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AB-1558 California Health Data Organization: all-payer claims database.(2013-2014)

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AB1558:v98#DOCUMENT

Amended  IN  Senate  June 05, 2014

CALIFORNIA LEGISLATURE— 2013–2014 REGULAR SESSION

Assembly Bill
No. 1558


Introduced by Assembly Member Roger Hernández

January 28, 2014


An act to add Title 22.5 (commencing with Section 100800) to the Government Code, to amend Sections 1375.7 and 1395.6 of the Health and Safety Code, and to amend Sections 10178.3 and 10178.4 of the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 1558, as amended, Roger Hernández. California Health Data Organization. Organization: all-payer claims database.
Existing law establishes the Office of Statewide Health Planning and Development (OSHPD) to perform various functions and duties with respect to health facilities, health professions development, and health policy and planning, including, but not limited to, consulting with the Insurance Commissioner, the Director of the Department of Managed Health Care, and others to adopt a California uniform billing form format for professional health care services and a California uniform billing form format for institutional provider services. Existing law requires organizations that operate or own a health facility to file specified reports with OSHPD containing various financial and patient data.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plans and health insurers to provide an explanation of benefits or explanation of review that identifies the name of the network that has a written agreement signed by the provider whereby the payor is entitled, directly or indirectly, to pay a preferred rate for the services rendered.
This bill would request the University of California to establish the California Health Data Organization and would require health care service plans and health insurers to provide the explanations of benefits or explanations of review to that organization to the extent permitted by federal law request the organization to collect data from payers, as specified, and establish an all-payer claims database. The bill would require certain private payers to submit claims data to the organization on utilization, payment, and cost sharing for services delivered to beneficiaries. The bill would request the organization to establish working groups consisting of specified representatives to coordinate with existing stakeholder processes related to federal and state price transparency and payment reform and would request the organization to consider the recommendations of those working groups, as specified. The bill would require request the organization to organize the data provided in those documents collected pursuant to the bill’s provisions and to design and maintain an Internet Web site that allows consumers to compare the prices paid by carriers payers for procedures, as specified. The bill would prohibit data made available to the public from containing sufficient information to identify an individual and would require the organization to keep confidential any proprietary information it obtains. The bill would request the University of California to seek available funding from the federal government and other private sources to cover the costs associated with these provisions and would authorize the organization to charge a fee to each person or entity requesting access to data stored in the database it creates.
Existing constitutional provisions require that a statute that limits the right of access to the meetings of public bodies or the writings of public officials and agencies be adopted with findings demonstrating the interest protected by the limitation and the need for protecting that interest.
This bill would make legislative findings to that effect.

Because a willful violation of the bill’s requirement for a health care service plan to provide an explanation of benefits or explanation of review to the organization would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YESNO  

The people of the State of California do enact as follows:


SECTION 1.

 Title 22.5 (commencing with Section 100800) is added to the Government Code, to read:

TITLE 22.5. California Health Data Organization

100800.
 For purposes of this title, the following definitions shall apply:
(a) “All-payer claims database” or “database” means a database that receives and stores claims data from payers.
(b) For purposes of this section, “beneficiary” means one of the following:
(1) With respect to a health care service plan, a subscriber or enrollee.
(2) With respect to a health insurer, a policyholder or insured.
(3) With respect to a self-insured employee welfare benefit plan, an employee or dependent of an employee.
(c) “Claims data” means claim or encounter data representing medical, dental, mental health, and substance use disorder services financed by payers.
(d) “Claim” means a submitted claim that was processed and adjudicated by a payer, representing the paid amount and any adjustments that occurred after the original submission.
(e) “Encounter” means a submitted record of a visit, a service delivered, a procedure, or other activity, reported by a provider to a payer when payment is not issued on a fee-for-service basis.
(f) “Exchange” means the California Health Benefit Exchange established by Section 100500 of the Government Code.

(a)“Organization” means the California Health Data Organization established pursuant to Section 100801.

(b)“Carrier claims database” or “database” means a database that receives and stores data from carriers reported to the organization pursuant to Section 1395.6 of the Health and Safety Code and Section 10178.3 of the Insurance Code.

(c)“Carrier” means either a private health insurer holding a valid outstanding certificate of authority from the Insurance Commissioner or a health care service plan licensed by the Department of Managed Health Care.

(d)

(g) “Health care service plan” has the same meaning as that term is defined in subdivision (f) of Section 1345 of the Health and Safety Code.

(e)

(h) “Health insurer” means an insurer admitted to transact health insurance business in this state. For purposes of this subdivision, “health insurance” has the meaning used in Section 106 of the Insurance Code.

(f)

(i) “Individually identifiable information” means information that includes or contains any element of personal identifying information sufficient to allow identification of the individual, including the person’s name, address, electronic mail address, telephone number, or social security number, or other information that, alone or in combination with other publicly available information, reveals the individual’s identity.
(j) “Organization” means the California Health Data Organization established pursuant to Section 100801.
(k) “Payer” means a private payer, the Medi-Cal program, or the Medicare program.
(l) “Private payer” means any of the following:
(1) A health care service plan.
(2) A health insurer.
(3) A third-party administrator processing claims on behalf of a self-insured employee welfare benefit plan that provides coverage for health care expenses to at least 200 beneficiaries.
(m) “Proprietary information” includes, but is not limited to, any information that supports or provides any of the clinical rationale used for the purposes of supporting claims processing decisions.

100801.
 (a) The Legislature hereby requests the University of California to establish the California Health Data Organization.
(b) The organization shall Legislature requests that the organization be staffed by persons with demonstrated experience in all of the following:
(1) Performing statewide individual-level data collection.
(2) Managing and analyzing complex patient-level data.
(3) Complying with HIPAA requirements.
(4) Communicating information to the public via a user-friendly web interface.
(c) In order to avoid potential conflicts of interest within the University of California between providers of health care services and individuals working within the organization, the Legislature hereby requests that the organization not be based in a school of medicine or a University of California medical center.

(c)

(d) The Legislature hereby requests the University of California to seek available funding from the federal government and other private sources to cover defray the costs associated with the planning, implementation, and administration of this title.

100803.
 The organization shall Legislature requests the organization to do all of the following:
(a) Establish a carrier an all-payer claims database using the data collected and organized as described in this title.
(b) Collect data from carriers reported pursuant to Section 1395.6 of the Health and Safety Code and Section 10178.3 of the Insurance Code private payers submitted pursuant to Section 100804.
(c) Until data is collected as described in subdivision (b), collect claims data for private payers from publicly available data sources.
(d) Request and collect available claims data from the Medi-Cal program and the Medicare program, including claims data reported to those programs by a health care service plan or health insurer participating in those programs.
(e) Request and collect data from the Exchange that is related to the quality of care provided by health plans through the Exchange.

(c)

(f) Organize data reported by carriers pursuant to Section 1395.6 of the Health and Safety Code and Section 10178.3 of the Insurance Code the data collected pursuant to this section into the following categories:
(1) Charges billed and total amounts paid by carriers payers and patients, including, but not limited to, charge amount, paid amount, prepaid amount, copayment, coinsurance, deductible, and allowed amount.
(2) Type of health care service, including, but not limited to, ambulatory care procedures and services and inpatient physician services reported by Common Procedural Terminology (CPT) codes, and inpatient hospital services reported by Diagnosis-Related Group (DRG) codes.
(3) Information relating to risk adjustment, including other diagnoses, length of stay, and discharge. diagnosis codes, dates of service, monthly enrollment, age, gender, length of stay, modifiers, and discharge disposition.
(g) Seek to combine existing quality, outcomes, and patient experience and satisfaction data with the other data collected pursuant to this section in order to facilitate value-based purchasing of health care coverage in the state.
(h) Pursue the calculation of quality measures based on claims data submitted by payers to allow for comparisons among facilities and provider groups.

(d)

(i) Ensure that patient privacy is protected in compliance with state and federal laws. Patient In collecting, managing, and analyzing claims data, patient privacy shall be protected using encryption and storage of the confidential information on secure servers. Data that is made available to the public by the organization, including, but not limited to, data made available pursuant to a request for access described in paragraph (3) of subdivision (a) of Section 100805, shall not contain sufficient information to identify an individual, including, but not limited to, an individual health care provider.
(j) Keep confidential any proprietary information the organization obtains pursuant to this title. Proprietary information obtained by the organization shall not be made available to the public, shall not be subject to subpoena or discovery, and shall not be subject to the California Open Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code).

100804.
 (a) Commencing on the date that the organization is established, a private payer shall regularly submit claims data to the organization on utilization, payment, and cost sharing for services delivered to beneficiaries. The data submitted shall, at a minimum, include the following for each claim or encounter:
(1) A linkable patient identifier that can be mapped across all claims or encounters.
(2) Date of service.
(3) Date of payment.
(4) Adjustment flag.
(5) Claim identification number.
(6) At least two diagnosis codes related to the claim or encounter based on current coding standards.
(7) Any procedure codes associated with the claim or encounter based on current coding standards.
(8) National Drug Code for prescription drugs.
(9) Revenue codes.
(10) Allowed amount.
(11) Patient billed share of cost, including amounts billed prior to the patient satisfying any applicable deductible requirements.
(12) Total charge.
(13) Patient demographics, including, but not limited to, age, gender, race, ethnicity, and language, if available.
(14) Product type (HMO, PPO, POS, EPO, or FFS).
(15) Whether the claim or encounter is billed or reported under a health plan covering a single individual or a family and whether that plan is an individual market plan, a group market plan, or a self-insured employee welfare benefit plan.
(16) Type of payment to which claim or encounter is related (capitated, diagnosis related group, bundled, per diem, or other negotiated rate).
(17) Procedure modifiers based on current coding standards.
(18) Setting of service, including, but not limited to, hospital, outpatient primary care, outpatient specialty care, freestanding clinic, freestanding federally qualified health center, or ambulatory surgery center.
(19) National provider identification information for the provider billing for the service, including name, federal tax identification number, and address.
(20) National provider identification information for the provider rendering the service, including name, federal tax identification number, and address.
(21) Monthly enrollment flags for the time period of the claims or encounter file indicating if the individual was covered by the payer for any given month in the year.
(b) A private payer may, with approval of the organization, modify the information required to be submitted under this section as necessary to comply with applicable federal and state privacy laws.
(c) A private payer shall not be required to report to the organization the data required under this section with respect to beneficiaries enrolled in the Medi-Cal or Medicare program.

100804.5.
 (a) The Legislature requests the organization to establish working groups consisting of representatives of private payers, physicians and surgeons, provider groups, state and federal regulators, academia, and consumer stakeholders.
(b) The Legislature requests the working groups established by the organization to coordinate, to the extent possible, with existing stakeholder processes related to federal and state price transparency and payment reform. The organization is requested to consider the recommendations made by the working groups in providing updates to the desired data fields for claims data reporting, collecting and displaying price, quality, and value information for consumers, making comparisons by geographic region, provider type, and individual health care facilities, and conducting additional analyses to inform consumer decisions on price, quality, and value.
(c) The Legislature requests that the working groups established by the organization provide guidance on additional data that would be important for consumers and stakeholders in making price, quality, and value comparisons and the appropriate information to be displayed by variables, including, but not limited to, geographic region, provider type, facility, and provider group.

100805.
 (a) The organization may do all of the following:
(1) Receive and accept gifts, grants, or donations of moneys from any agency of the United States, any agency of the state, any municipality, county, or other political subdivision of the state.
(2) Receive and accept gifts, grants, or donations from individuals, associations, private foundations, or corporations, in compliance with the existing conflict-of-interest provisions to be adopted by the board at a public meeting University of California.
(3) Charge a reasonable fee to each person or entity requesting access to data stored in the database, not to exceed the actual costs of providing that access.
(4) Explore alternative sources of funding, to the extent permitted by law, to ensure the sustainabilty sustainability of the organization.
(b) The organization shall not accept Legislature requests that the organization refuse gifts or grants from an entity that may have a vested interest in the decisions of the organization.

100809.
 (a) The organization shall Legislature requests the organization to disseminate the information collected pursuant to this title to the public in a meaningful and comprehensive manner.
(b) For purposes of this section, the organization shall is requested to do all of the following:
(1) Design and maintain an interactive searchable Internet Web site that is accessible to the public and in which both of the following requirements are satisfied:
(A) Information on payments for services is easily searchable by the average consumer.
(B) The format used allows for the comparison of prices paid by carriers payers per procedure without identifying the particular price paid by a particular private payer.
(2) Investigate how to combine price information with quality information, either within the database or by linkage to other searchable databases.
(3) Investigate the most efficient way of presenting information to the public, including, but not limited to, reporting on price information for the average severity of the condition or for different tiers of severity.
(4) Coordinate efforts with the health care coverage market and provide information to the public using the geographic areas used by carriers payers in order to do both of the following:
(A) Make price transparency readily available to all purchasers of health care coverage.
(B) Help guide consumers in their choice between different health plans available through the California Health Benefit Exchange established by Section 100500.
(5) Aggregate at a high level of detail the information collected pursuant to this title and made available to the public so as not to disclose any propriety information.
(c) Information disclosed pursuant to this section shall not contain any individually identifiable information comply with subdivision (g) of Section 100803.
(d) To allow for the development of the Internet Web site described in this section without delay, the organization may contract with a qualified, nongovernmental, independent third party for the delivery of a commercially available claims dataset with the appropriate level of detail in term of payments, geocoding, and provider information. This information shall The Legislature requests that this information be replaced or supplemented with information directly collected by the organization once the first set of data directly collected from carriers payers has been cleaned and analyzed.
(e) In order to ensure the confidentiality, security, and affordability of maintaining the organization, the Legislature requests that the organization expand its data storage and processing capacity internally to house the Internet Web site described in this section and the large data sets gathered from payers under this title.

100811.
 The organization shall Legislature requests the organization to use the data collected pursuant to this title and produce annual reports on the cost of specific ambulatory care procedures and services and inpatient physician services aggregated within geographic market areas in this state, as determined by the organization, so as not to identify individual physicians.

SEC. 2.

 The Legislature finds and declares that Section 1 of this act, which adds Section 100803 to the Government Code, imposes a limitation on the public’s right of access to the meetings of public bodies or the writings of public officials and agencies within the meaning of Section 3 of Article I of the California Constitution. Pursuant to that constitutional provision, the Legislature makes the following findings to demonstrate the interest protected by this limitation and the need for protecting that interest:
In order to protect the confidentiality of proprietary information collected pursuant to this act, it is necessary that this act limit the public’s right of access to that information.