Trial Engrossment of Amendment A04964 to Senate Bill 0841 P.N. 1410, Regular Session 2019-2020

HOUSE AMENDED

A04964

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

No.

841

Session of

2019

INTRODUCED BY MARTIN, GORDNER, YAW, MENSCH, KILLION, COSTA,

MASTRIANO, BARTOLOTTA AND K. WARD, SEPTEMBER 3, 2019

AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES,

NOVEMBER 21, 2019

AN ACT

Amending Title Titles 35 (Health and Safety) and 42 (Judiciary

and Judicial Procedure) 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.; providing for COVID-19 disaster

emergency; in local organizations and services, further

providing for general authority of political subdivisions;

and, in Uniform Unsworn Foreign Declarations Act, further

providing for heading of chapter, for short title of chapter,

for definitions, for applicability and for form of unsworn

declaration.

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

CHAPTER 33

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.

3317. Expiration.

§ 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:

"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 provider.

"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.

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(4) Hospices, including hospices operated by an agency

of State or local government.

"Health care insurer." As follows:

(1) 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:

(i) 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.

(ii) A hospital plan corporation as defined in 40

Pa.C.S. Ch. 61 (relating to hospital plan corporations).

(iii) A professional health service corporation as

defined in 40 Pa.C.S. Ch. 63 (relating to professional

health services plan corporations).

(iv) A health maintenance organization governed by

the act of December 29, 1972 (P.L.1701, No.364), known as

the Health Maintenance Organization Act.

(v) 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.

(2) The term does not include:

(i) 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.

(ii) The following types of insurance or any

combination thereof:

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(A) Accident only.

(B) Fixed indemnity.

(D) Limited benefit.

(E) Credit.

(F) Dental.

(G) Vision.

(H) Specified disease.

(I) Medicare supplement.

(J) Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS) supplement.

(K) Long-term care or disability income.

(L) Workers' compensation.

(M) Automobile medical payment insurance.

"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

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

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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

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

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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 ."

"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

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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

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

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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

Pennsylvania, Inc.

(11) (Reserved). TWO INDIVIDUALS APPOINTED BY THE

GOVERNOR WHO HAVE EXPERTISE IN HEALTH ECONOMICS AND OUTCOMES

RESEARCH.

(12) Representatives from the General Assembly as

follows:

(i) One Senator appointed by the President pro

tempore of the Senate.

(ii) One Senator appointed by the Minority Leader of

the Senate.

(iii) One member of the House of Representatives

appointed by the Speaker of the House of Representatives.

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(iv) One member of the House of Representatives

appointed by the Minority Leader 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 .

annually elect, by a majority vote of the members, a chairperson

and a vice chairperson of the council from the business and

labor members of the council.

(d) Quorum.--The council shall establish in the council's

bylaws the number of members necessary to constitute a quorum.

(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

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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 and the public .

(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 , on its publicly accessible

Internet website and as provided under 65 Pa.C.S. Ch. 7 . The

notice shall be published at least once in each calendar

quarter and shall list the schedule of meetings of the

council to be held in the subsequent calendar quarter. 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

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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

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;

(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

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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

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

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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.

(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

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subsection (b)(4), (5), (6), (7), (8), (8.1), (8.2), (9),

(10), (11) and (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

vote of at least 14 members of the council.

(4) No appointed member under subsection (b)(4), (5),

(6), (7), (8), (8.1), (8.2), (9), (10), (11) and (12) shall

be eligible to serve more than three 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

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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

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

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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.

(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.

(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

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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.

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

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

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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.

(3) (Reserved).

(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.

(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

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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

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) In consultation with the Insurance Department and

the Department of Health, 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:

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(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

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;

preferred provider organizations; 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,

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all data required in this section, according to uniform

submission formats, coding systems and other technical

specifications necessary to render the incoming data

substantially valid, consistent, compatible and manageable

using electronic data processing according to data submission

schedules. 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

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 (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 (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

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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

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 (d) .

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,

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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;

(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;

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(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) Provider quality and provider service effectiveness 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.

(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 (d) and section 3304(d)(4) and (5), or the

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council may delete data elements from the Pennsylvania Uniform

Claims and Billing Form only by a majority vote of the council

and only pursuant to the following procedure:

(1) The council shall obtain a cost-benefit analysis of

the proposed addition or deletion which shall include the

cost to data sources of any proposed additions.

(2) The council shall publish notice of the proposed

addition or deletion, along with a copy or summary of the

cost-benefit analysis, in the Pennsylvania Bulletin, and 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.

(f) Other data required to be submitted.--Each provider 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

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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;

(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).

(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

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appropriate data in its data files and subsequent reports.

(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 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.

(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.

(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

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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:

(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

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council shall ensure that factors which have the effect of

either reducing provider revenue or increasing provider costs

and other factors beyond a provider's control which reduce

provider competitiveness in the marketplace are explained in

the reports. The council shall also ensure that any

clarifications and dissents submitted by individual providers

under section 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

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for mandated health benefits or mandated health insurance

coverage should be accompanied by adequate, independently

certified documentation defining the social and financial

impact and medical efficacy of the proposal. To that end, the

council, upon receipt of such requests, is hereby authorized

to conduct a preliminary review of the material submitted by

both proponents and opponents concerning the proposed

mandated benefit. If, after this preliminary review, the

council is satisfied that both proponents and opponents have

submitted sufficient documentation necessary for a review

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

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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

as defined in paragraph (4).

(B) Whether or not the research cited in the

documentation meets professional standards.

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.

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