BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 275
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|AUTHOR: |Hernandez |
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|VERSION: |February 19, 2015 |
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|HEARING DATE: |April 8, 2015 | | |
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|CONSULTANT: |Vince Marchand |
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SUBJECT : Health facility data
SUMMARY : Requires the Office of Statewide Health Planning and
Development to adopt a regulation that adds physician
identifiers to the patient level data elements that are required
to be collected and reported by hospitals and surgical clinics.
Existing law:
1.Establishes the Office of Statewide Health Planning and
Development (OSHPD), and designates OSHPD as the single state
agency to collect specified health facility or clinic data for
use by all state agencies.
2.Requires hospitals to make and file with OSHPD certain
specified reports, including a Hospital Discharge Abstract
Data Record that is required to include 19 specified data
elements for each admission, including information on
diagnoses and disposition of the patient. In addition to this
discharge report, hospitals are required to file an Emergency
Care Data Record for each patient encounter in a hospital
emergency department, and hospitals and freestanding
ambulatory surgery clinics are required to file an Ambulatory
Surgery Data Record for each patient encounter during which at
least one ambulatory surgery procedure is performed, with both
of these data records including similar data elements to the
discharge data record.
3.Permits OSHPD to make additions or deletions to the data
elements required in the discharge reports, but limits OSHPD
to adding no more than a net of 15 elements to each data set
over any five-year period, and requires OSHPD to consider
costs and benefits of data collection and other factors prior
to adding or deleting any data element.
SB 275 (Hernandez) Page 2 of ?
4.Requires OSHPD, commencing July 1993, and annually thereafter,
to publish risk-adjusted outcome reports in accordance with a
schedule that requires reports to be published on three
conditions or procedures each year for three years, for a
total of nine reports by July 1995, and requires reports for
subsequent years to include conditions and procedures and
cover periods as appropriate. Requires the procedures and
conditions to be reported to be equally divided among medical,
surgical and obstetric conditions or procedures, and to be
selected by OSHPD in accordance with specified criteria.
5.Requires OSHPD, in addition to other established reports,
beginning July 1, 2004, to publish a risk-adjusted outcome
report for coronary artery bypass graft (CABG) surgery for all
CABG surgeries performed in the state. Requires the reports to
compare risk-adjusted outcomes by hospital in every year, and
by cardiac surgeon in every other year, but permits
information on individual hospitals and surgeons to be
excluded from the reports based upon the recommendation of a
clinical panel for statistical and technical considerations.
6.Requires OSHPD to appoint a clinical panel of nine members for
each risk-adjusted outcome report that includes reporting of
data by an individual physician. Specifies that for the
clinical panel for the CABG report, three members are to be
appointed from a list of names submitted by the California
Chapter of the American College of Cardiology, three members
from a list submitted by the California Medical Association,
and three members from a list submitted by consumer
organizations.
This bill: Requires OSHPD to adopt a regulation that adds
physician identifiers to the patient level data elements that
are required to be collected and reported by hospitals in the
Hospital Discharge Abstract Data Record and the Emergency Care
Data Record, and to the data elements collected and reported by
hospitals and freestanding ambulatory surgery clinics in the
Ambulatory Surgery Data Record.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, this bill would
SB 275 (Hernandez) Page 3 of ?
require OSHPD to adopt a regulation that would add physician
identifiers to the patient level data elements that are
required to be collected and reported by hospitals and
surgical clinics. Information on physicians is already
collected and reported for one procedure - CABG - and outcomes
following this procedure have greatly improved in the decade
since these outcome reports have been published. However,
despite it being within the authority of OSHPD to require
hospitals to begin adding physician identifiers to their
required reports in order to facilitate more outcome reports
at both the hospital and physician level, OSHPD has yet to
publish a single report other than CABG that includes
reporting at the physician level.
In 2013, the RAND Corporation published a research report,
sponsored by the California HealthCare Foundation, which
looked at this issue, and found that California is unique
among the 48 states with hospital discharge data reporting
programs in that it does not collect physician identifiers.
The report stated that potential benefits associated with
collecting and using physician-identified data include
benchmarking data for providers to use in quality improvement
efforts and providing information to help consumers make
informed decisions about where and from whom to receive care.
2.Background on data collection. Under existing law, OSHPD is
designated as the single state agency to collect specified
health facility or clinic data for use by all state agencies.
All licensed acute care hospitals are required to file with
OSHPD certain reports, including a Hospital Discharge Abstract
Data Record that includes 19 specified data elements for each
admission, including date of birth, sex, admission date,
discharge date, principal diagnosis, other diagnoses,
principal procedures, and disposition of the patient. In
addition to this discharge report, hospitals are required to
file an Emergency Care Data Record for each patient encounter
in a hospital emergency department, and hospitals and
freestanding ambulatory surgery clinics are required to file
an Ambulatory Surgery Data Record for each patient encounter
during which at least one ambulatory surgery procedure is
performed. For all three reports, OSHPD is permitted to make
additions or deletions to the data elements required in these
reports, as long as OSHPD adds no more than a net of 15
elements to each data set over any five-year period, and as
long as OSHPD considers the costs and benefits of data
SB 275 (Hernandez) Page 4 of ?
collection and other factors prior to adding or deleting any
data element.
3.RAND report. In February of 2013, the RAND Corporation
released a research paper, sponsored by the California
HealthCare Foundation, entitled "Exploring the Addition of
Physician Identifiers to the California Hospital Discharge
Data Set." According to this report, although research studies
have shown large unexplained variation in how physicians care
for patients with similar medical conditions, there is an
absence of routine measurement and reporting of individual
physician performance. Such measurement could help: (a)
providers understand how their performance compares with peers
to stimulate quality improvement; (b) consumers make more
informed choices about providers when they need care; (c)
researchers with understanding factors associated with
variations in processes of care and health outcomes; and, (d)
payers with value-based purchasing efforts.
The report found that of the 48 states that have hospital
discharge reporting programs, all but California collect
physician identifiers and do so without substantial burden to
hospitals. States vary in their release policies, but those
who do release that data have not reported problems.
California stakeholders interviewed for the report expressed
concerns related to who would have access to the data, how the
data would be analyzed, and how consumers would interpret the
information.
According to the report, the collection of physician identifiers
as part of the hospital discharge data set represents an
opportunity for California to generate performance data at the
physician level that could be used by many stakeholders for a
variety of purposes. The authors of the report recommended
that OSHPD should move forward without delay to add physician
identifiers to the list of data elements it collects as part
of the hospital discharge data. The report went on to
recommend that, given genuine concerns about how the data will
be analyzed and used once collected, stakeholders should come
together to forge a blueprint for appropriate data use that
could be used to guide the actions of the state and end users
of the data. The report recommended that the development of
the blueprint should happen in parallel with the regulatory
process.
SB 275 (Hernandez) Page 5 of ?
4.Risk-adjusted outcome reports and CABG. OSHPD uses the data it
collects, in part, to produce required "risk-adjusted" reports
of outcomes of various procedures and treatments performed at
hospitals. Risk-adjustment, in this instance, means that the
results are adjusted to take into account the condition of the
patient. In this manner, outcomes from hospitals that treat a
disproportionately high number of sick or frail patients, for
instance, can be compared with hospitals treating younger or
healthier patients. While the raw outcome data for the
hospital with a high number of sick patients might show a
relatively high number of deaths, the "risk-adjusted" report
might show both hospitals have equivalent outcomes.
Pursuant to SB 680 (Figueroa), Chapter 898, Statutes of 2001,
OSHPD began publishing CABG risk-adjusted outcome reports for
both hospitals and surgeons beginning in 2006 for data
collected in 2003, and have continued publishing these reports
each year. Unlike prior reports based on OSHPD discharge data,
the publication of the CABG reports required establishing a
clinical data registry for the collection of surgeon
information. According to OSHPD, the CABG Outcomes Reporting
Program is the largest public reporting program on CABG
surgery outcomes in the United States. According to the most
recent report, the operative mortality rate for isolated CABG
surgery in California was 2.01 percent in 2011, which
represents a 31 percent reduction in the operative mortality
rates since 2003 (2.91percent), the first year of mandated
reporting.
5.Expanding beyond CABG would require collection of physician
identifiers. Under existing law, OSHPD is supposed to have
been publishing a minimum of nine risk-adjusted reports in
addition to the CABG report since 1995, with the procedures
and conditions chosen by OSHPD and divided among medical,
surgical, and obstetrical conditions or procedures. These
reports were to have included reports for both hospitals and
physicians, unless OSHPD determined it was not appropriate to
report by individual physician. However, CABG remains the only
risk-adjusted outcome report that includes physician-level
reporting.
6.Prior legislation. SB 830 (Galgiani), of 2014, would have
required OSHPD to include "heart valve repair and replacement
surgeries" in their annual risk adjusted outcome reports for
SB 275 (Hernandez) Page 6 of ?
coronary artery bypass graft surgeries, and to annually
publish a new risk-adjusted outcome report for all
percutaneous cardiac interventions and transcatheter valve
procedures performed in California. SB 830 was held in Senate
Appropriations Committee
SB 680 (Figueroa), Chapter 898, Statutes of 2001, required OSHPD
to publish risk-adjusted outcome reports for CABG surgery,
required the existing risk-adjusted outcome reports that OSHPD
is required to publish to also report data by individual
physician where appropriate, and made various other changes to
the provisions of law required OSHPD to publish risk-adjusted
outcome reports.
7.Support. Consumers Union states in support that it sponsored
SB 680 (Figueroa) to require outcome reports for CABG
surgeries, both by individual hospital and by surgeon.
Consumers Union states that publicly reporting mortality rates
with this level of specificity not only gives consumers
actionable information in choosing hospitals and surgeons, it
also incentivizes self-improvement by medical professionals.
According to Consumers Union, the inclusion of physician
identifiers as required data elements by OSHPD from hospitals
and surgical clinics would provide valuable information to aid
quality improvement and to assist consumers with medical
decision-making. Health Access California also supports this
bill, stating that the data collected by OSHPD remains one of
the richest sources of public data on health facilities and
health outcomes available nationally. The lack of physician
identifiers has limited the usefulness of the data in health
policy research aimed at improving quality, increasing patient
safety, reducing patient deaths and co-morbidities while
reducing costs. Health Access states that moving forward on
the quadruple aim of better health, better health care, lower
costs, and reduced disparities requires data on all elements
of the health care system, including physicians as well as
hospitals and other facilities. The California State Council
of the Service Employees International Union (SEIU
California), states in support that according to the RAND
report, physician-linked data sets are key tracking clinical
quality across payer types, and therefore, valuable in
producing consumer quality report cards. SEIU California also
notes in support that because this practice is so commonplace
nationwide, its implementation in California would be
relatively straightforward and not burdensome to hospitals or
SB 275 (Hernandez) Page 7 of ?
the state.
8.Oppose unless amended. The California Medical Association
(CMA) states that while it agrees that accurate and reliable
data is important, it is also important that any program for
collecting data meet certain quality, accuracy, privacy, and
review standards. According to CMA, one key method for
ensuring patient privacy while processing large amounts of
data is de-identification, yet adding physician identifiers to
the data file may allow a user to re-identify patient-level
data. CMA states that concerns related to ensuring data is
reliable and privacy is properly protected is why many states
that do collect this data prohibit its release. In addition,
CMA notes that physician identifiers alone do not allow for an
accurate evaluation of hospital care, given that a physician
team and other practitioners and hospital employees are
involved in the care of patients. Therefore, CMA states that
all relevant practitioner identifiers would be needed to
provide an accurate analysis, and that the data must be
adjusted for risk as appropriate to control for differences in
case mix and avoid bias in reporting differences in outcomes
across providers. Finally, CMA states that review and comment
periods for data requests with the creation of stakeholder
panels to ensure provider involvement must be part of a
reliable process, including an opportunity to review and
appeal. CMA states that while it shares the goal of collecting
accurate and helpful data, it requests amendments that
specifically address its concerns to ensure that the goal can
be met.
The California Chapter of the American College of Emergency
Physicians (CalACEP) also writes that it is opposed to the
bill unless amended to aggregate the physician data so that it
is not individually identifiable, and to risk-adjust the raw
data to account for variations in the sickness of patients and
variability of other factors such as age and co-morbid
conditions. CalACEP states that while it supports the goal of
the bill to provide greater transparency to the public about
the healthcare system, it has concerns about publishing
physician identifiable information. According to CalACEP, when
view in isolation, outcomes can give a misleading read on
provider performance. For example, CalACEP states that
physicians who treat underserved or disadvantaged populations
may have poorer results if their patients are less able to
follow through with appointments and medications.
SB 275 (Hernandez) Page 8 of ?
SUPPORT AND OPPOSITION :
Support: Consumers Union
Health Access
SEIU California
Oppose: California Chapter American College of Emergency
Physicians (unless amended)
California Medical Association (unless amended)
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