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PRIOR PRINTER'S NO. 2136
PRINTER'S NO. 2412
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1613
Session of
2017
INTRODUCED BY CUTLER, PICKETT, MILLARD, RYAN, MACKENZIE, BAKER,
DRISCOLL, SCHLOSSBERG, GREINER, A. HARRIS, WARD, KAUFFMAN,
ROTHMAN, ZIMMERMAN, GODSHALL, PHILLIPS-HILL, DAY, V. BROWN,
KAUFER, STURLA, MENTZER, GROVE, DeLUCA, FABRIZIO, MATZIE,
B. MILLER, WHEELAND AND WATSON, JUNE 23, 2017
AS REPORTED FROM COMMITTEE ON HEALTH, HOUSE OF REPRESENTATIVES,
AS AMENDED, SEPTEMBER 13, 2017
AN ACT
Amending Title 35 (Health and Safety) of the Pennsylvania
Consolidated Statutes, providing for the Health Care Cost
Containment Council, for its powers and duties, for health
care cost containment through the collection and
dissemination of data, for public accountability of health
care costs and for health care for the indigent and creating
incentives for hospitals and managed care organizations to
improve health care outcomes and to reduce unnecessary and
inappropriate services in the Commonwealth's medical
assistance program.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Title 35 of the Pennsylvania Consolidated
Statutes is amended by adding a part to read:
PART II
REGULATED ENTITIES
Chapter
33. Health Care Cost Containment
35. Health Care Outcomes
CHAPTER 33
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HEALTH CARE COST CONTAINMENT
Sec.
3301. Short title of chapter.
3302. Definitions.
3303. Health Care Cost Containment Council.
3304. Powers and duties of council.
3305. Data submission and collection.
3306. Data dissemination and publication.
3307. Mandated health benefits.
3308. Right-to-Know Law and access to council data.
3309. Special studies and reports.
3310. Enforcement and penalty.
3311. Research and demonstration projects.
3312. Grievances and grievance procedures.
3313. Antitrust provisions.
3314. Contracts with vendors.
3315. Reporting.
3316 . Severability.
§ 3301. Short title of chapter.
This chapter shall be known and may be cited as the Health
Care Cost Containment Act.
§ 3302. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Allowance." The maximum allowed combined payment from a
payor and a patient to a provider for services rendered.
"Ambulatory service facility." A facility licensed in this
Commonwealth which is not part of a hospital and which provides
medical, diagnostic or surgical treatment to patients not
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requiring hospitalization, including ambulatory surgical
facilities, ambulatory imaging or diagnostic centers, birthing
centers, freestanding emergency rooms and any other facilities
providing ambulatory care which charge a separate facility
charge. The term does not include the offices of private
physicians or dentists, whether for individual or group
practices.
"Charge" or "rate." The amount billed by a provider for
specific goods or services provided to a patient, prior to any
adjustment for contractual allowances.
"Council." The Health Care Cost Containment Council.
"Covered services." Any health care services or procedures
connected with episodes of illness or injury that require either
inpatient hospital care or major ambulatory service, including
any initial and follow-up outpatient services associated with
the episode of illness or injury before, during or after
inpatient hospital care or major ambulatory service. The term
does not include routine outpatient services connected with
episodes of illness that do not require hospitalization or major
ambulatory service.
"Data." Data collected by the council under section 3305
(relating to data submission and collection) . The term includes
raw data.
"Data source." The term includes a health care payor data
source and a provider.
"Elective health care payor data source." An entity,
including:
(1) An employer, labor union or health and welfare fund
jointly or separately administered by an employer or labor
union that purchases or self-funds a program of health care
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benefits for its Commonwealth resident employees or members
and their dependents; or
(2) A health benefit plan offered or administered by or
on behalf of the Federal Government for Pennsylvania
residents;
that elects to participate as a health care payor data source
under this act.
"Health care facility." A general or special hospital,
including:
(1) Psychiatric hospitals.
(2) Kidney disease treatment centers, including
freestanding hemodialysis units.
(3) Ambulatory service facilities.
(4) Hospices, including hospices operated by an agency
of State or local government.
"Health care insurer." A person, corporation or other entity
that offers administrative, indemnity or payment services for
health care in exchange for a premium or service charge under a
program of health care benefits, including, but not limited to:
(1) An insurance company, association or exchange
issuing health insurance policies in this Commonwealth
governed by the act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921.
(2) A hospital plan corporation as defined in 40 Pa.C.S.
Ch. 61 (relating to hospital plan corporations).
(3) A professional health service corporation as defined
in 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
(4) A health maintenance organization governed by the
act of December 29, 1972 (P.L.1701, No.364), known as the
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Health Maintenance Organization Act.
(5) A third-party administrator governed by Article X of
the act of May 17, 1921 (P.L.789, No.285), known as The
Insurance Department Act of 1921.
The term does not include employers, labor unions or health and
welfare funds jointly or separately administered by employers or
labor unions that purchase or self-fund a program of health care
benefits for their employees or members and their dependents.
"Health care payor data source." The term includes:
(1) A health care insurer.
(2) A government program to provide health care services
to persons in this Commonwealth, whether directly or
indirectly through contract, including any State program
established under Title XIX or Title XXI of the Social
Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.)
(3) A health benefit plan offered or administered by or
on behalf of the Commonwealth or an agency or instrumentality
of the Commonwealth.
(4) An elective health care payor data source.
(5) Any other payor for health care services in the
Commonwealth other than:
(i) an individual person; or
(ii) an entity that otherwise meets the definition
of an elective health care payor data source except that
the entity does not elect to participate as a health care
payor data source under this act.
"Health maintenance organization." An organized system which
combines the delivery and financing of health care and which
provides basic health services to voluntarily enrolled
subscribers for a fixed prepaid fee, as defined in the Health
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Maintenance Organization Act.
"Hospital." An institution licensed in this Commonwealth
which is:
(1) A general, mental, chronic disease or other type of
hospital.
(2) A kidney disease treatment center, including kidney
disease treatment centers operated by an agency of State or
local government.
"Major ambulatory service." Surgical or medical procedures,
including diagnostic and therapeutic radiological procedures,
commonly performed in hospitals or ambulatory service
facilities, which are not of a type commonly performed, or which
cannot be safely performed, in physicians' offices and which
require special facilities such as operating rooms or suites or
special equipment such as fluoroscopic equipment or computed
tomographic scanners, or a postprocedure recovery room or short-
term convalescent room.
"Medical procedure incidence variations." The variation in
the incidence in the population of specific medical, surgical
and radiological procedures in any given year, expressed as a
deviation from the norm, as these terms are defined in the
classical statistical definition of "variation," "incidence,"
"deviation" and "norm."
"Payment." The payments that providers actually accept for
their services, exclusive of charity care, rather than the
charges they bill.
"Payor." Any person or entity, including, but not limited
to, health care insurers and purchasers, that make direct
payments to providers for covered services.
"Physician." An individual licensed under the laws of this
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Commonwealth to practice medicine and surgery within the scope
of the act of October 5, 1978 (P.L.1109, No.261), known as the
Osteopathic Medical Practice Act, or the act of December 20,
1985 (P.L.457, No.112), known as the Medical Practice Act of
1985.
"Preferred provider organization." Any arrangement between a
health care insurer and providers of health care services which
specifies rates of payment to such providers which differ from
their usual and customary charges to the general public and
which encourages enrollees to receive health services from such
providers.
"Provider." A hospital, a health care facility, an
ambulatory service facility or a physician.
"Provider quality." The extent to which a provider renders
care that, within the capabilities of modern medicine, obtains
for patients medically acceptable health outcomes and prognoses,
adjusted for patient severity, and treats patients
compassionately and responsively.
"Provider service effectiveness." The effectiveness of
services rendered by a provider, determined by measurement of
the medical outcome of patients grouped by severity receiving
those services.
"Purchaser." Corporations, labor organizations or other
entities that purchase benefits which provide covered services
for their employees or members, either through a health care
insurer or by means of a self-funded program of benefits, and a
certified bargaining representative that represents a group or
groups of employees for whom employers purchase a program of
benefits which provide covered services, but excluding any
entity defined in this section as a "health care insurer ."
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"Severity." In any patient, the measureable degree of the
potential for failure of one or more vital organs.
§ 3303. Health Care Cost Containment Council.
(a) Establishment.--The Health Care Cost Containment Council
is established as an independent council.
(b) Composition.--The council shall consist of voting
members, composed of and appointed in accordance with the
following:
(1) The Secretary of Health.
(2) The Secretary of Human Services.
(3) The Insurance Commissioner.
(4) Six representatives of the business community, at
least one of whom represents small business, who are
purchasers of health care, none of which is primarily
involved in the provision of health care or health insurance,
three of which shall be appointed by the President pro
tempore of the Senate and three of which shall be appointed
by the Speaker of the House of Representatives from a list of
12 qualified persons recommended by the Pennsylvania Chamber
of Business and Industry. Three nominees shall be
representatives of small business.
(5) Six representatives of organized labor, three of
which shall be appointed by the President pro tempore of the
Senate and three of which shall be appointed by the Speaker
of the House of Representatives from a list of twelve
qualified persons recommended by the Pennsylvania AFL-CIO.
(6) One representative of consumers who is not primarily
involved in the provision of health care or health care
insurance, appointed by the Governor from a list of three
qualified persons recommended jointly by the Speaker of the
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House of Representatives and the President pro tempore of the
Senate.
(7) Two representatives of hospitals, appointed by the
Governor from a list of five qualified hospital
representatives recommended by the Hospital and Health System
Association of Pennsylvania one of whom shall be a
representative of rural hospitals. Each representative under
this paragraph may appoint two additional delegates to act
for the representative only at meetings of committees, as
provided for in subsection (f).
(8) Two representatives of physicians, appointed by the
Governor from a list of five qualified physician
representatives recommended jointly by the Pennsylvania
Medical Society and the Pennsylvania Osteopathic Medical
Society. The representative under this paragraph may appoint
two additional delegates to act for the representative only
at meetings of committees, as provided for in subsection (f).
(8.1) An individual appointed by the Governor who has
expertise in the application of continuous quality
improvement methods in hospitals.
(8.2) One representative of nurses, appointed by the
Governor from a list of three qualified representatives
recommended by the Pennsylvania State Nurses Association.
(9) One representative of the Blue Cross and Blue Shield
plans in Pennsylvania, appointed by the Governor from a list
of three qualified persons recommended jointly by the Blue
Cross and Blue Shield plans of Pennsylvania.
(10) One representative of commercial insurance
carriers, appointed by the Governor from a list of three
qualified persons recommended by the Insurance Federation of
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Pennsylvania, Inc.
(11) One representative of health maintenance
organizations, appointed by the Governor, from a list of
three qualified persons recommended by the Managed Care
Association of Pennsylvania.
(12) Representatives from the General Assembly as
follows:
(i) One Senator appointed by the President pro
tempore of the Senate.
(ii) One member of the House of Representatives
appointed by the Speaker of the House of Representatives.
(13) In the case of each appointment to be made from a
list supplied by a specified organization, it is incumbent
upon that organization to consult with and provide a list
which reflects the input of other equivalent organizations
representing similar interests. Each appointing authority
will have the discretion to request additions to the list
originally submitted. Additional names will be provided not
later than 15 days after such request. Appointments shall be
made by the appointing authority no later than 90 days after
receipt of the original list. If, for any reason, any
specified organization supplying a list should cease to
exist, then the respective appointing authority shall specify
an equivalent organization to fulfill the responsibilities
set forth in this chapter .
(c) Chairperson and vice chairperson.--The members shall
annually elect, by a majority vote of the members, a chairperson
and a vice chairperson of the council from among the members the
council.
(d) Quorum.--Eleven members, at least four of whom shall be
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council members under subsection (b)(5) through (12), shall
constitute a quorum for the transaction of any business, and the
act by the majority of the members present at any meeting in
which there is a quorum shall be deemed to be the act of the
council. A quorum may be met by members who are attending by
electronic means under subsection (e)(1).
(e) Meetings.--All meetings of the council shall be
advertised and conducted under 65 Pa.C.S. Ch. 7 (relating to
open meetings), unless otherwise provided in this section. The
following apply:
(1) The council shall meet at least once every two
months and may provide for special meetings as it deems
necessary. Meeting dates shall be set by a majority vote of
the members of the council or by the call of the chairperson
upon seven days' notice to council members. Attendance at the
meeting may be accomplished by electronic means so long as
each council member attending via electronic means can
communicate in real time with the other members of the
council.
(2) All meetings of the council shall be publicly
advertised, as provided for in this subsection, and shall be
open to the public, except that the council, through its
bylaws, may provide for executive sessions of the council on
subjects permitted to be discussed in such sessions under 65
Pa.C.S. Ch. 7. No act of the council shall be taken in an
executive session.
(3) The council shall publish a schedule of its meetings
in the Pennsylvania Bulletin and on its publicly accessible
Internet website. The notice shall be published at least once
in each calendar quarter and shall list the schedule of
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meetings of the council to be held in the subsequent calendar
quarter. The notice shall specify the date, time and place of
the meeting and shall state that the council's meetings are
open to the general public, except that no notice shall be
required for executive sessions of the council.
(4) All action taken by the council shall be taken in
open public session, and action of the council shall not be
taken except upon the affirmative vote of a majority of the
members of the council present during meetings at which a
quorum is present.
(f) Bylaws.--The council shall adopt bylaws, not
inconsistent with this chapter, and may appoint such committees
or elect such officers subordinate to those provided for in
subsection (c) as it deems advisable.
(g) Technical advisory group.--
(1) The council shall appoint a technical advisory group
which shall, on an ad hoc basis, respond to issues presented
to it by the council or committees of the council and shall
make recommendations to the council. The technical advisory
group shall include:
(i) Physicians.
(ii) Researchers.
(iii) Biostatisticians.
(iv) One representative of the Hospital and
Healthsystem Association of Pennsylvania.
(v) One representative of the Pennsylvania Medical
Society.
(2) The Hospital and Healthsystem Association of
Pennsylvania and the Pennsylvania Medical Society
representatives shall not be subject to executive committee
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approval. In appointing other physicians, researchers and
biostatisticians to the technical advisory group, the council
shall consult with and take nominations from the
representatives of:
(i) the Hospital Association of Pennsylvania;
(ii) the Pennsylvania Medical Society;
(iii) the Pennsylvania Osteopathic Medical Society;
or
(iv) other like organizations.
(3) At its discretion and in accordance with this
section, nominations shall be approved by the executive
committee of the council. If the subject matter of any
project exceeds the expertise of the technical advisory
group, physicians in appropriate specialties who possess
current knowledge of the issue under study may be consulted.
The technical advisory group shall also review the
availability and reliability of severity of illness
measurements as they relate to small hospitals and
psychiatric, rehabilitation and children's hospitals and
shall make recommendations to the council based upon this
review. Meetings of the technical advisory group shall be
open to the general public.
(h) Payment data advisory group.--
(1) In order to assure the technical appropriateness and
accuracy of payment data, the council shall establish a
payment data advisory group to produce recommendations
surrounding the collection of payment data, the analysis and
manipulation of payment data and the public reporting of
payment data. The payment data advisory group shall include
technical experts and individuals knowledgeable in payment
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systems and claims data. The advisory group shall consist of
the following members appointed by the council:
(i) One member representing each plan under 40
Pa.C.S. Chs. 61 (relating to hospital plan corporations)
and 63 (relating to professional health services plan
corporations ).
(ii) Two members representing commercial insurance
carriers.
(iii) Three members representing health care
facilities.
(iv) Three members representing physicians.
(2) The payment data advisory group shall meet at least
four times a year and may provide for special meetings as may
be necessary.
(3) The payment data advisory group shall review and
concur with the technical appropriateness of the use and
presentation of data and report its findings to the council
prior to any vote to publicly release reports. If the council
elects to release a report without addressing the technical
concerns of the advisory group, it shall prominently disclose
this in the public report and include the comments of the
advisory group in the public report.
(4) The payment data advisory group shall exercise all
powers necessary and appropriate to carry out its duties,
including advising the council on the following:
(i) Collection of payment data by the council.
(ii) Manipulation, adjustments and methods used with
payment data.
(iii) Public reporting of payment data by the
council.
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(i) Compensation and expenses.--The members of the council
and any member of an advisory group appointed by the council
shall not receive a salary or per diem allowance for serving as
members or advisors of the council, but shall be reimbursed for
actual and necessary expenses incurred in the performance of
their duties. The expenses may include reimbursement of travel
and living expenses while engaged in council business.
(j) Terms of council members.--
(1) The terms of the Secretary of Health, the Secretary
of Human Services, the Insurance Commissioner and the
legislative representatives shall be concurrent with their
holding of public office. The council members under
subsection (b)(5) through (12) shall each serve for a term of
four years and shall continue to serve thereafter until their
successors are appointed.
(2) Vacancies on the council shall be filled in the
manner designated under subsection (b), within 60 days of the
vacancy, except that, when vacancies occur among the
representatives of business or organized labor, two
nominations shall be submitted by the organization specified
in subsection (b) for each vacancy on the council. If the
officer required in subsection (b) to make appointments to
the council fails to act within 60 days of the vacancy, the
council chairperson may appoint one of the persons
recommended for the vacancy until the appointing authority
makes the appointment.
(3) Except for the Secretary of Health, the Secretary of
Human Services, the Insurance Commissioner and the
legislative representatives, a member may be removed for just
cause by the appointing authority after recommendation by a
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vote of at least 14 members of the council.
(4) No appointed member under subsection (b)(5) through
(12) shall be eligible to serve more than two full
consecutive terms of four years beginning on the effective
date of this paragraph.
(k) Subsequent appointments.--Submission of lists of
recommended persons and appointments of council members for
succeeding terms shall be made in the same manner as prescribed
in subsection (b), except that:
(1) Organizations required under subsection (b) to
submit lists of recommended persons shall do so at least 60
days prior to expiration of the council members' terms.
(2) The officer required under subsection (b) to make
appointments to the council shall make the appointments at
least 30 days prior to expiration of the council members'
terms. If the appointments are not made within the specified
time, the council chairperson may make interim appointments
from the lists of recommended individuals. An interim
appointment shall be valid only until the appropriate officer
under subsection (b) makes the required appointment. Whether
the appointment is by the required officer or by the
chairperson of the council, the appointment shall become
effective immediately upon expiration of the incumbent
member's term.
§ 3304 . Powers and duties of council.
(a) General powers.--The council shall exercise all powers
necessary and appropriate to carry out its duties, including the
following:
(1) To employ an executive director, investigators and
other staff necessary to comply with the provisions of this
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chapter and regulations promulgated thereunder, to employ or
retain legal counsel and to engage professional consultants,
as it deems necessary to the performance of its duties. Any
consultants, other than sole source consultants, engaged by
the council shall be selected in accordance with the
provisions for contracting with vendors set forth in section
3314 (relating to contracts with vendors).
(2) To fix the compensation of all employees and to
prescribe their duties. Notwithstanding the independence of
the council under section 3303(a) (relating to Health Care
Cost Containment Council) , employees under this paragraph
shall be deemed employees of the Commonwealth for the
purposes of participation in the Pennsylvania Employee
Benefit Trust Fund.
(3) To make and execute contracts and other instruments,
including those for purchase of services and purchase or
leasing of equipment and supplies, necessary or convenient to
the exercise of the powers of the council. Any such contract
shall be in accordance with the provision for contracting
with vendors set forth in section 3314. This requirement does
not include the execution of lease agreements for office
space so long as the Commonwealth or a Commonwealth agency
has available office space within a 10-mile radius of
Harrisburg, Pennsylvania, which may be utilized by the
council.
(4) To conduct examinations and investigations, to
conduct audits, under the provisions of subsection (c), and
to hear testimony and take proof, under oath or affirmation,
at public or private hearings, on any matter necessary to its
duties.
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(5) To provide hospitals with individualized data on
patient safety indicators under section 3305(c)(8) (relating
to data submission and collection) . The data shall be risk
adjusted and made available to hospitals electronically and
free of charge on a quarterly basis within 45 days of receipt
of the corrected quarterly data from the hospitals. The data
is intended to provide the patient safety committee of each
hospital with information necessary to assist in conducting
patient safety analysis.
(6) To do all things necessary to carry out its duties
under the provisions of this chapter.
(b) Rules and regulations.--
(1) The council may promulgate rules and regulations as
necessary and appropriate to implement this act.
(2) Regulations promulgated by the council shall be
promulgated in accordance with the act of June 25, 1982
(P.L.633, No.181), known as the Regulatory Review Act.
(3) Rules and regulations in effect prior to the
effective date of this section shall remain in effect.
(c) Audit powers.--The council shall have the right to
independently audit all information required to be submitted by
data sources as needed to corroborate the accuracy of the
submitted data, pursuant to the following:
(1) Audits of information submitted by providers or
health care insurers shall be performed on a sample and
issue-specific basis, as needed by the council, and shall be
coordinated, to the extent practicable, with audits performed
by the Commonwealth. All health care insurers and providers
are hereby required to make those books, records of accounts
and any other data needed by the auditors available to the
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council at a convenient location within 30 days of written
notification by the council.
(2) Audits of information submitted by purchasers shall
be performed on a sample basis, unless there exists
reasonable cause to audit specific purchasers, but in no case
shall the council have the power to audit financial
statements of purchasers.
(3) All audits performed by the council shall be
performed at the expense of the council.
(4) The results of audits of providers or health care
insurers shall be provided to the audited providers and
health care insurers on a timely basis, not to exceed 30 days
beyond presentation of audit findings to the council.
(d) General duties and functions.--The council is hereby
authorized to and shall perform the following duties and
functions:
(1) Develop a computerized system for the collection,
analysis and dissemination of data. The council may contract
with a vendor who will provide data processing services. The
council shall assure that the system will be capable of
processing all data required to be collected under this
chapter. Any vendor selected by the council shall be selected
in accordance with the provisions of section 3314, and the
vendor shall relinquish any and all proprietary rights or
claims to the database created as a result of implementation
of the data processing system.
(2) Establish a Pennsylvania Uniform Claims and Billing
Form for all data sources and all providers, which shall be
utilized and maintained by all data sources and all providers
for all services covered under this chapter.
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(3) Establish a health care payor claims data submission
manual for all health care payor data sources. The manual
shall be utilized by all health care payor data sources to
submit data to be used by the council to establish and
maintain a health care payor claims database.
(4) Collect and disseminate data, as specified in
sections 3305 and 3306 (relating to data dissemination and
publication), and other information from data sources to
which the council is entitled, prepared according to formats,
time frames and confidentiality provisions as specified in
sections 3305 and 3308 (relating to Right-to-Know Law and
access to council data), and by the council. The council
shall begin collection of the data identified in paragraph
(3) within 12 months of the effective date of this section.
(5) Adopt and implement a methodology to collect and
disseminate data reflecting provider quality, provider
service effectiveness, utilization and the cost of health
care services under sections 3305 and 3306.
(6) Subject to the restrictions on access to raw data
set forth in section 3308, issue special reports and make
available raw data to a purchaser requesting it. Sale by a
recipient or exchange or publication by a recipient, other
than a purchaser, of council raw data to other parties
without the express written consent of, and under terms
approved by, the council shall be unauthorized use of data
under section 3308(d).
(7) On an annual basis, publish in the Pennsylvania
Bulletin a list of all the raw data reports it has prepared
under section 3308(g) and a description of the data obtained
through each computer-to-computer access it has provided
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under section 3308(g) and of the names of the parties to whom
the council provided the reports or the computer-to-computer
access during the previous month.
(8) Promote competition in the health care and health
insurance markets.
(9) Assure that the use of council data does not raise
access barriers to care.
(10) Provide information on the allowed and paid costs
of medical services in terminology that may be reasonably
understood by the average individual consumer of health care
services. The council shall present the cost information in
conjunction with information on quality of care delivery, if
quality information is reasonably available to the council,
so that the average individual consumer of health care
services may use the information to inform purchasing
decisions.
(11) Make annual reports to the General Assembly on the
rate of increase in the cost of health care in this
Commonwealth, including, but not limited to, the following:
(i) The rate of increase in health insurance
premiums in this Commonwealth.
(ii) Regional trends in cost of health care and
health insurance premiums.
(iii) The effectiveness of the council in carrying
out the legislative intent of this chapter.
(iv) The quality and effectiveness of health care
and access to health care for all citizens of this
Commonwealth.
(12) In the discretion of the council, make
recommendations on the need for further health care cost
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containment legislation.
(13) Conduct studies and publish reports analyzing the
effects that outpatient, alternative health care delivery
systems have on health care costs. The systems shall include,
but are not limited to, health maintenance organizations
(HMOs); preferred provider organizations (PPOs); primary
health care facilities; home health care; attendant care;
ambulatory service facilities; freestanding emergency
centers; birthing centers; and hospice care. The reports
shall be submitted to the General Assembly and shall be made
available to the public.
(14) Conduct studies and make reports concerning the
utilization of experimental and nonexperimental transplant
surgery and other highly technical and experimental
procedures, including costs and mortality rates.
§ 3305. Data submission and collection.
(a) Submission of data.--
(1) The council is authorized to collect and data
sources are required to submit, upon request of the council,
all data required in this section, according to uniform
submission formats, coding systems, the health care payor
claims data submission manual and other technical
specifications necessary to render the incoming data
substantially valid, consistent, compatible and manageable
using electronic data processing according to data submission
schedules. The schedules shall avoid, to the extent possible,
submission of identical data from more than one data source.
The uniform submission formats, coding systems and other
technical specifications may be established by the council
pursuant to its authority under section 3304(b) (relating to
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powers and duties of council). If payor data is requested by
the council, it shall, to the extent possible, be obtained
from primary payor sources. The council shall not require any
data source to contract with any specific vendor for
submission of any specific data elements to the council.
(2) In carrying out its responsibilities, the council
shall not require health care facilities to report data
elements which are not included in the manual developed by
the National Uniform Billing Committee. The council shall
publish in the Pennsylvania Bulletin a list of no more than
35 diseases, procedures and medical conditions for which data
under subsections (c)(22) and (e) (D) shall be required. The
list shall not represent more than 50% of total hospital
discharges, based upon the previous year's hospital discharge
data. Subsequent to the publication of the list, any data
submission requirements under subsections (c)(22) and (e) (D)
previously in effect shall be null and void for diseases,
procedures and medical conditions not found on the list. All
other data elements under subsection (c) shall continue to be
required from data sources. The council shall review the list
and may add no more than a net of three diseases, procedures
or medical conditions per year over a five-year period. The
adjusted list of diseases, procedures and medical conditions
shall at no time be more than 50% of total hospital
discharges.
(b) Pennsylvania Uniform Claims and Billing Form.--The
council shall maintain a Pennsylvania Uniform Claims and Billing
Form format. The council shall furnish the claims and billing
form format to all data sources, and the claims and billing form
shall be utilized and maintained by all data sources for all
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services covered by this chapter. The Pennsylvania Uniform
Claims and Billing Form shall consist of the Uniform Hospital
Billing Form, as developed by the National Uniform Billing
Committee, with additional fields as necessary to provide all of
the data set forth in subsections (c) and (e) and those data
elements identified in subsection (d) that, in the council's
discretion, should be included (D) .
(c) Data elements.--For each covered service performed in
this Commonwealth, the council shall be required to collect the
following data elements:
(1) uniform patient identifier, continuous across
multiple episodes and providers;
(2) patient date of birth;
(3) patient sex;
(4) patient race, consistent with the method of
collection of race/ethnicity data by the United States Bureau
of the Census and the United States Standard Certificates of
Live Birth and Death;
(5) patient zip code number;
(6) date of admission;
(7) date of discharge;
(8) principal and secondary diagnoses by standard code,
including external cause of injury, complication, infection
and childbirth;
(9) principal procedure by council-specified standard
code and date;
(10) up to three secondary procedures by council-
specified standard codes and dates;
(11) uniform health care facility identifier, continuous
across episodes, patients and providers;
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(12) uniform identifier of admitting physician, by
unique physician identification number established by the
council, continuous across episodes, patients and providers;
(13) uniform identifier of consulting physicians, by
unique physician identification number established by the
council, continuous across episodes, patients and providers;
(14) total charges of health care facility, segregated
into major categories, including, but not limited to, room
and board, radiology, laboratory, operating room, drugs,
medical supplies and other goods and services according to
guidelines specified by the council;
(15) actual payments to health care facility,
segregated, if available, according to the categories
specified in paragraph (14);
(16) charges of each physician or professional rendering
service relating to an incident of hospitalization or
treatment in an ambulatory service facility;
(17) actual payments to each physician or professional
rendering service under paragraph (16);
(18) uniform identifier of primary payor;
(19) zip code number of facility where health care
service is rendered;
(20) uniform identifier for payor group contract number;
(21) patient discharge status; and
(22) provider service effectiveness and provider quality
under section 3304(d).
(d) Pennsylvania health care payor claims data submission
manual.--
(1) The health care payor claims data submission manual
shall define the data elements needed to establish and
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maintain a health care payor claims database for all claims
paid on behalf of patients receiving health care in this
Commonwealth. The health care payor claims database shall not
be limited in its data collection by the definition of
"covered services" in section 3302 (relating to definitions).
A health care payor data source shall comply with the manual
to submit data.
(2) The health care payor claims data submission manual
shall use and build upon existing data collection standards
and methods, and shall include, for each claim, including
each medical, dental and pharmacy claim:
(i) Each of the uniform identifier data elements set
forth in subsection (c).
(ii) Other eligibility and provider data files
associated with the claim as necessary;
(iii) The billed, allowed and paid amounts; and
(iv) Other data elements, as identified in the
health care payor claims data submission manual, to
further the intent of this chapter, including:
(A) Additional patient and provider identifiers.
(B) Patient demographic information.
(C) Data necessary to identify the date and time
of service and the location and type of provider and
facility, such as a hospital, office or clinic.
(D) Data describing the nature of health care
services provided to the patient, including diagnosis
codes.
(E) Other data relating to health care costs,
prices and utilization.
(e) (D) Provider quality and provider service effectiveness
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data elements.--In carrying out its duty to collect data on
provider quality and provider service effectiveness under
subsection (c)(22) and section 3304 (d)(5), the council shall
define a methodology to measure provider service effectiveness,
which may include additional data elements to be specified by
the council sufficient to carry out its responsibilities under
section 3304 (d)(5). The council shall not require health care
insurers to report on data elements that are not reported to
nationally recognized accrediting organizations, to the
Department of Health, the Department of Human Services or the
Insurance Department, in quarterly or annual reports. The
council shall not require reporting by health care insurers in
different formats than are required for reporting to nationally
recognized accrediting organizations or on quarterly or annual
reports submitted to the Department of Health, the Department of
Human Services or the Insurance Department. The council may
adopt the quality findings as reported to nationally recognized
accrediting organizations. Additional quality data elements must
be defined and released for public comment prior to use.
(f) (E) Reserve field utilization and addition or deletion
of data elements.--The council shall include in the Pennsylvania
Uniform Claims and Billing Form a reserve field. The council may
utilize the reserve field by adding other data elements beyond
those required to carry out its responsibilities under
subsections (c) and (e) (D) and section 3304(d)(4) and (5), or
the council may delete data elements from the Pennsylvania
Uniform Claims and Billing Form only by a majority vote of the
council and only pursuant to the following procedure:
(1) The council shall obtain a cost-benefit analysis of
the proposed addition or deletion which shall include the
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cost to data sources of any proposed additions.
(2) The council shall publish notice of the proposed
addition or deletion, along with a copy or summary of the
cost-benefit analysis, in the Pennsylvania Bulletin, and the
notice shall include provision for a 60-day comment period.
(3) The council may hold additional hearings or request
such other reports as it deems necessary and shall consider
the comments received during the 60-day comment period and
any additional information gained through the hearings or
other reports in making a final determination on the proposed
addition or deletion.
(g) (F) Other data required to be submitted.--Each provider
and health care payor data source is hereby required to submit,
and the council is hereby authorized to collect, in accordance
with submission dates and schedules established by the council,
the following additional data in its possession, provided the
data is not available to the council from public records:
(1) Audited annual financial reports of all hospitals
and ambulatory service facilities providing covered services
as defined in section 3302.
(2) The Medicare cost report for Medical Assistance or
successor forms, including the settled Medicare cost report.
(3) Additional data, including, but not limited to, data
which can be used in reports about:
(i) the incidence of medical and surgical procedures
in the population for individual providers;
(ii) physicians who provide covered services and
accept medical assistance patients;
(iii) physicians who provide covered services and
accept Medicare assignment as full payment;
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(iv) mortality rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(v) rates of infection for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(vi) morbidity rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(vii) readmission rates for specified diagnoses and
treatments, grouped by severity, for individual
providers;
(viii) rate of incidence of postdischarge
professional care for selected diagnoses and procedures,
grouped by severity, for individual providers; and
(ix) data from other public sources.
(4) Any other data the council requires to carry out its
responsibilities under section 3304(d).
(h) (G) Review and correction of data.--The council shall
provide a reasonable period for data sources to review and
correct the data submitted under this section which the council
intends to prepare and issue in reports to the General Assembly,
to the general public or in special studies and reports under
section 3309 (relating to special studies and reports). When
corrections are provided, the council shall correct the
appropriate data in its data files and subsequent reports.
(i) (H) Allowance for clarification or dissents.--The
council shall maintain a file of written statements submitted by
data sources who wish to provide an explanation of data that
they feel might be misleading or misinterpreted. The council
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shall provide access to the file to any person and shall, where
practical, in its reports and data files indicate the
availability of such statements. When the council agrees with
such statements, it shall correct the appropriate data and
comments in its data files and subsequent reports.
(j) (I) Allowance for correction.--The council shall verify
the patient safety indicator data submitted by hospitals under
subsection (c)(8) within 60 days of receipt. The council may
allow hospitals to make changes to the data submitted during the
verification period. After the verification period, but within
45 days of receipt of the adjusted hospital data, the council
shall risk adjust the information and provide reports to the
patient safety committee of the relevant hospital.
(k) (J) Availability of data.--Nothing in this chapter shall
prohibit a purchaser from obtaining from its health care
insurer, nor relieve the health care insurer from the obligation
of providing the purchaser, on terms consistent with past
practices, data previously provided or additional data not
currently provided to the purchaser by the health care insurer
pursuant to any existing or future arrangement, agreement or
understanding.
§ 3306. Data dissemination and publication.
(a) Public reports.--Subject to the restrictions on access
to council data set forth in section 3308 (relating to Right-to-
Know Law and access to council data) and utilizing the data
collected under section 3305 (relating to data submission and
collection), as well as other data, records and matters of
record available to it, the council shall prepare and issue
reports to the General Assembly and to the general public
according to the following provisions:
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(1) The council shall, for every provider of both
inpatient and outpatient services within this Commonwealth
and within appropriate regions and subregions, prepare and
issue reports on provider quality and service effectiveness
on diseases or procedures that, when ranked by volume, cost,
payment and high variation in outcome, represent the best
opportunity to improve overall provider quality, improve
patient safety and provide opportunities for cost reduction.
These reports shall provide comparative information on the
following:
(i) Differences in mortality rates; differences in
length of stay; differences in complication rates;
differences in readmission rates; differences in
infection rates; and other comparative outcome measures
the council may develop that will allow purchasers,
providers and consumers to make purchasing and quality
improvement decisions based upon quality patient care and
to restrain costs.
(ii) The incidence rate of selected medical or
surgical procedures, the quality and service
effectiveness and the payments received for those
providers, identified by the name and type or specialty,
for which these elements vary significantly from the
norms for all providers.
(2) In preparing its reports under paragraph (1), the
council shall ensure that factors which have the effect of
either reducing provider revenue or increasing provider costs
and other factors beyond a provider's control which reduce
provider competitiveness in the marketplace are explained in
the reports. The council shall also ensure that any
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clarifications and dissents submitted by individual providers
under section 3305(i) 3305(H) are noted in any reports that
include release of data on that individual provider.
(b) Raw data reports and computer access to council data.--
The council shall provide special reports derived from raw data
and a means for computer-to-computer access to its raw data to a
purchaser under section 3308(g). The council shall provide the
reports and computer-to-computer access, at its discretion, to
other parties under section 3308(i). The council shall provide
these special reports and computer-to-computer access in as
timely a fashion as the council's responsibilities to publish
the public reports required in this section will allow. Any
provision of special reports or computer-to-computer access by
the council shall be made only subject to the restrictions on
access to raw data set forth in section 3308(c) and only after
payment for costs of preparation or duplication under section
3308(g) or (i).
§ 3307. Mandated health benefits.
In relation to current law or proposed legislation, the
council shall, upon the request of the appropriate committee
chairman in the Senate and in the House of Representatives or
upon the request of the Secretary of Health or the Secretary of
Human Services, provide information on the proposed mandated
health benefit pursuant to the following:
(1) The General Assembly hereby declares that proposals
for mandated health benefits or mandated health insurance
coverage should be accompanied by adequate, independently
certified documentation defining the social and financial
impact and medical efficacy of the proposal. To that end, the
council, upon receipt of such requests, is hereby authorized
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to conduct a preliminary review of the material submitted by
both proponents and opponents concerning the proposed
mandated benefit. If, after this preliminary review, the
council is satisfied that both proponents and opponents have
submitted sufficient documentation necessary for a review
under paragraphs (3) and (4), the council is directed to
contract with individuals, pursuant to the selection
procedures for vendors set forth in section 3314 (relating to
contracts with vendors), who will constitute a Mandated
Benefits Review Panel to review mandated benefits proposals
and provide independently certified documentation, as
provided for in this section.
(2) The panel shall consist of the following senior
researchers, each of whom shall be a recognized expert:
(i) one in health research;
(ii) one in biostatistics;
(iii) one in economic research;
(iv) one, a physician, in the appropriate specialty
with current knowledge of the subject being proposed as a
mandated benefit; and
(v) one with experience in insurance or actuarial
research.
(3) The Mandated Benefits Review Panel shall have the
following duties and responsibilities:
(i) To review documentation submitted by a person
proposing or opposing mandated benefits within 90 days of
submission of the documentation to the panel.
(ii) To report to the council, pursuant to the
council's review under subparagraph (i), the following:
(A) Whether or not the documentation is complete
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as defined in paragraph (4).
(B) Whether or not the research cited in the
documentation meets professional standards.
(C) Whether or not all relevant research
respecting the proposed mandated benefit has been
cited in the documentation.
(D) Whether or not the conclusions and
interpretations in the documentation are consistent
with the data submitted.
(4) A person proposing or opposing legislation mandating
benefits coverage should, to provide the Mandated Benefits
Review Panel with sufficient information to carry out the
Mandated Benefits Review Panel's duties and responsibilities
under paragraph (3), submit documentation to the council,
pursuant to the procedure established under paragraph (5),
which demonstrates the following:
(i) The extent to which the proposed benefit and the
services the proposed benefit would provide are needed
by, available to and utilized by the population of this
Commonwealth.
(ii) The extent to which insurance coverage for the
proposed benefit already exists or, if no coverage
exists, the extent to which the lack of coverage results
in inadequate health care or financial hardship for the
population of this Commonwealth.
(iii) The demand for the proposed benefit from the
public and the source and extent of opposition to
mandating the benefit.
(iv) All relevant findings bearing on the social
impact of the lack of the proposed benefit.
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(v) If the proposed benefit mandates coverage of a
particular therapy, the results of at least one
professionally accepted, controlled trial comparing the
medical consequences of the proposed therapy, alternative
therapies and no therapy.
(vi) If the proposed benefit mandates coverage of an
additional class of practitioners, the results of at
least one professionally accepted, controlled trial
comparing the medical results achieved by the additional
class of practitioners and those practitioners already
covered by benefits.
(vii) The results of any other relevant research.
(viii) Evidence of the financial impact of the
proposed legislation, including at least the following:
(A) The extent to which the proposed benefit
would increase or decrease cost for treatment or
service.
(B) The extent to which similar mandated
benefits in other states have affected charges, costs
and payments for services.
(C) The extent to which the proposed benefit
would increase the appropriate use of the treatment
or service.
(D) The impact of the proposed benefit on
administrative expenses of health care insurers.
(E) The impact of the proposed benefits on
benefits costs of purchasers.
(F) The impact of the proposed benefits on the
total cost of health care within this Commonwealth.
(5) The procedure for review of documentation shall be
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as follows:
(i) A person wishing to submit information on
proposed legislation mandating insurance benefits for
review by the panel must submit the documentation
specified under paragraph (4) to the council.
(ii) The council shall, within 30 days of receipt of
the documentation:
(A) Publish in the Pennsylvania Bulletin notice
of receipt of the documentation, a description of the
proposed legislation, provision for a period of 60
days for public comment and the time and place at
which a person may examine the documentation.
(B) Submit copies of the documentation to the
Secretary of Health, the Secretary of Human Services
and the Insurance Commissioner, who shall review and
submit comments to the council on the proposed
legislation within 30 days.
(C) Submit copies of the documentation to the
panel, which shall review the documentation and issue
their findings, subject to paragraph (3), within 90
days.
(iii) Upon receipt of the comments of the Secretary
of Health, the Secretary of Human Services and the
Insurance Commissioner and of the findings of the panel,
under subparagraph (ii), but no later than 120 days
following the publication required in subparagraph (ii),
the council shall submit the comments and findings,
together with the council's recommendations respecting
the proposed legislation, to the Governor, the President
pro tempore of the Senate, the Speaker of the House of
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Representatives, the Secretary of Health, the Secretary
of Human Services, the Insurance Commissioner and the
person who submitted the information under subparagraph
(i).
§ 3308. Right-to-Know Law and access to council data.
(a) Public access.--The information and data received by the
council shall be utilized by the council for the benefit of the
public and public officials. Subject to the specific limitations
set forth in this section and section 3101.1 of the act of
February 14, 2008 (P.L.6, No.3), known as the Right-to-Know Law,
the council shall make determinations on requests for
information in favor of access.
(b) Outreach programs.--The council shall develop and
implement outreach programs designed to make the council's
information understandable and usable to purchasers, providers,
other Commonwealth agencies and the general public. The programs
shall include efforts to educate through pamphlets, booklets,
seminars and other appropriate measures and to facilitate making
more informed health care choices.
(c) Limitations on access. --Unless specifically provided for
under this chapter, neither the council nor any contracting
system vendor shall release and no data source, person, member
of the public or other user of any data of the council shall
gain access to:
(1) Any raw data of the council which could reasonably
be expected to reveal the identity of an individual patient.
(2) Any raw data of the council which could reasonably
be expected to reveal the identity of any purchaser, other
than a purchaser requesting data on the purchaser's own group
or an entity entitled to the purchaser's data under
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subsection (g).
(3) Any raw data disclosing discounts or allowances
between identified payors and providers which is prejudicial
to an individual payor or provider.
(d) Unauthorized use of data.--A person who knowingly
releases council data violating raw data safeguards under this
section to an unauthorized person commits a misdemeanor of the
first degree and shall, upon conviction, be sentenced to pay a
fine of $10,000 or to imprisonment for not more than five years,
or both. An unauthorized person who knowingly receives or
possesses the data commits a misdemeanor of the first degree.
(e) Unauthorized access to data.--If person inadvertently or
by council error gains access to data that violates the
safeguards under this section, the data must immediately be
returned, without duplication, to the council with proper
notification.
(f) Public access to records.--Each public report prepared
by the council shall be a public record and shall be available
to the public for a reasonable fee. Copies shall be provided,
upon request of the chair, to the Health and Human Services
Committee of the Senate and the Health Committee and Human
Services Committee of the House of Representatives.
(g) Access to council raw data by purchasers.--Pursuant to
sections 3304(d)(6) (relating to powers and duties of council)
and 3306(b) (relating to data dissemination and publication) and
subject to the limitations on access under subsection (c), the
council shall provide access to the council's raw data to
purchasers , excluding purchasers that provide covered services
other than through the purchase of fully funded insurance from a
health care insurer but that are not elective health care payor
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data sources, in accordance with the following procedure:
(1) Special reports derived from raw data of the council
shall be provided by the council to the purchaser requesting
such reports.
(2) A means to enable computer-to-computer access by the
purchaser to raw data of the council shall be developed,
adopted and implemented by the council. The council shall
provide the access to the council's raw data to a purchaser
upon request.
(3) If an employer obtains from the council, under
paragraph (1) or (2), data pertaining to the employer's
employees and the employees' dependents for whom the employer
purchases or otherwise provides covered services and who are
represented by a certified collective bargaining
representative, the collective bargaining representative
shall be entitled to the data, after payment of fees under
paragraph (4). If a certified collective bargaining
representative obtains from the council, under paragraph (1)
or (2), data pertaining to the employer's members and the
member's dependents who are employed by and for whom covered
services are purchased or otherwise provided by an employer,
the employer shall be entitled to the data, after payment of
fees under paragraph (4).
(4) In providing for access to its raw data, the council
shall charge the purchasers which originally obtained the
access a fee sufficient to cover the council's costs to
prepare and provide special reports requested under paragraph
(1) or to provide computer-to-computer access to its raw data
requested under paragraph (2). If a second or subsequent
party requests the information under paragraph (3), the
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council shall charge the party a reasonable fee.
(h) Access to council raw data by State agencies.--The
council shall develop and execute memoranda of understanding
with any State agency upon request of that agency, including the
Insurance Department, the Department of Health and the
Department of Human Services, to allow the agency access to the
data.
(i) Access to council raw data by other parties.--Subject to
the limitations on access to council raw data under subsection
(c), the council may provide special reports derived from the
council's raw data or computer-to-computer access to parties
other than purchasers provided access under subsection (g). The
council may publish regulations that set forth the criteria and
the procedure the council shall use in making determinations on
the access, pursuant to the powers vested in the council under
section 3304. In providing the access, the council shall charge
the party requesting the access a reasonable fee.
§ 3309. Special studies and reports.
(a) Special studies.--A Commonwealth agency, the Senate or
the House of Representatives may direct the council to publish
or contract for publication of special studies, including, but
not limited to, a special study on diseases and the cost of
health care related to particular diseases in this Commonwealth.
A special study published under this subsection shall become a
public document.
(b) Special reports.--
(1) A Commonwealth agency, the Senate or the House of
Representative may study and issue a report on the special
medical needs, demographic characteristics, access or lack
thereof to health care services and need for financing of
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health care services of:
(i) Senior citizens, particularly low-income senior
citizens, senior citizens who are members of minority
groups and senior citizens residing in low-income urban
or rural areas.
(ii) Low-income urban or rural areas.
(iii) Minority communities.
(iv) Women.
(v) Children.
(vi) Unemployed workers.
(vii) Veterans.
(2) The reports under paragraph (1) shall include
information on the current availability of services to the
targeted parts of the population under paragraph (1), whether
access to the services has increased or decreased over the
past 10 years and specific recommendations for the
improvement of the primary care and health delivery systems
of targeted parts of the population under paragraph (1),
including disease prevention and comprehensive health care
services. The agency may study and report on the effects of
using prepaid, capitated or health maintenance organization
health delivery systems as ways to promote the delivery of
primary health care services to the underserved segments of
the population enumerated above.
(3) The agency may study and report on the short-term
and long-term fiscal and programmatic impact on the health
care consumer of changes in ownership of hospitals from
nonprofit to profit, whether through purchase, merger or the
like. The agency may study and report on factors which have
the effect of either reducing provider revenue or increasing
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provider cost and other factors beyond a provider's control
which reduce provider competitiveness in the marketplace.
§ 3310. Enforcement and penalty.
(a) Compliance enforcement.--The council shall have standing
to bring an action in law or in equity through private counsel
in any court of common pleas to enforce compliance with any
provision of this chapter, except section 3309 (relating to
special studies and reports), or any requirement or appropriate
request of the council made under this chapter. The Attorney
General is authorized and shall bring an enforcement action in
aid of the council in a court of common pleas at the request of
the council and in the name of the Commonwealth.
(b) Penalty.--
(1) Any person who fails to supply data under section
3305 (relating to data submission and collection) may be
assessed a civil penalty not to exceed $1,000 for each day
the data is not submitted.
(2) Any person who knowingly submits inaccurate data
under section 3305 commits a misdemeanor of the third degree
and shall, upon conviction, be sentenced to pay a fine of
$1,000 or to imprisonment for not more than one year, or
both.
§ 3311. Research and demonstration projects.
The council shall actively encourage research and
demonstrations to design and test improved methods of assessing
provider quality, provider service effectiveness, efficiency and
cost containment. If no data submission requirements in a
mandated demonstration exceed the current reserve field on the
Pennsylvania Uniform Claims and Billing Form or the data
submission requirements of the Pennsylvania health care payor
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claims data submission manual, the council may:
(1) Authorize contractors engaged in health services
research selected by the council, under section 3314
(relating to contracts with vendors), to have access to the
council's raw data files, if the entity assumes a contractual
obligation imposed by the council to assure patient identity
confidentiality.
(2) Place data sources participating in research and
demonstrations on different data submission requirements from
other data sources in this Commonwealth.
(3) Require data source participation in research and
demonstration projects if this is the only testing method the
council determines is promising.
§ 3312. Grievances and grievance procedures.
(a) Procedures and requirements.--Pursuant to its powers to
publish regulations under section 3304 (relating to powers and
duties of council) and with the requirements of this section,
the council may establish procedures and requirements for the
filing, hearing and adjudication of grievances against the
council of a data source. The procedures and requirements shall
be published in the Pennsylvania Bulletin pursuant to law.
(b) Claims and hearings.--Grievance claims of a data source
shall be submitted to the council or to a third party designated
by the council. The council or the designated third party shall
convene a hearing, if requested, and adjudicate the grievance.
§ 3313. Antitrust provisions.
A person or entity required or permitted to submit data or
information under this chapter or receiving data or information
from the council in accordance with this chapter are declared to
be acting pursuant to State requirements embodied in this
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chapter and shall be exempt from antitrust claims or actions
grounded upon submission or receipt of the data or information.
§ 3314. Contracts with vendors.
A contract with a vendor other than a sole source vendor for
purchase of services or for purchase or lease of supplies and
equipment related to the council's powers and duties shall be
let only after a public bidding process and only in accordance
with the following provisions:
(1) The council shall prepare specifications fully
describing the services to be rendered or equipment or
supplies to be provided by a vendor and shall make the
specifications available for inspection by a person at the
council's offices during normal working hours and at other
places and other times as the council deems advisable.
(2) The council shall publish notice of invitations to
bid in the Pennsylvania Bulletin and on the council's
publicly accessible Internet website. The notice shall
include at least the following:
(i) The deadline for submission of bids by
prospective vendors, which shall be no sooner than 30
days following the latest publication of the notice as
prescribed under this paragraph.
(ii) The locations, dates and times during which
prospective vendors may examine the specifications
required under paragraph (1).
(iii) The date, time and place of the meeting or
meetings of the council at which bids will be opened and
accepted.
(iv) A statement to the effect that any person is
eligible to bid.
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(3) Bids shall be accepted as follows:
(i) A council member who is affiliated in any way
with a bidder may not vote on the awarding of a contract
for which the bidder has submitted a bid. A council
member who has an affiliation with a bidder shall state
the nature of the affiliation prior to a vote of the
council.
(ii) Bids shall be opened and reviewed by the
appropriate council committee, which shall make
recommendations to the council on approval. Bids shall be
accepted and the acceptance shall be announced only at a
public meeting of the council as defined in section
3303(e) (relating to Health Care Cost Containment
Council). A bid may not be accepted at an executive
session of the council.
(iii) The council may require that a certified
check, in an amount determined by the council, accompany
every bid. If required, a bid may not be accepted unless
accompanied by a certified check.
(4) In order to prevent a party from deliberately
underbidding contracts in order to gain or prevent access to
council data, the council may award a contract at the
council's discretion, regardless of the amount of the bid, as
follows:
(i) A bid accepted must reasonably reflect the
actual cost of services provided.
(ii) A vendor selected by the council under this
paragraph must be found by the council to be of the
character and integrity as to assure, to the maximum
extent possible, adherence to this chapter in the
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provision of contracted services.
(iii) The council may require the selected vendor to
furnish, within 20 days after the contract has been
awarded, a bond with suitable and reasonable requirements
guaranteeing the services to be performed with sufficient
surety in an amount determined by the council. If the
bond is not furnished within the time specified, the
previous award shall be void.
(5) The council shall make efforts to assure that the
council's vendors have established affirmative action plans
to assure equal opportunity policies for hiring and promoting
employees.
§ 3315. Reporting.
The council shall provide an annual report of its financial
expenditures to the Appropriations Committee and Public Health
and Welfare Committee of the Senate and the Appropriations
Committee, the Health Committee and the Human Services Committee
of the House of Representatives. Failure to issue a timely
report will result in a prohibition on money being distributed
from the General Fund to the council for the following fiscal
year. Each appropriation from the General Fund to the council
shall be held until 60 days after compliance with this section.
§ 3316. Severability.
The provisions of this chapter are severable. If a provision
of this chapter or the provision's application to a person or
circumstance is held invalid, the invalidity shall not affect
other provisions or applications of this chapter which can be
given effect without the invalid provision or application.
CHAPTER 35
HEALTH CARE OUTCOMES
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Subchapter
A. Preliminary Provisions
B. Medicaid Outcomes-Based Payment Programs
C. Hospital Outcomes Program
D. Managed Care Outcomes Program
SUBCHAPTER A
PRELIMINARY PROVISIONS
Sec.
3501. Definitions.
§ 3501. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"All Patient Refined Diagnosis Related Groups." A version of
Diagnosis Related Groups that further subdivide the Diagnosis
Related Groups into four severity-of-illness and four risk-of-
mortality subclasses within each Diagnosis Related Groups.
"Department." The Department of Human Services of the
Commonwealth.
"Diagnosis Related Groups." A classification system that
uses patient discharge information to classify patients into
clinically meaningful groups.
"Hospital." A public or private institution licensed as a
hospital under the laws of this Commonwealth that participates
in the Medicaid program.
"Managed care organization." A licensed managed care
organization with whom the department has contracted to provide
or arrange for services to a Medicaid recipient.
"Medicaid program." The Commonwealth's Medicaid program.
"Potentially avoidable admission." An admission of an
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individual to a hospital or long-term care facility that may
have reasonably been prevented with adequate access to
ambulatory care or health care coordination.
"Potentially avoidable complication." A harmful event or
negative outcome with respect to an individual, including an
infection or surgical complication, that:
(1) occurs after the person's admission to a hospital or
long-term care facility; and
(2) may have resulted from the care, lack of care or
treatment provided during the hospital or long-term care
facility stay rather than from a natural progression of an
underlying disease.
"Potentially avoidable emergency visit." Treatment of an
individual in a hospital emergency room or freestanding
emergency medical care facility for a condition that may not
require emergency medical attention because the condition could
be or could have been treated or prevented by a physician or
other health care provider in a nonemergency setting.
"Potentially avoidable event." Any of the following:
(1) A potentially avoidable admission.
(2) A potentially avoidable ancillary service.
(3) A potentially avoidable complication.
(4) A potentially avoidable emergency visit.
(5) A potentially avoidable readmission.
(6) A combination of the events listed under this
definition.
"Potentially avoidable readmission." A return
hospitalization of an individual within a period specified by
the department that may have resulted from a deficiency in the
care or treatment provided to the individual during a previous
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hospital stay or from a deficiency in post-hospital discharge
follow-up. The term does not include a hospital readmission
necessitated by the occurrence of unrelated events after the
discharge. The term includes the readmission of an individual to
a hospital for:
(1) The same condition or procedure for which the
individual was previously admitted.
(2) An infection or other complication resulting from
care previously provided.
(3) A condition or procedure that indicates that a
surgical intervention performed during a previous admission
was unsuccessful in achieving the anticipated outcome.
SUBCHAPTER B
MEDICAID OUTCOMES-BASED PAYMENT PROGRAMS
Sec.
3511. Establishment.
3512. Selection of potentially avoidable event methodology.
3513. Statewide analysis of Medicaid system waste.
§ 3511. Establishment.
The department shall establish the following linked Medicaid
outcomes-based payment programs:
(1) A Hospital Outcomes Program designed to provide a
hospital with information and incentives to reduce
potentially avoidable events and reduce waste in Medicaid
hospital services.
(2) A Managed Care Organization Outcomes Program
designed to provide a Medicaid managed-care organization with
information and incentives to reduce potentially avoidable
events and reduce waste in Medicaid managed care programs.
§ 3512. Selection of potentially avoidable event methodology.
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The department shall select a methodology for identifying
potentially avoidable events and the costs associated with the
events and for measuring hospital and managed care organization
performance with respect to the events. The following shall
apply:
(1) The department shall develop parameters for each of
the potentially avoidable events in accordance with the
selected methodology.
(2) To the extent possible, the methodology shall be one
that has been used by a State program under Title XIX of the
Social Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.)
or by a commercial payer in health care outcomes performance
measurement and in outcome-based payment programs.
(3) The methodology shall be open, transparent and
available for review by the public.
§ 3513. Statewide analysis of Medicaid system waste.
The department shall conduct a comprehensive analysis of
relevant State databases to identify waste in the Medicaid
system. The following shall apply:
(1) The analysis shall identify instances of potentially
avoidable events in the Medicaid system and the costs
associated with these cases.
(2) The overall estimate of waste shall by broken down
into actionable categories, including, but not limited to,
regions, hospitals, managed care organizations, physicians,
service lines, Diagnosis Related Groups, medical conditions
and procedures, patient characteristics, provider
characteristics and Medicaid program type.
(3) Information collected from the potentially avoidable
event study shall be utilized in the Hospital Outcomes
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Program and Managed Care Organization Outcomes Program.
SUBCHAPTER C
HOSPITAL OUTCOMES PROGRAM
Sec.
3521. Procedure.
3522. Phase 1 hospital performance reporting.
3523. Hospital outcomes information sharing.
3524. Phase 2 hospital financial incentives.
3525. Rate adjustment.
3526. Hospital Medicaid contract.
3527. Hospital Outcomes Program budget neutrality.
§ 3521. Procedure.
The Hospital Outcomes Program shall:
(1) Target reduction of potentially avoidable
readmissions and complications.
(2) Apply to each State acute care hospital
participating in the Medicaid program, except that program
adjustments may be made for certain types of hospitals.
(3) Be implemented in two phases:
(i) Phase 1, performance reporting.
(ii) Phase 2, the addition of outcomes-based
financial incentives.
§ 3522. Phase 1 hospital performance reporting.
The department shall develop and maintain a reporting system
to provide each hospital with regular confidential reports
regarding the hospital's performance with respect to potentially
avoidable readmissions and potentially avoidable complications.
The department shall:
(1) Conduct ongoing analyses of relevant State claims
databases to identify instances of potentially avoidable
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complications and readmissions and the expenditures
associated with the cases.
(2) Create or locate State complications and
readmissions norms.
(3) Measure actual-to-expected hospital performance
compared to State norms.
(4) Compare hospitals with the hospitals' peers using
risk adjustment procedures that account for the severity of
illness of each hospital's patients.
(5) Distribute reports to hospitals to provide them with
actionable information to create policies, contracts and
programs designed to improve target outcomes.
(6) Foster collaboration among hospitals in sharing best
practices.
§ 3523. Hospital outcomes information sharing.
A hospital may share the information contained in the outcome
performance reports with physicians and other health care
providers providing services at the hospital to foster
coordination and cooperation in the hospital's outcome
improvement and waste reduction initiatives.
§ 3524. Phase 2 hospital financial incentives.
Beginning 12 months after implementation of Phase 1
performance reporting, the department shall establish financial
incentives to motivate hospitals to improve on rates of reducing
avoidable complications and readmissions.
§ 3525. Rate adjustment.
The department shall adjust the reimbursement that the
hospital receives under the All Patient Refined Diagnosis
Related Groups inpatient prospective payment system based on the
hospital's performance with respect to exceeding or failing to
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achieve outcome results based on the rates of potentially
avoidable readmissions and complications. The methodology for
determining a hospital's inpatient base rate adjustment shall:
(1) Apply to each hospital discharge.
(2) Determine a hospital-specific potentially avoidable
outcome adjustment factor based on the hospital's actual
versus expected risk-adjusted performance compared to the
State average or best practice norm.
(3) Be based on a retrospective analysis of performance
prospectively applied.
(4) Include both rewards and penalties.
(5) Be communicated to the hospitals in a clear and
transparent manner.
§ 3526. Hospital Medicaid contract.
The department shall amend contracts with the department's
participating hospitals as necessary to incorporate the
financial incentives established under the Hospital Outcomes
Program.
§ 3527. Hospital Outcomes Program budget neutrality.
The Hospital Outcomes Program shall be implemented in a
budget-neutral manner with respect to aggregate Medicaid
hospital expenditures.
SUBCHAPTER D
MANAGED CARE OUTCOMES PROGRAM
Sec.
3531. Procedure.
3532. Phase 1 managed care organization performance reporting.
3533. Managed care organization outcomes information sharing.
3534. Phase 2 managed care organization financial incentives.
3535. Premium adjustment.
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3536. Managed care organization Medicaid contracts.
3537. Managed Care Organization Outcomes Program budget
neutrality.
§ 3531. Procedure.
The Managed Care Organization Outcomes Program shall:
(1) Target reduction of avoidable admissions,
readmissions and emergency visits.
(2) Apply to each managed-care organizations
participating in the Medicaid program.
(3) Be implemented in two phases:
(i) Phase 1, performance reporting.
(ii) Phase 2, the addition of outcomes-based
financial incentives.
§ 3532. Phase 1 managed care organization performance
reporting.
The department shall develop and maintain a reporting system
to provide each managed care organization with regular
confidential reports regarding the managed care organization's
performance with respect to potentially avoidable admissions,
readmissions and emergency visits. The department shall:
(1) Conduct ongoing analyses of relevant State claims
databases to identify instances of potentially avoidable
admissions, readmissions and emergency visits with potential
excess expenditures associated with the cases.
(2) Create or locate State norms for admissions,
readmissions and emergency visits.
(3) Measure actual-to-expected managed care organization
performance compared to State norms.
(4) Compare managed care organizations with the managed
care organizations' peers using risk adjustment procedures
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that account for the chronic illness burden of each plan's
enrollees.
(5) Distribute reports to managed care organizations to
provide the managed care organizations with actionable
information to create policies, contracts and programs
designed to improve target outcomes.
§ 3533. Managed care organization outcomes information sharing.
A managed care organization may share the information
contained in the outcome performance reports with the managed
care organization's participating providers to foster
coordination and cooperation in the managed care organization's
outcome improvement and waste reduction initiatives.
§ 3534. Phase 2 managed care organization financial incentives.
Beginning 12 months after implementation of Phase 1
performance reporting, the department shall establish financial
incentives to motivate the department's managed care
organizations to improve on rates of reducing avoidable
admissions, readmissions and emergency visits.
§ 3535. Premium adjustment.
The department shall adjust each managed care organization's
capitation rate based on the managed care organization's
performance with respect to exceeding or failing to achieve
outcome results based on the rates of potentially avoidable
readmissions, admissions and emergency visits. The methodology
for determining a managed care organization's capitation rate
adjustment shall:
(1) Apply to the plan's annual capitation rate.
(2) Determine a plan's specific potentially avoidable
outcome adjustment factor based on the plan's actual versus
expected risk-adjusted performance compared to the State
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average or a best practice norm.
(3) Be based on a retrospective analysis of performance
and prospectively applied.
(4) Contain both rewards and penalties.
(5) Include risk corridors.
(6) Be communicated to the managed care organizations in
a clear and transparent manner.
§ 3536. Managed care organization Medicaid contracts.
The department shall amend contracts with the department's
participating managed care organizations as necessary to
incorporate the financial incentives established under the
Managed Care Organization Outcomes Program.
§ 3537. Managed Care Organization Outcomes Program budget
neutrality.
The Managed Care Organization Outcomes Program shall be
implemented in a budget neutral manner with respect to aggregate
Medicaid managed care expenditures.
Section 2. The following apply:
(1) Actions taken by the Health Care Cost Containment
Council from the period from June 30, 2014, to the effective
date of this section are validated.
(2) New positions on the Health Care Cost Containment
Council created under 35 Pa.C.S. Ch. 33 shall be filled in
the manner designated under 35 Pa.C.S. § 3303(b) no later
than 60 days after the effective date of this section.
Organizations required under 35 Pa.C.S. § 3303(b) to submit
lists of recommended persons to fill new positions on the
council shall do so no later than 30 days after the effective
date of this section.
(3) There shall be no lapse in the employment
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relationship for employees of the Health Care Cost
Containment Council, including salary, seniority, benefits
and retirement eligibility of the employees.
Section 3. This act shall take effect immediately.
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