HEALTH CARE COST CONTAINMENT ACT - EXPIRED JUNE 30, 2014 — 1986 Pa. Act 89 (historical enacted text)

Historical Act text

PRIOR PRINTER'S NOS. 307, 450, 1905, PRINTER'S NO. 2324
2104, 2124, 2135
Report of the Committee of Conference
To the Members of the Senate and House of Representatives:
We, the undersigned, Committee of Conference on the part of
the Senate and House of Representatives for the purpose of
considering Senate Bill No. 293, entitled:
"An act amending the act of April 9, 1929 (P.L.177, No.175),
entitled 'An act providing for and reorganizing the conduct of
the executive and administrative work of the Commonwealth by the
Executive Department thereof and the administrative departments,
boards, commissions, and officers thereof, including the boards
of trustees of State Normal Schools, or Teachers Colleges; * * *
AND further providing for leases on certain areas of State
forests MINIMUM STAFFING LEVELS AT STATE MENTAL INSTITUTIONS
MENTAL HOSPITALS; AND IMPOSING RESTRICTIONS ON RELINQUISHMENT,"
respectfully submit the following bill as our report:
ROY W. WILT
JOHN STAUFFER
HARDY WILLIAMS
(Committee on the part of the Senate.)
JAMES J. MANDERINO
FRANK J. PISTELLA
DONALD W. DORR
(Committee on the part of the House of Representatives.)
AN ACT
1 Providing for the creation of the Health Care Cost Containment
2 Council, for its powers and duties, for health care cost
3 containment through the collection and dissemination of data,
4 for public accountability of health care costs, and for
5 health care for the indigent; establishing the Indigent Care
6 Program; and making an appropriation.
7 TABLE OF CONTENTS
8 Section 1. Short title.
9 Section 2. Legislative finding and declaration.
10 Section 3. Definitions.
11 Section 4. Health Care Cost Containment Council.
12 Section 5. Powers and duties of the council.
13 Section 6. Data submission and collection.
14 Section 7. Data dissemination and publication.
15 Section 8. Health care for the medically indigent.
16 Section 9. Mandated health benefits.
17 Section 10. Access to council data.
18 Section 11. Special studies and reports.
19 Section 12. Enforcement; penalty.
20 Section 13. Research and demonstration projects.
21 Section 14. Grievances and grievance procedures.
22 Section 15. Antitrust provisions.
23 Section 16. Contracts with vendors.
24 Section 17. Appropriations.
25 Section 18. Severability.
26 Section 19. Sunset.
27 Section 20. Effective date.
28 The General Assembly of the Commonwealth of Pennsylvania
29 hereby enacts as follows:
30 Section 1. Short title.
1 This act shall be known and may be cited as the Health Care
2 Cost Containment Act.
3 Section 2. Legislative finding and declaration.
4 The General Assembly finds that there exists in this
5 Commonwealth a major crisis because of the continuing escalation
6 of costs for health care services. Because of the continuing
7 escalation of costs, an increasingly large number of
8 Pennsylvania citizens have severely limited access to
9 appropriate and timely health care. Increasing costs are also
10 undermining the quality of health care services currently being
11 provided. Further, the continuing escalation is negatively
12 affecting the economy of this Commonwealth, is restricting new
13 economic growth and is impeding the creation of new job
14 opportunities in this Commonwealth.
15 The continuing escalation of health care costs is
16 attributable to a number of interrelated causes, including:
17 (1) Inefficiency in the present configuration of health
18 care service systems and in their operation.
19 (2) The present system of health care cost payments by
20 third parties.
21 (3) The increasing burden of indigent care which
22 encourages cost shifting.
23 (4) The absence of a concentrated and continuous effort
24 in all segments of the health care industry to contain health
25 care costs.
26 Therefore, it is hereby declared to be the policy of the
27 Commonwealth of Pennsylvania to promote health care cost
28 containment by creating an independent council to be known as
29 the Health Care Cost Containment Council.
30 It is the purpose of this legislation to promote the public
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1 interest by encouraging the development of competitive health
2 care services, in which health care costs are contained and to
3 assure that all citizens have reasonable access to quality
4 health care.
5 It is further the intent of this act to facilitate the
6 continuing provision of quality, cost-effective health services
7 throughout the Commonwealth by providing data and information to
8 the purchasers and consumers of health care on both cost and
9 quality of health care services, and to assure access to health
10 care services.
11 Nothing in this act shall prohibit a purchaser from obtaining
12 from its third-party insurer, carrier or administrator, nor
13 relieve said third-party insurer, carrier or administrator from
14 the obligation of providing, on terms consistent with past
15 practices, data previously provided to a purchaser pursuant to
16 any existing or future arrangement, agreement or understanding.
17 Section 3. Definitions.
18 The following words and phrases when used in this act shall
19 have the meanings given to them in this section unless the
20 context clearly indicates otherwise:
21 "Ambulatory service facility." A facility licensed in this
22 Commonwealth, not part of a hospital, which provides medical,
23 diagnostic or surgical treatment to patients not requiring
24 hospitalization, including ambulatory surgical facilities,
25 ambulatory imaging or diagnostic centers, birthing centers,
26 freestanding emergency rooms and any other facilities providing
27 ambulatory care which charge a separate facility charge. This
28 term does not include the offices of private physicians or
29 dentists, whether for individual or group practices.
30 "Charge" or "rate." The amount billed by a provider for
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1 specific goods or services provided to a patient, prior to any
2 adjustment for contractual allowances.
3 "Council." The Health Care Cost Containment Council.
4 "Covered services." Any health care services or procedures
5 connected with episodes of illness that require either inpatient
6 hospital care or major ambulatory service such as surgical,
7 medical or major radiological procedures, including any initial
8 and followup outpatient services associated with the episode of
9 illness before, during or after inpatient hospital care or major
10 ambulatory service. The term does not include routine outpatient
11 services connected with episodes of illness that do not require
12 hospitalization or major ambulatory service.
13 "Data source." A hospital; ambulatory service facility;
14 physician; health maintenance organization as defined in the act
15 of December 29, 1972 (P.L.1701, No.364), known as the Health
16 Maintenance Organization Act; hospital, medical or health
17 service plan with a certificate of authority issued by the
18 Insurance Department, including, but not limited to, hospital
19 plan corporations as defined in 40 Pa.C.S. Ch. 61 (relating to
20 hospital plan corporations), and professional health services
21 plan corporations as defined in 40 Pa.C.S. Ch. 63 (relating to
22 professional health services plan corporations); commercial
23 insurer with a certificate of authority issued by the Insurance
24 Department providing health or accident insurance; self-insured
25 employer providing health or accident coverage or benefits for
26 employees employed in the Commonwealth; administrator of a self-
27 insured or partially self-insured health or accident plan
28 providing covered services in the Commonwealth; any health and
29 welfare fund that provides health or accident benefits or
30 insurance pertaining to covered service in the Commonwealth; the
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1 Department of Public Welfare for those covered services it
2 purchases or provides through the medical assistance program
3 under the act of June 13, 1967 (P.L.31, No.21), known as the
4 Public Welfare Code, and any other payor for covered services in
5 the Commonwealth other than an individual.
6 "Health care facility." A general or special hospital,
7 including tuberculosis and psychiatric hospitals, kidney disease
8 treatment centers, including freestanding hemodialysis units,
9 and ambulatory service facilities as defined in this section,
10 and hospices, both profit and nonprofit and including those
11 operated by an agency of State or local government.
12 "Health care insurer." Any person, corporation or other
13 entity that offers administrative, indemnity or payment services
14 for health care in exchange for a premium or service charge
15 under a program of health care benefits, including, but not
16 limited to, an insurance company, association or exchange
17 issuing health insurance policies in this Commonwealth; hospital
18 plan corporation, as defined in 40 Pa.C.S. Ch. 61 (relating to
19 hospital plan corporations); professional health services plan
20 corporation as defined in 40 Pa.C.S. Ch. 63 (relating to
21 professional health services plan corporations); health
22 maintenance organization; preferred provider organization;
23 fraternal benefit societies; beneficial societies; and third-
24 party administrators; but excluding employers, labor unions or
25 health and welfare funds jointly or separately administered by
26 employers or labor unions that purchase or self-fund a program
27 of health care benefits for their employees or members and their
28 dependents.
29 "Health maintenance organization." An organized system which
30 combines the delivery and financing of health care and which
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1 provides basic health services to voluntarily enrolled
2 subscribers for a fixed prepaid fee, as defined in the act of
3 December 29, 1972 (P.L.1701, No.364), known as the Health
4 Maintenance Organization Act.
5 "Hospital." An institution, licensed in this Commonwealth,
6 which is a general, tuberculosis, mental, chronic disease or
7 other type of hospital, or kidney disease treatment center,
8 whether profit or nonprofit, and including those operated by an
9 agency of State or local government.
10 "Indigent care." The actual costs, as determined by the
11 council, for the provision of appropriate health care, on an
12 inpatient or outpatient basis, given to individuals who cannot
13 pay for their care because they are above the medical assistance
14 eligibility levels, and have no health insurance or other
15 financial resources which can cover their health care.
16 "Major ambulatory service." Surgical or medical procedures,
17 including diagnostic and therapeutic radiological procedures,
18 commonly performed in hospitals or ambulatory service
19 facilities, which are not of a type commonly performed or which
20 cannot be safely performed in physicians' offices, and which
21 require special facilities such as operating rooms or suites or
22 special equipment such as fluoroscopic equipment or computed
23 tomographic scanners, or a postprocedure recovery room or short-
24 term convalescent room.
25 "Medical procedure incidence variations." The variation in
26 the incidence in the population of specific medical, surgical
27 and radiological procedures in any given year, expressed as a
28 deviation from the norm, as these terms are defined in the
29 classical statistical definition of "variation," "incidence,"
30 "deviation," and "norm."
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1 "Medically indigent" or "indigent." The status of a person
2 as described in the definition of indigent care.
3 "Payment." The payments that providers actually accept for
4 their services, exclusive of charity care, rather than the
5 charges they bill.
6 "Payor." Any person or entity, including, but not limited
7 to, health care insurers and purchasers, that make direct
8 payments to providers for covered services.
9 "Physician." An individual licensed under the laws of this
10 Commonwealth to practice medicine and surgery within the scope
11 of the act of October 5, 1978 (P.L.1109, No.261), known as the
12 Osteopathic Medical Practice Act, or the act of December 20,
13 1985 (P.L.457, No.112), known as the Medical Practice Act of
14 1985.
15 "Preferred provider organization." Any arrangement between a
16 health care insurer and providers of health care services which
17 specifies rates of payment to such providers which differ from
18 their usual and customary charges to the general public and
19 which encourage enrollees to receive health services from such
20 providers.
21 "Provider." A hospital, an ambulatory service facility or a
22 physician.
23 "Provider quality." The extent to which a provider renders
24 care that, within the capabilities of modern medicine, obtains
25 for patients medically acceptable health outcomes and prognoses,
26 adjusted for patient severity, and treats patients
27 compassionately and responsively.
28 "Provider service effectiveness." The effectiveness of
29 services rendered by a provider, determined by measurement of
30 the medical outcome of patients grouped by severity receiving
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1 those services.
2 "Purchaser." All corporations, labor organizations and other
3 entities that purchase benefits which provide covered services
4 for their employees or members, either through a health care
5 insurer or by means of a self-funded program of benefits, and a
6 certified bargaining representative that represents a group or
7 groups of employees for whom employers purchase a program of
8 benefits which provide covered services, but excluding entities
9 defined in this section as "health care insurers."
10 "Raw data" or "data." Data collected by the council under
11 section 6 in the form initially received. No data shall be
12 released by the council except as provided for in section 11.
13 "Severity." In any patient, the measureable degree of the
14 potential for failure of one or more vital organs.
15 Section 4. Health Care Cost Containment Council.
16 (a) Establishment.--The General Assembly hereby establishes
17 an independent council to be known as the Health Care Cost
18 Containment Council.
19 (b) Composition.--The council shall consist of 21 voting
20 members, composed of and appointed in accordance with the
21 following:
22 (1) The Secretary of Health.
23 (2) The Secretary of Public Welfare.
24 (3) The Insurance Commissioner.
25 (4) Six representatives of the business community, at
26 least one of whom represents small business, who are
27 purchasers of health care as defined in section 3, none of
28 which is primarily involved in the provision of health care
29 or health insurance, three of which shall be appointed by the
30 President pro tempore of the Senate and three of which shall
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1 be appointed by the Speaker of the House of Representatives
2 from a list of twelve qualified persons recommended by the
3 Pennsylvania Chamber of Commerce. Three nominees shall be
4 representatives of small business.
5 (5) Six representatives of organized labor, three of
6 which shall be appointed by the President pro tempore of the
7 Senate and three of which shall be appointed by the Speaker
8 of the House of Representatives from a list of twelve
9 qualified persons recommended by the Pennsylvania AFL-CIO.
10 (6) One representative of consumers who is not primarily
11 involved in the provision of health care or health care
12 insurance, appointed by the Governor from a list of three
13 qualified persons recommended jointly by the Speaker of the
14 House of Representatives and the President pro tempore of the
15 Senate.
16 (7) One representative of hospitals, appointed by the
17 Governor from a list of three qualified hospital
18 representatives recommended by the Hospital Association of
19 Pennsylvania.
20 (8) One representative of physicians, appointed by the
21 Governor from a list of three qualified physician
22 representatives recommended jointly by the Pennsylvania
23 Medical Society and the Pennsylvania Osteopathic Medical
24 Society.
25 (9) One representative of the Blue Cross and Blue Shield
26 plans in Pennsylvania, appointed by the Governor from a list
27 of three qualified persons recommended jointly by the Blue
28 Cross and Blue Shield plans of Pennsylvania.
29 (10) One representative of commercial insurance
30 carriers, appointed by the Governor from a list of three
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1 qualified persons recommended by the Insurance Federation of
2 Pennsylvania, Inc.
3 (11) One representative of health maintenance
4 organizations, appointed by the Governor from a list of three
5 qualified persons recommended by the Pennsylvania Association
6 of Health Maintenance Organizations.
7 (12) In the case of each appointment to be made from a
8 list supplied by a specified organization, it is incumbent
9 upon that organization to consult with and provide a list
10 which reflects the input of other equivalent organizations
11 representing similar interests. Each appointing authority
12 will have the discretion to request additions to the list
13 originally submitted. Additional names will be provided not
14 later than 15 days after such request. Appointments shall be
15 made by the appointing authority no later than 90 days after
16 receipt of the original list. If, for any reason, any
17 specified organization supplying a list should cease to
18 exist, then the respective appointing authority shall specify
19 a new equivalent organization to fulfill the responsibilities
20 of this act.
21 (c) Chairperson and vice chairperson.--The members shall
22 annually elect, by a majority vote of the members, a chairperson
23 and a vice chairperson of the council from among the business
24 and labor representatives on the council.
25 (d) Quorum.--Eleven members, a majority of which in any
26 combination shall be made up of representatives of business and
27 labor, shall constitute a quorum for the transaction of any
28 business, and the act by the majority of the members present at
29 any meeting in which there is a quorum shall be deemed to be the
30 act of the council.
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1 (e) Meetings.--All meetings of the council shall be
2 advertised and conducted pursuant to the act of July 19, 1974
3 (P.L.486, No.175), referred to as the Public Agency Open Meeting
4 Law, unless otherwise provided in this section.
5 (1) The council shall meet at least once every two
6 months, and may provide for special meetings as it deems
7 necessary. Meeting dates shall be set by a majority vote of
8 the members of the council or by the call of the chairperson
9 upon seven days' notice to all council members.
10 (2) All meetings of the council shall be publicly
11 advertised, as provided for in this subsection, and shall be
12 open to the public, except that the council, through its
13 bylaws, may provide for executive sessions of the council on
14 subjects permitted to be discussed in such sessions under the
15 Public Agency Open Meeting Law. No act of the council shall
16 be taken in an executive session.
17 (3) The council shall publish a schedule of its meetings
18 in the Pennsylvania Bulletin and in at least four newspapers
19 in general circulation in the Commonwealth. Such notice shall
20 be published at least once in each calendar quarter and shall
21 list the schedule of meetings of the council to be held in
22 the subsequent calendar quarter. Such notice shall specify
23 the date, time and place of the meeting and shall state that
24 the council's meetings are open to the general public, except
25 that no such notice shall be required for executive sessions
26 of the council.
27 (4) All action taken by the council shall be taken in
28 open public session, and action of the council shall not be
29 taken except upon the affirmative vote of a majority of the
30 members of the council present during meetings at which a
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1 quorum is present.
2 (f) Bylaws.--The council shall adopt bylaws, not
3 inconsistent with this act, and may appoint such committees or
4 elect such officers subordinate to those provided for in
5 subsection (c) as it deems advisable.
6 (g) Compensation and expenses.--The members of the council
7 shall not receive a salary or per diem allowance for serving as
8 members of the council but shall be reimbursed for actual and
9 necessary expenses incurred in the performance of their duties.
10 Said expenses may include reimbursement of travel and living
11 expenses while engaged in council business.
12 (h) Terms of council members.--
13 (1) The terms of the Secretary of Health, the Secretary
14 of Public Welfare and the Insurance Commissioner shall be
15 concurrent with their holding of public office. The eighteen
16 appointed council members shall each serve for a term of
17 three years and shall continue to serve thereafter until
18 their successor is appointed, except that of the members
19 first appointed:
20 (i) Two each of the representatives of business and
21 organized labor and the representative of consumers shall
22 serve for a term to expire on June 30 of the year
23 following their appointment.
24 (ii) Two each of the representatives of business and
25 organized labor and the representatives of the Blue Cross
26 and Blue Shield plans of Pennsylvania and the commercial
27 insurance carriers shall serve for a term to expire on
28 June 30 of the second year following their appointment.
29 (iii) Two each of the representatives of business
30 and organized labor and the representatives of hospitals,
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1 physicians and health maintenance organizations shall
2 serve for a term to expire on June 30 of the third year
3 following their appointment.
4 (2) No appointed member shall be eligible to serve more
5 than two full consecutive terms of three years. Vacancies on
6 the council shall be filled in the same manner in which they
7 were originally designated under subsection (b), within 60
8 days of the vacancy, except that when vacancies occur among
9 the representatives of business or organized labor, two
10 nominations shall be submitted by the organization specified
11 in subsection (b) for each vacancy on the council.
12 (3) A member may be removed for just cause by the
13 appointing authority after recommendation by a vote of at
14 least 14 members of the council.
15 (i) Commencement of operations.--
16 (1) Within 60 days after the effective date of this act,
17 each organization or individual required to submit a list of
18 recommended persons to the Governor, the President pro
19 tempore of the Senate or the Speaker of the House of
20 Representatives under subsection (b) shall submit said list.
21 (2) Within 90 days of the effective date of this act,
22 the Governor, the President pro tempore of the Senate and the
23 Speaker of the House of Representatives shall make all of the
24 appointments called for in subsection (b) and the council
25 shall begin operations immediately following these
26 appointments.
27 (j) Subsequent appointments.--Submission of lists of
28 recommended persons and appointments of council members for the
29 second and succeeding terms shall be made in the same manner as
30 prescribed in subsection (b), except that:
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1 (1) Organizations required under subsection (b) to
2 submit lists of recommended persons shall do so at least 60
3 days prior to expiration of the council members' terms.
4 (2) The officer required under subsection (b) to make
5 appointments to the council shall make said appointments at
6 least 30 days prior to expiration of the council members'
7 terms, and the appointment shall become effective immediately
8 upon expiration of the incumbent members' terms.
9 (k) Appointments of acting councilors.--Should any
10 organization or individual fail to submit a list of recommended
11 persons as required under subsection (b) within the time limits
12 in subsections (i) or (j), the officer designated to make the
13 appointment under subsection (b) shall appoint as many acting
14 councilors as required under subsection (b) until such time as
15 the list of recommended persons is submitted by the original
16 organization as required in subsection (b).
17 Section 5. Powers and duties of the council.
18 (a) General powers.--The council shall exercise all powers
19 necessary and appropriate to carry out its duties, including the
20 following:
21 (1) To employ an executive director, legal counsel,
22 investigators and other staff necessary to comply with the
23 provisions of this act and regulations promulgated
24 thereunder, and to engage professional consultants, as it
25 deems necessary to the performance of its duties. Any
26 consultants engaged by the council shall be selected in
27 accordance with the provisions for contracting with vendors
28 set forth in section 16.
29 (2) To fix the compensation of all employees and to
30 prescribe their duties.
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1 (3) To make and execute contracts and other instruments,
2 including those for purchase of services and purchase or
3 leasing of equipment and supplies, necessary or convenient to
4 the exercise of the powers of the council. Any such contract
5 shall be let only in accordance with the provision for
6 contracting with vendors set forth in section 16.
7 (4) To conduct examinations and investigations, to
8 conduct audits, pursuant to the provisions of subsection (c),
9 and to hear testimony, and take proof, under oath or
10 affirmation, at public or private hearings, on any matter
11 necessary to its duties.
12 (5) To do all things necessary to carry out its duties
13 under the provisions of this act.
14 (b) Rules and regulations.--The council may, in a manner
15 provided by law, promulgate rules and regulations necessary to
16 carry out its duties under this act.
17 (c) Audit powers.--The council shall have the right to
18 independently audit all information required to be submitted by
19 data sources as needed to corroborate the accuracy of the
20 submitted data, pursuant to the following:
21 (1) Audits of information submitted by providers or
22 health care insurers shall be performed on a sample and
23 issue-specific basis, as needed by the council, and shall be
24 coordinated, to the extent practicable, with audits performed
25 by the Commonwealth. All health care insurers and providers
26 are hereby required to make those books, records of accounts
27 and any other data needed by the auditors available to the
28 council at a convenient location within 30 days of a written
29 notification by the council.
30 (2) Audits of information submitted by purchasers shall
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1 be performed on a sample basis, unless there exists
2 reasonable cause to audit specific purchasers, but in no case
3 shall the council have the power to audit financial
4 statements of purchasers.
5 (3) All audits performed by the council shall be
6 performed at the expense of the council.
7 (d) General duties and functions.--The council is hereby
8 authorized to and shall perform the following duties and
9 functions:
10 (1) Develop a computerized system for the collection,
11 analysis and dissemination of data. The council may contract
12 with a vendor who will provide such data processing services.
13 The council shall assure that the system will be capable of
14 processing all data required to be collected under this act.
15 Any vendor selected by the council shall be selected in
16 accordance with the provisions of section 16, and said vendor
17 shall relinquish any and all proprietary rights or claims to
18 the data base created as a result of implementation of the
19 data processing system.
20 (2) Establish a Pennsylvania Uniform Claims and Billing
21 Form for all data sources and all providers which shall be
22 utilized and maintained by all data sources and all providers
23 for all services covered under this act.
24 (3) Collect and disseminate data, as specified in
25 section 6, and other information from data sources to which
26 the council is entitled, prepared according to formats, time
27 frames and confidentiality provisions as specified in
28 sections 6 and 10, and by the council.
29 (4) Adopt and implement a methodology and collect and
30 disseminate data reflecting provider quality and provider
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1 service effectiveness pursuant to section 6.
2 (5) Subject to the restrictions on access to raw data
3 set forth in section 10, issue special reports and make
4 available raw data as defined in section 3 to any purchaser
5 requesting it. Sale by any recipient, or exchange or
6 publication by a recipient other than a purchaser of raw
7 council data to other parties without the express written
8 consent of, and under terms approved by, the council shall be
9 unauthorized use of data pursuant to section 10(c).
10 (6) On a monthly basis, publish in the Pennsylvania
11 Bulletin a list of all the raw data reports it has prepared
12 under section 10(f) and a description of the data obtained
13 through each computer-to-computer access it has provided
14 under section 10(f) and of the names of the parties to whom
15 the council provided the reports or the computer-to-computer
16 access during the previous month.
17 (7) Promote competition in the health care and health
18 insurance markets.
19 (8) Assure that the use of council data does not raise
20 access barriers to care.
21 (9) Recommend a permanent indigent care program as
22 specified in, and incorporating the results of the study
23 required in, section 8.
24 (10) Make annual reports to the General Assembly on the
25 rate of increase in the cost of health care in the
26 Commonwealth and the effectiveness of the council in carrying
27 out the legislative intent of the act. In addition, the
28 council may make recommendations on the need for further
29 health care cost containment legislation. The council shall
30 also make annual reports to the General Assembly on the
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1 quality and effectiveness of health care and access to health
2 care for all citizens of the Commonwealth.
3 (11) Adopt, within 180 days following commencement of
4 its operations pursuant to section 4(i), as part of the
5 Pennsylvania Uniform Claims and Billing Form for covered
6 services pursuant to sections 5(d)(2) and 6(b), a standard
7 billing form for all providers, which shall include, in
8 addition to information required pursuant to section 6(c),
9 such other information and explanations as the council deems
10 necessary, and which itemizes all charges for services,
11 equipment, supplies and medicine. Each provider shall be
12 required to utilize said standard billing form for covered
13 services within 90 days of adoption of said form by the
14 council. Such itemized billings shall be written in language
15 that is understandable to the average person and be presented
16 to each patient upon discharge from a health care facility or
17 provision of physician services or within a reasonable time
18 thereafter.
19 (12) Conduct studies and publish reports thereon
20 analyzing the effects that noninpatient, alternative health
21 care delivery systems have on health care costs. These
22 systems shall include, but not be limited to: HMO's; PPO's;
23 primary health care facilities; home health care; attendant
24 care; ambulatory service facilities; free standing emergency
25 centers; birthing centers; and hospice care. These reports
26 shall be submitted to the General Assembly and shall be made
27 available to the public.
28 Section 6. Data submission and collection.
29 (a) Submission of data.--The council is hereby authorized to
30 collect and data sources are hereby required to submit upon
19850S0293B2324 - 18 -
1 request of the council all data required in this section,
2 according to uniform submission formats, coding systems and
3 other technical specifications necessary to render the incoming
4 data substantially valid, consistent, compatible and manageable
5 using electronic data processing according to data submission
6 schedules, such schedules to avoid to the extent possible,
7 submission of identical data from more than one data source,
8 established and promulgated by the council in regulations
9 pursuant to its authority under section 5(b).
10 (b) Pennsylvania Uniform Claims and Billing Form.--The
11 council shall adopt, within 180 days of the commencement of its
12 operations pursuant to section 4(i), a Pennsylvania Uniform
13 Claims and Billing Form format. The council shall furnish said
14 claims and billing form format to all data sources and said
15 claims and billing form shall be utilized and maintained by all
16 data sources for all services covered by this act. The
17 Pennsylvania Uniform Claims and Billing Form shall consist of
18 the Uniform Hospital Billing Form UB-82/HCFA-1450, and the HCFA-
19 1500, or their successors, as developed by the National Uniform
20 Billing Committee, with additional fields as necessary to
21 provide all of the data set forth in subsections (c) and (d).
22 (c) Data elements.--For each covered service performed in
23 Pennsylvania, the council shall be required to collect the
24 following data elements:
25 (1) uniform patient identifier, continuous across
26 multiple episodes and providers;
27 (2) patient date of birth;
28 (3) patient sex;
29 (4) patient ZIP Code number;
30 (5) date of admission;
19850S0293B2324 - 19 -
1 (6) date of discharge;
2 (7) principal and up to four secondary diagnoses by
3 standard code;
4 (8) principal procedure by council specified standard
5 code and date;
6 (9) up to three secondary procedures by council
7 specified standard codes and dates;
8 (10) uniform health care facility identifier, continuous
9 across episodes, patients and providers;
10 (11) uniform identifier of admitting physician, by
11 unique physician identification number established by the
12 council, continuous across episodes, patients and providers;
13 (12) uniform identifier of consulting physicians, by
14 unique physician identification number established by the
15 council, continuous across episodes, patients and providers;
16 (13) total charges of health care facility, segregated
17 into major categories, including, but not limited to, room
18 and board, radiology, laboratory, operating room, drugs,
19 medical supplies and other goods and services according to
20 guidelines specified by the council;
21 (14) actual payments to health care facility,
22 segregated, if available, according to the categories
23 specified in paragraph (13);
24 (15) charges of each physician or professional rendering
25 service relating to an incident of hospitalization or
26 treatment in an ambulatory service facility;
27 (16) actual payments to each physician or professional
28 rendering service pursuant to paragraph (15);
29 (17) uniform identifier of primary payor;
30 (18) ZIP Code number of facility where health care
19850S0293B2324 - 20 -
1 service is rendered;
2 (19) uniform identifier for payor group contract number;
3 (20) patient discharge status; and
4 (21) provider service effectiveness and provider quality
5 pursuant to section 5(d)(4) and subsection (d).
6 (d) Provider quality and provider service effectiveness data
7 elements.--In carrying out its duty to collect data on provider
8 quality and provider service effectiveness under section 5(d)(4)
9 and subsection (c)(21), the council shall define a methodology
10 to measure provider service effectiveness which may include
11 additional data elements to be specified by the council
12 sufficient to carry out its responsibilities under section
13 5(d)(4). The council may adopt a nationally recognized
14 methodology of quantifying and collecting data on provider
15 quality and provider service effectiveness until such time as
16 the council has the capability of developing its own methodology
17 and standard data elements. The council shall include in the
18 Pennsylvania Uniform Claims and Billing Form a field consisting
19 of the data elements required, pursuant to subsection (c)(21),
20 to provide information on each provision of covered services
21 sufficient to permit analysis of provider quality and provider
22 service effectiveness within 180 days of commencement of its
23 operations pursuant to section 4.
24 (e) Reserve field utilization and addition or deletion of
25 data elements.--The council shall include in the Pennsylvania
26 Uniform Claims and Billing Form a reserve field. The council may
27 utilize the reserve field by adding other data elements beyond
28 those required to carry out its responsibilities under section
29 5(d)(3) and (4) and subsections (c) and (d), or the council may
30 delete data elements from, the Pennsylvania Uniform Claims and
19850S0293B2324 - 21 -
1 Billing Form only by a majority vote of the council, and only
2 pursuant to the following procedure:
3 (1) The council shall obtain a cost-benefit analysis of
4 the proposed addition or deletion which shall include the
5 cost to data sources of any proposed additions.
6 (2) The council shall publish notice of the proposed
7 addition or deletion, along with a copy or summary of the
8 cost-benefit analysis, in the Pennsylvania Bulletin, and such
9 notice shall include provision for a 60-day comment period.
10 (3) The council may hold additional hearings or request
11 such other reports as it deems necessary and shall consider
12 the comments received during the 60-day comment period and
13 any additional information gained through such hearings or
14 other reports in making a final determination on the proposed
15 addition or deletion.
16 (f) Other data required to be submitted.--Providers are
17 hereby required to submit and the council is hereby authorized
18 to collect, in accordance with submission dates and schedules
19 established by the council, the following additional data,
20 provided such data is not available to the council from public
21 records:
22 (1) Audited annual financial reports of all hospitals
23 and ambulatory service facilities providing covered services
24 as defined in section 3.
25 (2) The Medicare cost report (OMB Form 2552 or
26 equivalent Federal form), or the AG-12 form for Medical
27 Assistance or successor forms, whether completed or partially
28 completed, and including the settled Medicare cost report and
29 the certified AG-12 form.
30 (3) Additional data including, but not limited to, data
19850S0293B2324 - 22 -
1 which can be used to provide at least the following
2 information:
3 (i) the incidence of medical and surgical procedures
4 in the population for individual providers;
5 (ii) physicians who provide covered services and
6 accept medical assistance patients;
7 (iii) physicians who provide covered services and
8 accept Medicare assignment as full payment;
9 (iv) status of licensure and accreditation of
10 hospitals and ambulatory service facilities;
11 (v) mortality rates for specified diagnoses and
12 treatments, grouped by severity, for individual
13 providers;
14 (vi) rates of infection for specified diagnoses and
15 treatments, grouped by severity, for individual
16 providers;
17 (vii) morbidity rates for specified diagnoses and
18 treatments, grouped by severity, for individual
19 providers;
20 (viii) readmission rates for specified diagnoses and
21 treatments, grouped by severity, for individual
22 providers; and
23 (ix) rate of incidence of postdischarge professional
24 care for selected diagnoses and procedures, grouped by
25 severity, for individual providers.
26 (4) Any other data the council requires to carry out its
27 responsibilities pursuant to section 5(d).
28 (g) Allowance for clarification or dissents.--The council
29 shall maintain a file of written statements submitted by data
30 sources who wish to provide an explanation of data that they
19850S0293B2324 - 23 -
1 feel might be misleading or misinterpreted. The council shall
2 provide access to such file to any person and shall where
3 practical in its reports and data files indicate the
4 availability of such statements. When the council agrees with
5 such statements, it shall correct the appropriate data and
6 comments in its data files and subsequent reports.
7 (h) Availability of data.--Nothing in this act shall
8 prohibit a purchaser from obtaining from its health care insurer
9 nor relieve said health care insurer from the obligation of
10 providing said purchaser, on terms consistent with past
11 practices, data previously provided or additional data not
12 currently provided, to said purchaser by said health care
13 insurer pursuant to any existing or future arrangement,
14 agreement or understanding.
15 Section 7. Data dissemination and publication.
16 (a) Public reports.--Subject to the restrictions on access
17 to council data set forth in section 10, and utilizing the data
18 collected under section 6, as well as other data, records and
19 matters of record available to it, the council shall prepare and
20 issue reports to the General Assembly and to the general public,
21 according to the following provisions:
22 (1) The council shall, for every provider within the
23 Commonwealth and within appropriate regions and subregions
24 within the Commonwealth and for those inpatient and
25 outpatient services which, when ranked by order of frequency,
26 account for at least 65% of all covered services and which,
27 when ranked by order of total payments, account for at least
28 65% of total payments, prepare and issue quarterly reports
29 that at least provide information on the following:
30 (i) Comparisons among all providers of payments
19850S0293B2324 - 24 -
1 received, charges, population-based admission or
2 incidence rates, and provider service effectiveness, such
3 comparisons to be grouped according to diagnosis and
4 severity, and to identify each provider by name and type
5 or speciality.
6 (ii) Comparisons among all providers, except
7 physicians, of inpatient and outpatient charges and
8 payments for room and board, ancillary services, drugs,
9 equipment and supplies and total services, such
10 comparisons to be grouped according to provider quality
11 and provider service effectiveness and according to
12 diagnosis and severity, and to identify each health care
13 facility by name and type.
14 (iii) Until and unless a methodology to measure
15 provider quality and provider service effectiveness
16 pursuant to sections 5(d)(4) and 6(c) and (d) is
17 available to the council, comparisons among all
18 providers, grouped according to diagnosis, procedure and
19 severity, which identify facilities by name and type and
20 physicians by name and speciality, of charges and
21 payments received, readmission rates, mortality rates,
22 morbidity rates, and infection rates. Following adoption
23 of the methodology specified in sections 5(d)(4) and 6(c)
24 and (d), the council may, at its discretion, discontinue
25 publication of this component of the report.
26 (iv) The incidence rate of selected medical or
27 surgical procedures, the provider service effectiveness,
28 and the payments received for those providers, identified
29 by the name and type or speciality, for which these
30 elements vary significantly from the norms for all
19850S0293B2324 - 25 -
1 providers.
2 (2) In preparing its reports under paragraph (1), the
3 council shall ensure that factors which have the effect of
4 either reducing provider revenue or increasing provider
5 costs, and other factors beyond a provider's control which
6 reduce provider competitiveness in the market place, are
7 explained in the reports. It shall also ensure that any
8 clarifications and dissents submitted by individual providers
9 under section 6(g) are noted in any reports that include
10 release of data on that individual provider.
11 (3) The council shall, for all providers within the
12 Commonwealth and within appropriate regions and subregions
13 within the Commonwealth, prepare and issue quarterly reports
14 that at least provide information on the following:
15 (i) The number of physicians, by speciality, on the
16 staff of each hospital or ambulatory service facility and
17 those physicians on the staff that accept Medicare
18 assignment as full payment and that accept medical
19 assistance patients.
20 (ii) The status of hospitals respecting
21 accreditation and licensure.
22 (4) The council shall publish all reports required in
23 this section in the Pennsylvania Bulletin and shall publish
24 in at least one newspaper of general circulation in each
25 subregion within the Commonwealth reports on the providers in
26 that subregion and subregions adjacent to it. In addition,
27 the council shall advertise the availability of these reports
28 and the charge for duplication in the Pennsylvania Bulletin
29 and in at least one newspaper of general circulation in each
30 subregion within the Commonwealth at least once in each
19850S0293B2324 - 26 -
1 calendar quarter.
2 (b) Raw data reports and computer access to council data.--
3 The council shall provide special reports derived from raw data
4 and a means for computer-to-computer access to its raw data to
5 any purchaser, pursuant to section 10(f). The council shall
6 provide such reports and computer-to-computer access, at its
7 discretion, to other parties, pursuant to section 10(g). The
8 council shall provide these special reports and computer-to-
9 computer access, in as timely a fashion as the council's
10 responsibilities to publish the public reports required in this
11 section will allow. Any such provision of special reports or
12 computer-to-computer access by the council shall be made only
13 subject to the restrictions on access to raw data set forth in
14 section 10(b) and only after payment for costs of preparation or
15 duplication pursuant to section 10(f) or (g).
16 Section 8. Health care for the medically indigent.
17 (a) Declaration of policy.--The General Assembly finds that
18 every person in this Commonwealth should receive timely and
19 appropriate health care services from any provider operating in
20 this Commonwealth; that, as a continuing condition of licensure,
21 each provider should offer and provide medically necessary,
22 lifesaving and emergency health care services to every person in
23 this Commonwealth, regardless of financial status or ability to
24 pay; and that health care facilities may transfer patients only
25 in instances where the facility lacks the staff or facilities to
26 properly render definitive treatment.
27 (b) Indigent Care Program.--To reduce the undue burden on
28 the several providers that disproportionately treat medically
29 indigent people on an uncompensated basis, to contain the long-
30 term costs generated by untreated or delayed treatment of
19850S0293B2324 - 27 -
1 illness and disease, and to determine the most appropriate means
2 of treating and financing the treatment of medically indigent
3 persons, there is hereby created an Indigent Care Program. To
4 fulfill its duties and responsibilities respecting the Indigent
5 Care Program, the council is authorized and directed to:
6 (1) Study the medically indigent population, the
7 magnitude of uncompensated care for the medically indigent,
8 the degree of access to and the result of any lack of access
9 by the medically indigent to appropriate care, the types of
10 providers and the settings in which they provide indigent
11 care and the cost of the provision of that care pursuant to
12 subsection (c).
13 (2) Determine, from the study required in paragraph (1),
14 a definition of the medically indigent population, the most
15 appropriate method for the delivery of timely and appropriate
16 health care services to the medically indigent.
17 (3) Develop a plan for an ongoing program of indigent
18 care to provide those services determined to be required
19 pursuant to paragraph (2) in accordance with the conditions
20 and requirements set forth in subsection (d).
21 (c) Study.--The council shall conduct a study pursuant to
22 subsection (b)(1), conduct public hearings and take testimony,
23 and thereafter report to the Governor and the General Assembly
24 the results of that study, and the results of those public
25 hearings and its recommendations for an ongoing program to
26 finance and deliver care to the medically indigent within 18
27 months of commencement of the council's operations. The council
28 may contract with an independent vendor to conduct this study in
29 accordance with the provisions for selecting vendors in section
30 16. The study shall include, but not be limited to, the
19850S0293B2324 - 28 -
1 following:
2 (1) the number and characteristics of the medically
3 indigent population, including such factors as income,
4 employment status, health status, patterns of health care
5 utilization, type of health care needed and utilized,
6 eligibility for health care insurance, distribution of this
7 population on a geographic basis and by age, sex and racial
8 or linguistic characteristics, and the changes in these
9 characteristics, including the following:
10 (i) the needs and problems of indigent persons in
11 urban areas;
12 (ii) the needs and problems of indigent persons in
13 rural areas;
14 (iii) the needs and problems of indigent persons who
15 are members of racial or linguistic minorities;
16 (iv) the needs and problems of indigent persons in
17 areas of high unemployment; and
18 (v) the needs and problems of the underinsured;
19 (2) the degree of and any change in access of this
20 population to sources of health care, including hospitals,
21 physicians and other providers;
22 (3) the distribution and means of financing indigent
23 care between and among providers, insurers, government,
24 purchasers and consumers, and the effect of that distribution
25 on each;
26 (4) the major types of care rendered to the indigent,
27 the setting in which each type of care is rendered and the
28 need for additional care of each type by the indigent;
29 (5) the likely impact of the current competitive
30 environment, the impact of the provision of care by for-
19850S0293B2324 - 29 -
1 profit provider entities, and the effects of cost containment
2 in the Commonwealth on the access to, availability of and
3 financing of needed care for the indigent, including the
4 impact on providers which provide a disproportionate amount
5 of care to the indigent;
6 (6) the distribution of delivered care and actual cost
7 to render such care by provider, region and subregion;
8 (7) the provision of care to the indigent through
9 improvements in the primary health care system, including the
10 management of needed hospital care by primary care providers;
11 (8) innovative means to finance indigent care through
12 such mechanisms as assigned-claims insurance programs,
13 prepaid or capitated delivery programs, contributions to a
14 pool, donations of professional services or a combination of
15 these or other methods;
16 (9) reduction in the dependence of indigent persons on
17 hospital services through improvements in preventive health
18 measures; and
19 (10) the extent to which the proposed Permanent Indigent
20 Care Program required under subsection (d) can be used in
21 conjunction with the medically needy program of Medicaid,
22 through such mechanisms as alterations in eligibility
23 requirements and purchasing methods based upon price and
24 quality of care under the Medical Assistance Program.
25 (d) Establishing the Permanent Indigent Care Program.--On or
26 before July 1, 1988, the council shall provide to the Governor
27 and the General Assembly a plan, based upon its determination
28 made pursuant to subsection (b)(2), for an ongoing program for
29 the delivery and financing of care to medically indigent persons
30 in the Commonwealth, as defined by the council pursuant to
19850S0293B2324 - 30 -
1 subsection (b)(3). Said plan shall be submitted to the Governor
2 and to the General Assembly for their review. In developing its
3 plan, the council shall be required to address the
4 recommendations developed pursuant to subsection (c). Within 120
5 days of the submission of the council's plan, the General
6 Assembly shall:
7 (1) enact the plan as submitted;
8 (2) modify and enact the plan; or
9 (3) enact a substitute indigent care program.
10 Section 9. Mandated health benefits.
11 In relation to current law or proposed legislation the
12 council shall, upon the request of the appropriate committee
13 chairman in the Senate and in the House of Representatives, or
14 upon the request of the Secretary of Health, provide information
15 on the proposed mandated health benefit pursuant to the
16 following:
17 (1) The General Assembly hereby declares that proposals
18 for mandated health benefits or mandated health insurance
19 coverage should be accompanied by adequate, independently
20 certified documentation defining the social and financial
21 impact and medical efficacy of the proposal. To that end the
22 council, upon receipt of such requests, is hereby authorized
23 and directed to contract with individuals, pursuant to the
24 selection procedures for vendors set forth in section 16, who
25 will constitute a Mandated Benefits Review Panel to review
26 mandated benefits proposals and provide independently
27 certified documentation, as provided for in this section.
28 (2) The panel shall consist of three senior researchers,
29 each of whom shall be a recognized expert, one in health
30 research, one in biostatistics and one in economics research.
19850S0293B2324 - 31 -
1 (3) The Mandated Benefits Review Panel shall have the
2 following duties and responsibilities:
3 (i) To review documentation submitted by persons
4 proposing or opposing mandated benefits within 90 days of
5 submission of said documentation to the panel.
6 (ii) To report to the council, pursuant to its
7 review in subparagraph (i) the following:
8 (A) Whether or not the documentation is complete
9 as defined in paragraph (4).
10 (B) Whether or not the research cited in the
11 documentation meets professional standards.
12 (C) Whether or not all relevant research
13 respecting the proposed mandated benefit has been
14 cited in the documentation.
15 (D) Whether or not the conclusions and
16 interpretations in the documentation are consistent
17 with the data submitted.
18 (4) To provide the Mandated Benefits Review Panel with
19 sufficient information to carry out its duties and
20 responsibilities pursuant to paragraph (3), persons proposing
21 or opposing legislation mandating benefits coverage should
22 submit documentation to the council pursuant to the procedure
23 established in paragraph (5), which demonstrates the
24 following:
25 (i) The extent to which the proposed benefit and the
26 services it would provide are needed by, available to and
27 utilized by the population of the Commonwealth.
28 (ii) The extent to which insurance coverage for the
29 proposed benefit already exists, or if no such coverage
30 exists, the extent to which this lack of coverage results
19850S0293B2324 - 32 -
1 in inadequate health care or financial hardship for the
2 population of the Commonwealth.
3 (iii) The demand for the proposed benefit from the
4 public and the source and extent of opposition to
5 mandating the benefit.
6 (iv) All relevant findings bearing on the social
7 impact of the lack of the proposed benefit.
8 (v) Where the proposed benefit would mandate
9 coverage of a particular therapy, the results of at least
10 one professionally accepted, controlled trial comparing
11 the medical consequences of the proposed therapy,
12 alternative therapies and no therapy.
13 (vi) Where the proposed benefit would mandate
14 coverage of an additional class of practitioners, the
15 results of at least one professionally accepted,
16 controlled trial comparing the medical results achieved
17 by the additional class of practitioners and those
18 practitioners already covered by benefits.
19 (vii) The results of any other relevant research.
20 (viii) Evidence of the financial impact of the
21 proposed legislation, including at least:
22 (A) The extent to which the proposed benefit
23 would increase or decrease cost for treatment or
24 service.
25 (B) The extent to which similar mandated
26 benefits in other states have affected charges, costs
27 and payments for services.
28 (C) The extent to which the proposed benefit
29 would increase the appropriate use of the treatment
30 or service.
19850S0293B2324 - 33 -
1 (D) The impact of the proposed benefit on
2 administrative expenses of health care insurers.
3 (E) The impact of the proposed benefits on
4 benefits costs of purchasers.
5 (F) The impact of the proposed benefits on the
6 total cost of health care within the Commonwealth.
7 (5) The procedure for review of documentation is as
8 follows:
9 (i) Any person wishing to submit information on
10 proposed legislation mandating insurance benefits for
11 review by the panel should submit the documentation
12 specified in paragraph (4) to the council.
13 (ii) The council shall, within 30 days of receipt of
14 the documentation:
15 (A) Publish in the Pennsylvania Bulletin notice
16 of receipt of the documentation, a description of the
17 proposed legislation, provision for a period of 60
18 days for public comment, and the time and place at
19 which any person may examine the documentation.
20 (B) Submit copies of the documentation to the
21 Secretary of Health and the Insurance Commissioner,
22 who shall review and submit comments to the council
23 on the proposed legislation within 30 days.
24 (C) Submit copies of the documentation to the
25 panel, which shall review the documentation and issue
26 their findings, pursuant to paragraph (3) within 90
27 days.
28 (iii) Upon receipt of the comments of the Secretary
29 of Health and the Insurance Commissioner and of the
30 findings of the panel, pursuant to subparagraph (ii), but
19850S0293B2324 - 34 -
1 no later than 120 days following the publication required
2 in subparagraph (ii), the council shall submit said
3 comments and findings, together with its recommendations
4 respecting the proposed legislation to the Governor, the
5 President pro tempore of the Senate, the Speaker of the
6 House of Representatives, the Secretary of Health, the
7 Insurance Commissioner and the person who submitted the
8 information pursuant to subparagraph (i).
9 Section 10. Access to council data.
10 (a) Public access.--The information and data received by the
11 council shall be utilized by the council for the benefit of the
12 public. Subject to the specific limitations set forth in this
13 section, the council shall make determinations on requests for
14 information in favor of access.
15 (b) Limitations on access.--Unless specifically provided for
16 in this act, neither the council nor any contracting system
17 vendor shall release and no data source, person, member of the
18 public or other user of any data of the council shall gain
19 access to:
20 (1) Any raw data of the council that does not
21 simultaneously disclose payment, as well as provider quality
22 and provider service effectiveness pursuant to sections
23 5(d)(4) and 6(d) or 7(a)(1)(iii).
24 (2) Any raw data of the council which could reasonably
25 be expected to reveal the identity of an individual patient.
26 (3) Any raw data of the council which could reasonably
27 be expected to reveal the identity of any purchaser, as
28 defined in section 3, other than a purchaser requesting data
29 on its own group or an entity entitled to said purchaser's
30 data pursuant to subsection (f).
19850S0293B2324 - 35 -
1 (4) Any raw data of the council relating to actual
2 payments to any identified provider made by any purchaser,
3 except that this provision shall not apply to access by a
4 purchaser requesting data on the group for which it purchases
5 or otherwise provides covered services or to access to that
6 same data by an entity entitled to the purchaser's data
7 pursuant to subsection (f).
8 (5) Any raw data disclosing discounts or differentials
9 between payments accepted by providers for services and their
10 billed charges obtained by identified payors from identified
11 providers unless comparable data on all other payors is also
12 released and the council determines that the release of such
13 information is not prejudicial or inequitable to any
14 individual payor or provider or group thereof. In making such
15 determination the council shall consider that it is primarily
16 concerned with the analysis and dissemination of payments to
17 providers, not with discounts.
18 (c) Unauthorized use of data.--Any person who knowingly
19 releases council data violating the patient confidentiality,
20 actual payments, discount data or raw data safeguards set forth
21 in this section to an unauthorized person commits a misdemeanor
22 of the first degree and shall, upon conviction, be sentenced to
23 pay a fine of $10,000 or to imprisonment for not more than five
24 years, or both. An unauthorized person who knowingly receives or
25 possesses such data commits a misdemeanor of the first degree.
26 (d) Unauthorized access to data.--Should any person
27 inadvertently or by council error gain access to data that
28 violates the safeguards set forth in this section, the data must
29 immediately be returned, without duplication, to the council
30 with proper notification.
19850S0293B2324 - 36 -
1 (e) Public access to records.--All public reports prepared
2 by the council shall be public records, and shall be available
3 to the public for a reasonable fee, not to exceed the cost of
4 duplication.
5 (f) Access to raw council data by purchasers.--Pursuant to
6 sections 5(d)(5) and 7(b) and subject to the limitations on
7 access set forth in subsection (b), the council shall provide
8 access to its raw data to purchasers in accordance with the
9 following procedure:
10 (1) Special reports derived from raw data of the council
11 shall be provided by the council to any purchaser requesting
12 such reports.
13 (2) A means to enable computer-to-computer access by any
14 purchaser to raw data of the council as defined in section 3
15 shall be developed, adopted and implemented by the council,
16 and the council shall provide such access to its raw data to
17 any purchaser upon request.
18 (3) In the event that any employer obtains from the
19 council, pursuant to paragraph (1) or (2), data pertaining to
20 its employees and their dependents for whom said employer
21 purchases or otherwise provides covered services as defined
22 in section 3 and who are represented by a certified
23 collective bargaining representative, said collective
24 bargaining representative shall be entitled to that same
25 data, after payment of fees as specified in paragraph (4).
26 Likewise, should a certified collective bargaining
27 representative obtain from the council, pursuant to paragraph
28 (1) or (2), data pertaining to its members and their
29 dependents who are employed by and for whom covered services
30 are purchased or otherwise provided by any employer, said
19850S0293B2324 - 37 -
1 employer shall be entitled to that same data, after payment
2 of fees as specified in paragraph (4).
3 (4) In providing for access to its raw data, the council
4 shall charge the purchasers which originally obtained such
5 access a fee sufficient to cover its costs to prepare and
6 provide special reports requested pursuant to paragraph (1)
7 or to provide computer-to-computer access to its raw data
8 requested pursuant to paragraph (2). Should a second or
9 subsequent party or parties request this same information
10 pursuant to paragraph (3), the council shall charge said
11 party a fee sufficient to cover only the costs of duplicating
12 the original access.
13 (g) Access to raw council data by other parties.--Subject to
14 the limitations on access to raw council data set forth in
15 subsection (b), the council may, at its discretion, provide
16 special reports derived from its raw data or computer-to-
17 computer access to parties other than purchasers. The council
18 shall publish regulations that set forth the criteria and the
19 procedure it shall use in making determinations on such access,
20 pursuant to the powers vested in the council in section 4. In
21 providing such access the council shall charge the party
22 requesting the access a fee sufficient to cover its costs of
23 providing such access.
24 Section 11. Special studies and reports.
25 (a) Special studies.--The Department of Health may publish
26 or contract for publication of special studies. Any special
27 study so published shall become a public document.
28 (b) Special reports.--
29 (1) The Department of Health may study and issue a
30 report on the special medical needs, demographic
19850S0293B2324 - 38 -
1 characteristics, access or lack thereof to health care
2 services and need for financing of health care services of:
3 (i) Senior citizens, particularly low-income senior
4 citizens, senior citizens who are members of minority
5 groups and senior citizens residing in low-income urban
6 or rural areas.
7 (ii) Low-income urban or rural areas.
8 (iii) Minority communities.
9 (iv) Women.
10 (v) Children.
11 (vi) Unemployed workers.
12 (vii) Veterans.
13 The reports shall include information on the current
14 availability of services to these targeted parts of the
15 population, and whether access to such services has increased
16 or decreased over the past ten years, and specific
17 recommendations for the improvement of their primary care and
18 health delivery systems, including disease prevention and
19 comprehensive health care services. The department may also
20 study and report on the effects of using prepaid, capitated
21 or HMO health delivery systems as ways to promote the
22 delivery of primary health care services to the underserved
23 segments of the population enumerated above.
24 (2) The department may study and report on the short-
25 term and long-term fiscal and programmatic impact on the
26 health care consumer of changes in ownership of hospitals
27 from nonprofit to profit, whether through purchase, merger or
28 the like. The department may also study and report on factors
29 which have the effect of either reducing provider revenue or
30 increasing provider cost, and other factors beyond a
19850S0293B2324 - 39 -
1 provider's control which reduce provider competitiveness in
2 the marketplace, are explained in the reports.
3 Section 12. Enforcement; penalty.
4 (a) Compliance enforcement.--The council shall have standing
5 to bring an action in law or in equity through private counsel
6 in any court of common pleas to enforce compliance with any
7 provision of this act, except section 11, or any requirement or
8 appropriate request of the council made pursuant to this act. In
9 addition, the Attorney General is authorized and shall bring any
10 such enforcement action in aid of the council in any court of
11 common pleas at the request of the council in the name of the
12 Commonwealth.
13 (b) Penalty.--Any person who fails to supply data pursuant
14 to section 6 commits a misdemeanor of the first degree and
15 shall, upon conviction, be sentenced to pay a fine of $10,000 or
16 to imprisonment for not more than five years, or both.
17 Section 13. Research and demonstration projects.
18 The council shall actively encourage research and
19 demonstrations to design and test improved methods of assessing
20 provider quality, provider service effectiveness and efficiency.
21 To that end, provided that no data submission requirements in a
22 mandated demonstration may exceed the current reserve field on
23 the Pennsylvania Uniform Claims and Billing Form, the council
24 may:
25 (1) Authorize contractors engaged in health services
26 research selected by the council pursuant to the provisions
27 of section 16, to have access to the council's raw data
28 files, providing such entities assume any contractual
29 obligations imposed by the council to assure patient identity
30 confidentiality.
19850S0293B2324 - 40 -
1 (2) Place data sources participating in research and
2 demonstrations on different data submission requirements from
3 other data sources in this Commonwealth.
4 (3) Require data source participation in research and
5 demonstration projects when this is the only testing method
6 the council determines is promising.
7 Section 14. Grievances and grievance procedures.
8 (a) Procedures and requirements.--Pursuant to its powers to
9 publish regulations under section 5(b) and with the requirements
10 of this section, the council is hereby authorized and directed
11 to establish procedures and requirements for the filing, hearing
12 and adjudication of grievances against the council of any data
13 source. Such procedures and requirements shall be published in
14 the Pennsylvania Bulletin pursuant to law.
15 (b) Claims; hearings.--Grievance claims of any data source
16 shall be submitted to the council, or to a third party
17 designated by the council, and the council or the designated
18 third party shall convene a hearing, if requested, and
19 adjudicate the grievance.
20 Section 15. Antitrust provisions.
21 Persons or entities required to submit data or information
22 under this act or receiving data or information from the council
23 in accordance with this act are declared to be acting pursuant
24 to State requirements embodied in this act and shall be exempt
25 from antitrust claims or actions grounded upon submission or
26 receipt of such data or information.
27 Section 16. Contracts with vendors.
28 Any contract with any vendor for purchase of services or for
29 purchase or lease of supplies and equipment related to the
30 council's powers and duties shall be let only after a public
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1 bidding process and only in accordance with the following
2 provisions, and no contract shall be let by the council that
3 does not conform to these provisions:
4 (1) The council shall prepare specifications fully
5 describing the services to be rendered or equipment or
6 supplies to be provided by a vendor and shall make these
7 specifications available for inspection by any person at the
8 council's offices during normal working hours and at such
9 other places and such other times as the council deems
10 advisable.
11 (2) The council shall publish notice of invitations to
12 bid in the Pennsylvania Bulletin. The council shall also
13 publish such notice in at least four newspapers in general
14 circulation in the Commonwealth on at least three occasions
15 at intervals of not less than three days. Said notice shall
16 include at least the following:
17 (i) The deadline for submission of bids by
18 prospective vendors, which shall be no sooner than 30
19 days following the latest publication of the notice as
20 prescribed in this paragraph.
21 (ii) The locations, dates and times during which
22 prospective vendors can examine the specifications
23 required in paragraph (1).
24 (iii) The date, time and place of the meeting or
25 meetings of the council at which bids will be opened and
26 accepted.
27 (iv) A statement to the effect that any person is
28 eligible to bid.
29 (3) Bids shall be accepted as follows:
30 (i) No council member who is affiliated in any way
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1 with any bidder shall vote on the awarding of any
2 contract for which said bidder has submitted a bid, and
3 any council member who has an affiliation with a bidder
4 shall state the nature of the affiliation prior to any
5 vote of the council.
6 (ii) Bids shall be accepted and such acceptance
7 shall be announced only at a public meeting of the
8 council as defined in section 4(e), and no bids shall be
9 accepted at an executive session of the council.
10 (iii) The council may require that a certified
11 check, in an amount determined by the council, accompany
12 every bid and, when so required, no bid shall be accepted
13 unless so accompanied.
14 (4) In order to prevent any party from deliberately
15 underbidding contracts in order to gain or prevent access to
16 council data, the council may award any contract at its
17 discretion, regardless of the amount of the bid pursuant to
18 the following:
19 (i) Any bid accepted must reasonably reflect the
20 actual cost of services provided.
21 (ii) Any vendor so selected by the council shall be
22 found by the council to be of such character and such
23 integrity as to assure, to the maximum extent possible,
24 adherence to all the provisions of this act in the
25 provision of contracted services.
26 (iii) The council may require the selected vendor to
27 furnish, within 20 days after the contract has been
28 awarded, a bond with suitable and reasonable requirements
29 guaranteeing the services to be performed with sufficient
30 surety in an amount determined by the council, and upon
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1 failure to furnish such bond within the time specified,
2 the previous award shall be void.
3 Section 17. Appropriations.
4 (a) General appropriation.--The sum of $1,850,000, or as
5 much thereof as may be necessary, is hereby appropriated to the
6 Health Care Cost Containment Council for the fiscal year July 1,
7 1986, to June 30, 1987, to carry out all the provisions of this
8 act required of the council.
9 (b) Study on indigent care.--The sum of $400,000, or as much
10 thereof as may be necessary, is hereby appropriated to the
11 Health Care Cost Containment Council to carry out the study on
12 indigent care required by section 8.
13 (c) Reallocation upon receipt of other funds.--Should other
14 funds become available to the council for the purpose of the
15 study on indigent care required by section 8, the council may
16 reallocate a portion of the $400,000 appropriation established
17 in subsection (b) for the purpose of subsection (a).
18 Section 18. Severability.
19 The provisions of this act are severable. If any provision of
20 this act or its application to any person or circumstance is
21 held invalid, the invalidity shall not affect other provisions
22 or applications of this act which can be given effect without
23 the invalid provision or application.
24 Section 19. Sunset.
25 This act shall expire December 31, 1992, unless reestablished
26 prior to that date in accordance with the act of December 22,
27 1981 (P.L.508, No.142), known as the Sunset Act.
28 Section 20. Effective date.
29 This act shall take effect immediately.
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