Amended in Senate March 28, 2016

Senate Bill No. 1159

Introduced by Senator Hernandez

February 18, 2016

begin delete An act to amend Section 136000 of the Health and Safety Code, relating to health care. end delete begin insert An act to add Chapter 8 (commencing with Section 127670) to Part 2 of Division 107 of, and to repeal the heading of Chapter 8 (formerly commencing with Section 127670) of Part 2 of Division 107 of, the Health and Safety Code, relating to health care. end insert

LEGISLATIVE COUNSEL’S DIGEST

SB 1159, as amended, Hernandez. begin delete Health Care: Office of Patient Advocate. end delete begin insert California Health Care Cost and Quality Database. end insert

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Existing law establishes health care coverage programs to provide health care to segments of the population meeting specified criteria who are otherwise unable to afford health care coverage and provides for the licensure and regulation of health insurers and health care service plans.

end insert begin insert

This bill would require certain health care entities, including health care service plans, to provide specified information to the Secretary of California Health and Human Services. The bill would authorize the secretary to report a health care entity that fails to comply with that requirement to the health care entity’s regulating agency and would authorize the regulating agency to enforce that requirement using its existing enforcement procedures.

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The bill would require all data disclosures made pursuant to these provisions to comply with all applicable state and federal laws for the protection of the privacy and security of data and would prohibit the public disclosure of any unaggregated, individually identifiable health information. The bill would require that certain confidentially negotiated contract terms be protected in data disclosures made pursuant to these provisions and would prohibit certain individually identifiable proprietary contract information from being disclosed in an unaggregated format.

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This bill would also require the secretary to convene an advisory committee composed of a broad spectrum of health care stakeholders and experts, as specified, to, among other things, develop the parameters for establishing, implementing, and administering a health care cost and quality database. The bill would require the secretary to arrange for the preparation of an annual report to the Legislature and the Governor that examines and addresses specified issues, including, among others, containing the cost of health care services and coverage. The bill would provide that members of the committee not receive a per diem or travel expense reimbursement, or any other expense reimbursement.

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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.

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This bill would make legislative findings to that effect.

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Existing law establishes the Office of Patient Advocate within the California Health and Human Services Agency, to provide assistance to, and advocate on behalf of, health care consumers. The duties of the office, include, among other things, compiling an annual publication, to be made available on the office’s Internet Web site, of specified information relating to certain publicly operated consumer assistance centers.

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This bill would require the office to log, and include in the annual publication, a call center’s record of answering calls within 30 seconds, the number of abandoned calls, and the number of busy messages sent to consumers.

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Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

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

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begin insert SECTION 1. end insert   

end insert

begin insert The heading of Chapter 8 (formerly commencing
with Section 127670) of Part 2 of Division 107 of the end insert begin insert Health and
Safety Code end insert begin insert , as amended by Section 230 of Chapter 183 of the
Statutes of 2004, is repealed. end insert

begin delete

 

Chapter  8. California Health Care Quality Improvement and Cost Containment Commission

 

end delete

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Chapter 8 (commencing with Section 127670) is added
to Part 2 of Division 107 of the end insert begin insert Health and Safety Code end insert begin insert , to read: end insert

begin insert

 

Chapter   begin insert 8. end insert California Health Care Cost and Quality
Database

 

begin insert 127670. end insert   

(a) It is the intent of the Legislature to establish a
system to provide valid, timely, and comprehensive health care
performance information that is publicly available and can be
used to improve the safety, appropriateness, and medical
effectiveness of health care, and to provide care that is
patient-centered, timely, affordable, and equitable. It is also the
intent of the Legislature to grant access to provider performance
information to consumers and purchasers in order for them to
understand the potential financial consequences and liabilities
and obtain maximum quality and value and to minimize health
disparities in health care services.

(b) It is the intent of the Legislature, by making cost and quality
data available, to encourage health care service plans, health
insurers, and providers to develop innovative approaches, services,
and programs that may have the potential to deliver health care
that is both cost effective and responsive to the needs of enrollees,
including recognizing the diversity of California and the impact
of social determinants of health.

begin insert 127671. end insert   

(a) (1) Solely for the purpose of developing
information for inclusion in a health care cost and quality
database, a health care service plan, including a specialized health
care service plan, an insurer licensed to provide health insurance,
as defined in Section 106 of the Insurance Code, a supplier, as
defined in paragraph (3) of subdivision (b) of Section 1367.50, or
a provider, as defined in paragraph (2) of subdivision (b) of Section
1367.50, shall, and a self-insured employer, a multiemployer
self-insured plan that is responsible for paying for health care
services provided to beneficiaries, and the trust administrator for
a multiemployer self-insured plan may, provide all of the following
to the Secretary of California Health and Human Services:

(A) Utilization data from the health care service plans’ and
insurers’ medical, dental, and pharmacy claims or, in the case of
entities that do not use claims data, including, but not limited to,
integrated delivery systems, encounter data consistent with the
core set of data elements for data submission proposed by the
APCD Council, the University of New Hampshire, and the National
Association of Health Data Organizations.

(B) Pricing information for health care items, services, and
medical and surgical episodes of care gathered from allowed
charges for covered health care items and services or, in the case
of entities that do not use or produce individual claims, price
information that is the best possible proxy to pricing information
for health care items, services, and medical and surgical episodes
of care available in lieu of actual cost data to allow for meaningful
comparisons of provider prices and treatment costs.

(C) Information sufficient to determine the impacts of social
determinants of health, including age, gender, race, ethnicity,
limited English proficiency, sexual orientation and gender identity,
ZIP Code, and any other factors for which there is peer-reviewed
evidence.

(2) (A) The secretary may report an entity’s failure to comply
with paragraph (1) to the entity’s regulating agency.

(B) The regulating agency of an entity described in paragraph
(1) may enforce paragraph (1) using its existing enforcement
procedures. Notwithstanding any other law, moneys collected
pursuant to this authorization shall be subject to appropriation
by the Legislature, and the failure to comply with paragraph (1)
is not a crime.

(b) (1) All uses and disclosures of data made pursuant to this
section shall comply with all applicable state and federal laws for
the protection of the privacy and security of data, including, but
not limited to, the Confidentiality of Medical Information Act (Part
2.6 (commencing with Section 56) of Division 1 of the Civil Code),
the Information Practices Act of 1977 (Chapter 1 (commencing
with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil
Code), Title 1.81 (commencing with Section 1798.80) of Part 4 of
Division 3 of the Civil Code, and the federal Health Insurance
Portability and Accountability Act of 1996 (Public Law 104-191)
and the federal Health Information Technology for Economic and
Clinical Health Act, Title XIII of the federal American Recovery
and Reinvestment Act of 2009 (Public Law 111-5), and
implementing regulations.

(2) (A) All policies and protocols developed pursuant to this
section shall ensure that the privacy, security, and confidentiality
of individually identifiable health information is protected. The
secretary shall not publicly disclose any unaggregated, individually
identifiable health information and shall develop a protocol for
assessing the risk of reidentification stemming from public
disclosure of any health information that is aggregated,
individually identifiable health information.

(B) For the purposes of this paragraph, “individually
identifiable health information” has the same meaning as in
Section 160.103 of Title 45 of the Code of Federal Regulations.

(3) Confidentially negotiated contract terms contained in a
contract between a health care service plan or insurer and a
provider or supplier shall be protected in any public disclosure of
data made pursuant to this section. Individually identifiable
proprietary contract information included in a contract between
a health care service plan or insurer and a provider or supplier
shall not be disclosed in an unaggregated format.

begin insert 127672. end insert   

(a) The Secretary of California Health and Human
Services shall convene an advisory committee, composed of a
broad spectrum of health care stakeholders and experts, including,
but not limited to, representatives of the entities that are required
to provide information pursuant to subdivision (a) of Section
127671 and representatives of purchasers, including, but not
limited to, businesses, organized labor, and consumers, to develop
the parameters for the establishment, implementation, and ongoing
administration of a health care cost and quality database, including
a business plan for sustainability without using moneys
appropriated from the General Fund, and to identify the type of
data, purpose of use, and entities and individuals that are required
to report to, or that may have access to, a health care cost and
quality database. The advisory committee shall hold public
meetings with stakeholders, solicit input, and set its own meeting
agendas. Meetings of the advisory committee are subject to the
Bagley-Keene Open Meeting Act (Article 9 (commencing with
Section 11120) of Chapter 1 of Part 1 of Division 3 of Title 2 of
the Government Code).

(b) The secretary shall arrange for the preparation of an annual
report to the Legislature and the Governor, to be submitted in
compliance with Section 9795 of the Government Code, based on
the findings of the advisory committee, including input from the
public meetings, that shall, at a minimum, examine and address
the following issues:

(1) Assessing California health care needs and available
resources.

(2) Containing the cost of health care services and coverage.

(3) Improving the quality and medical appropriateness of health
care.

(4) Reducing health disparities and addressing the social
determinants of health.

(5) Increasing the transparency of health care costs and the
relative efficiency with which care is delivered.

(6) Use of disease management, wellness, prevention, and other
innovative programs to keep people healthy, reduce disparities
and costs, and improve health outcomes for all populations.

(7) Efficient utilization of prescription drugs and technology.

(8) Reducing unnecessary, inappropriate, and wasteful health
care.

(9) Educating consumers in the use of health care information.

(10) Using existing data sources to build a health care cost and
quality database.

(c) Notwithstanding any other law, the members of the advisory
committee shall not receive per diem or travel expense
reimbursement, or any other expense reimbursement.

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begin insert

begin insert SEC. 3. end insert   

end insert begin insert

The Legislature finds and declares that Section 2 of
this act, which adds Section 127671 to the Health and Safety 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:

end insert begin insert

In order to protect confidential and proprietary information
submitted to the Secretary of California Health and Human
Services, it is necessary for that information to remain confidential.

end insert

begin delete

SECTION 1.  

Section 136000 of the Health and Safety Code
is amended to read:

136000.  

(a) (1) The Office of Patient Advocate is hereby
established within the California Health and Human Services
Agency, to provide assistance to, and advocate on behalf of, health
care consumers. The goal of the office shall be to coordinate
amongst, provide assistance to, and collect data from, all of the
state agency consumer assistance or patient assistance programs
and call centers, to better enable health care consumers to access
the health care services to which they are eligible under the law,
including, but not limited to, commercial and Exchange coverage,
Medi-Cal, Medicare, and federal veterans health benefits.
Notwithstanding any provision of this division, each regulator and
health coverage program shall retain its respective authority,
including its authority to resolve complaints, grievances, and
appeals.

(2) The office shall be headed by a patient advocate appointed
by the Governor. The patient advocate shall serve at the pleasure
of the Governor.

(b) (1) The duties of the office shall include, but not be limited
to, all of the following:

(A) Coordinate and work in consultation with state agency and
local, nongovernment health care consumer or patient assistance
programs and health care ombudsperson programs.

(B) Produce a baseline review and annual report to be made
publically available on the office’s Internet Web site by July 1,
2015, and annually thereafter, of health care consumer or patient
assistance help centers, call centers, ombudsperson, or other
assistance centers operated by the Department of Managed Health
Care, the Department of Health Care Services, the Department of
Insurance, and the Exchange, that includes, at a minimum, all of
the following:

(i) The types of calls received and the number of calls.

(ii) The call center’s role with regard to each type of call,
question, complaint, or grievance.

(iii) The call center’s protocol for responding to requests for
assistance from health care consumers, including any performance
standards.

(iv) The protocol for referring or transferring calls outside the
jurisdiction of the call center.

(v) The call center’s methodology of tracking calls, complaints,
grievances, or inquiries.

(vi) The call center’s record of answering calls within 30
seconds, the number of abandoned calls, and the number of busy
messages sent to consumers.

(C) (i) Collect, track, and analyze data on problems and
complaints by, and questions from, consumers about health care
coverage for the purpose of providing public information about
problems faced and information needed by consumers in obtaining
coverage and care. The data collected shall include demographic
data, source of coverage, regulator, type of problem or issue or
comparable types of problems or issues, and resolution of
complaints, including timeliness of resolution. Notwithstanding
Section 10231.5 of the Government Code, the office shall submit
a report by July 1, 2015, and annually thereafter to the Legislature.
The report shall be submitted in compliance with Section 9795 of
the Government Code. The format may be modified annually as
needed based upon comments from the Legislature and
stakeholders.

(ii) For the purpose of publically reporting information as
required in subparagraph (B) and this subparagraph about the
problems faced by consumers in obtaining care and coverage, the
office shall analyze data on consumer complaints and grievances
resolved by the agencies listed in subdivision (c), including
demographic data, source of coverage, insurer or plan, resolution
of complaints, and other information intended to improve health
care and coverage for consumers.

(D) Make recommendations, in consultation with stakeholders,
for improvement or standardization of the health consumer
assistance functions, referral process, and data collection and
analysis.

(E) Develop model protocols, in consultation with consumer
assistance call centers and stakeholders, that may be used by call
centers for responding to and referring calls that are outside the
jurisdiction of the call center, program, or regulator.

(F) Compile an annual publication, to be made publically
available on the office’s Internet Web site, of a quality of care
report card, including, but not limited, to health care service plans,
preferred provider organizations, and medical groups.

(G) Make referrals to the appropriate state agency, whether
further or additional actions may be appropriate, to protect the
interests of consumers or patients.

(H) Assist in the development of educational and informational
guides for consumers and patients describing their rights and
responsibilities and informing them on effective ways to exercise
their rights to secure and access health care coverage, produced
by the Department of Managed Health Care, the Department of
Health Care Services, the Exchange, and the California Department
of Insurance, and to endeavor to make those materials easy to read
and understand and available in all threshold languages, using an
appropriate literacy level and in a culturally competent manner.

(I) Coordinate with other state and federal agencies engaged in
outreach and education regarding the implementation of federal
health care reform, and to assist in these duties, may provide or
assist in the provision of grants to community-based consumer
assistance organizations for these purposes.

(J) If appropriate, refer consumers to the appropriate regulator
of their health coverage programs for filing complaints or
grievances.

(2) The office shall employ necessary staff. The office may
employ or contract with experts when necessary to carry out the
functions of the office. The patient advocate shall make an annual
budget request for the office that shall be identified in the annual
Budget Act.

(3) The patient advocate shall annually issue a public report on
the activities of the office, and shall appear before the appropriate
policy and fiscal committees of the Senate and Assembly, if
requested, to report and make recommendations on the activities
of the office.

(4) The office shall adopt standards for the organizations with
which it contracts pursuant to this section to ensure compliance
with the privacy and confidentiality laws of this state, including,
but not limited to, the Information Practices Act of 1977 (Chapter
1 (commencing with Section 1798) of Title 1.8 of Part 4 of
Division 3 of the Civil Code). The office shall conduct privacy
trainings as necessary, and regularly verify that the organizations
have measures in place to ensure compliance with this provision.

(c) The Department of Managed Health Care, the Department
of Health Care Services, the Department of Insurance, the
Exchange, and any other public health coverage programs shall
provide to the office data concerning call centers to meet the
reporting requirements in subparagraph (B) of paragraph (1) of
subdivision (b) and consumer complaints and grievances to meet
the reporting requirements in clause (i) of subparagraph (C) of
paragraph (1) of subdivision (b).

(d) For purposes of this section, the following definitions apply:

(1) “Consumer” or “individual” includes the individual or his
or her parent, guardian, conservator, or authorized representative.

(2) “Exchange” means the California Health Benefit Exchange
established pursuant to Title 22 (commencing with Section 100500)
of the Government Code.

(3) “Health care” includes services provided by any of the health
care coverage programs.

(4) “Health care service plan” has the same meaning as that set
forth in subdivision (f) of Section 1345. Health care service plan
includes “specialized health care service plans,” including
behavioral health plans.

(5) “Health coverage program” includes the Medi-Cal program,
Healthy Families Program, tax subsidies and premium credits
under the Exchange, the Basic Health Program, if enacted, county
health coverage programs, and the Access for Infants and Mothers
Program.

(6) “Health insurance” has the same meaning as set forth in
Section 106 of the Insurance Code.

(7) “Health insurer” means an insurer that issues policies of
health insurance.

(8) “Office” means the Office of Patient Advocate.

(9) “Threshold languages” has the same meaning as for
Medi-Cal managed care.

end delete