BILL ANALYSIS                                                                                                                                                                                                    



          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.







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          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  








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            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  








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            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.








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          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  








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            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  








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            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.








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           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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