BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 275|
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THIRD READING
Bill No: SB 275
Author: Hernandez (D)
Introduced:2/19/15
Vote: 21
SENATE HEALTH COMMITTEE: 7-0, 4/8/15
AYES: Hernandez, Hall, Mitchell, Monning, Pan, Roth, Wolk
NO VOTE RECORDED: Nguyen, Nielsen
SENATE APPROPRIATIONS COMMITTEE: 5-0, 4/20/15
AYES: Lara, Beall, Hill, Leyva, Mendoza
NO VOTE RECORDED: Bates, Nielsen
SUBJECT: Health facility data
SOURCE: Author
DIGEST: This bill 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.
ANALYSIS:
Existing law:
1)Establishes the Office of Statewide Health Planning and
Development (OSHPD), and designates OSHPD as the single state
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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.
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.
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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.
Comments
1.Author's statement. According to the author, this bill
requires 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
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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
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.
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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 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.
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,
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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% in 2011, which represents a
31% reduction in the operative mortality rates since 2003
(2.91%), 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.
Prior Legislation
SB 830 (Galgiani, 2014) would have required OSHPD to include
"heart valve repair and replacement surgeries" in their annual
risk adjusted outcome reports for 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 the 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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee, one-time costs
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of about $100,000 to develop policies, adopt regulations, and
make necessary changes to computer systems (California Health
Data and Planning Fund).
SUPPORT: (Verified4/21/15)
Consumers Union
Health Access
SEIU California
OPPOSITION: (Verified4/21/15)
California Chapter of the American College of Emergency
Physicians
California Medical Association
ARGUMENTS IN 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 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
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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 the state.
ARGUMENTS IN OPPOSITION: 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) writes that it is opposed to this 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
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this bill to provide greater transparency to the public, 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.
Prepared by:Vince Marchand / HEALTH /
4/22/15 17:30:32
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