges obtained by identified payors from identified |
27 | providers unless the data is released in a Statewide, |
28 | aggregate format that does not identify any individual payor |
29 | or class of payors and the council assures that the release |
30 | of such information is not prejudicial or inequitable to any |
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1 | individual payor or provider or group thereof. Payor data |
2 | shall be released to individual providers for purposes of |
3 | verification and validation prior to inclusion in a public |
4 | report. An individual provider shall verify and validate the |
5 | payor data within 30 days of its release to that specific |
6 | individual provider. |
7 | * * * |
8 | Section 3. The act is amended by adding sections to read: |
9 | Section 17.2. Health Care Cost Containment Council Act Review |
10 | Committee. |
11 | (a) Establishment.--There is hereby established an |
12 | independent committee to be known as the Health Care Cost |
13 | Containment Council Act Review Committee. |
14 | (b) Composition.--The committee shall consist of the |
15 | following voting members composed of and appointed as follows: |
16 | (1) One member appointed by the Governor. |
17 | (2) Four members appointed by the General Assembly, one |
18 | of whom shall be appointed by each of the following: |
19 | (i) one by the President pro tempore of the Senate; |
20 | (ii) one by the Minority Leader of the Senate; |
21 | (iii) one by the Majority Leader of the House of |
22 | Representatives; and |
23 | (iv) one by the Minority Leader of the House of |
24 | Representatives . |
25 | (3) Two representatives of the business community, at |
26 | least one of whom represents small business, and neither of |
27 | whom is primarily involved in the provision of health care or |
28 | health insurance, one of whom shall be appointed by the |
29 | President pro tempore of the Senate and one of whom shall be |
30 | appointed by the Speaker of the House of Representatives from |
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1 | a list of four qualified persons recommended by the |
2 | Pennsylvania Chamber of Business and Industry. |
3 | (4) Two representatives of organized labor, one of whom |
4 | shall be appointed by the President pro tempore of the Senate |
5 | and one of whom shall be appointed by the Speaker of the |
6 | House of Representatives from a list of four qualified |
7 | persons recommended by the Pennsylvania AFL-CIO. |
8 | (5) One representative of consumers who is not primarily |
9 | involved in the provision of health care or health care |
10 | insurance, appointed by the Governor from a list of three |
11 | qualified persons recommended jointly by the President pro |
12 | tempore of the Senate and the Speaker of the House of |
13 | Representatives. |
14 | (6) One representative of hospitals, appointed by the |
15 | Governor from a list of three qualified hospital |
16 | representatives recommended by the Hospital and Health System |
17 | Association of Pennsylvania. |
18 | (7) One representative of physicians, appointed by the |
19 | Governor from a list of three qualified physician |
20 | representatives recommended jointly by the Pennsylvania |
21 | Medical Society and the Pennsylvania Osteopathic Medical |
22 | Society. |
23 | (8) One representative of nurses, appointed by the |
24 | Governor from a list of three qualified representatives |
25 | recommended by the Pennsylvania State Nurses Association. |
26 | (9) One representative of the Blue Cross and Blue Shield |
27 | plans in Pennsylvania, appointed by the Governor from a list |
28 | of three qualified persons recommended jointly by the Blue |
29 | Cross and Blue Shield plans of Pennsylvania. |
30 | (10) One representative of commercial insurance |
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1 | carriers, appointed by the Governor from a list of three |
2 | qualified persons recommended by the Insurance Federation of |
3 | Pennsylvania, Inc. |
4 | (c) Chairperson.--The appointment made by the Governor under |
5 | subsection (b)(1) shall serve as chairman of the committee. |
6 | (d) Quorum.--Eleven members shall constitute a quorum for |
7 | the transaction of any business, and the act by the majority of |
8 | the members present at any meeting in which there is a quorum |
9 | shall be deemed to be the act of the committee. |
10 | (e) Meetings.-- |
11 | (1) All meetings of the committee shall be advertised |
12 | and conducted pursuant to 65 Pa.C.S. Ch. 7 (relating to open |
13 | meetings). |
14 | (2) All action taken by the committee shall be taken in |
15 | open public session, and action of the committee shall not be |
16 | taken except upon the affirmative vote of a majority of the |
17 | members of the committee present during meetings at which a |
18 | quorum is present. |
19 | (f) Compensation and expenses.--The members of the committee |
20 | shall not receive a salary or per diem allowance for serving as |
21 | members of the committee but shall be reimbursed for actual and |
22 | necessary expenses incurred in the performance of their duties. |
23 | Expenses may include reimbursement of travel and living expenses |
24 | while engaged in committee business. |
25 | (g) Commencement of committee.-- |
26 | (1) Within 15 days after the effective date of this |
27 | section, each organization or individual required to submit a |
28 | list of recommended persons to the Governor, the President |
29 | pro tempore of the Senate or the Speaker of the House of |
30 | Representatives under subsection (b) shall submit the list. |
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1 | (2) Within 30 days of the effective date of this |
2 | section, the Governor, the President pro tempore of the |
3 | Senate and the Speaker of the House of Representatives shall |
4 | make the appointments called for in subsection (b), and the |
5 | committee shall begin operations immediately following the |
6 | appointments. |
7 | (h) Responsibilities of the committee.--The committee shall |
8 | have the following powers and duties: |
9 | (1) To study, review and recommend changes to this act. |
10 | (2) To accept and review suggested changes to this act |
11 | submitted by members of the committee. |
12 | (3) To approve, by a majority vote of the members of the |
13 | committee, a report recommending statutory changes to this |
14 | act. The report shall include, at a minimum, the following: |
15 | (i) The establishment of an Internet database for |
16 | the general public showing Medicare reimbursement rates |
17 | for common covered services and treatment. |
18 | (ii) In consultation with experts in the fields of |
19 | quality data and outcome measures, the definition and |
20 | implementation of: |
21 | (A) A methodology by provider type for the |
22 | council to risk adjust quality data. |
23 | (B) A methodology for the council to collect and |
24 | disseminate data reflecting provider quality and |
25 | provider service effectiveness. |
26 | (4) To submit the report approved under paragraph (3) to |
27 | the President pro tempore of the Senate and the Speaker of |
28 | the House of Representatives by April 30, 2009. |
29 | (i) Committee support.--The council shall offer staff and |
30 | administrative support from the council or its work groups |
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1 | necessary for the committee to carry out its duties under this |
2 | section. |
3 | Section 4. Section 19 of the act is amended to read: |
4 | Section 19. Sunset. |
5 | This act shall expire [June 30, 2008] June 30, 2013, unless |
6 | reenacted prior to that date. By September 1, [2007] 2012, a |
7 | written report by the Legislative Budget and Finance Committee |
8 | evaluating the management, visibility, awareness and performance |
9 | of the council shall be provided to the Public Health and |
10 | Welfare Committee of the Senate and the Health and Human |
11 | Services Committee of the House of Representatives. The report |
12 | shall include a review of the council's procedures and policies, |
13 | the availability and quality of data for completing reports [to |
14 | hospitals and outside vendor purchasers, the ability of the |
15 | council to become self-sufficient by selling data to outside |
16 | purchasers], whether there is a more cost-efficient way of |
17 | accomplishing the objectives of the council and the need for |
18 | reauthorization of the council. |
19 | Section 5. This act shall take effect as follows: |
20 | (1) The amendment of section 6 of the act shall take |
21 | effect January 1, 2010. |
22 | (2) The remainder of this act shall take effect |
23 | immediately. |
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