BILL ANALYSIS
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|SENATE RULES COMMITTEE | AB 2533|
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CONSENT
Bill No: AB 2533
Author: Fuentes (D)
Amended: 6/23/10 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 8-0, 6/30/10
AYES: Alquist, Strickland, Aanestad, Cedillo, Leno,
Negrete McLeod, Pavley, Romero
NO VOTE RECORDED: Cox
SENATE APPROPRIATIONS COMMITTEE : Senate Rule 28.8
ASSEMBLY FLOOR : 77-0, 5/13/10 - See last page for vote
SUBJECT : Health care coverage: quality rating
SOURCE : California Medical Association
DIGEST : This bill expands the reporting requirements
required of health care service plans (health plans) and
health insurers, as specified, related to economic
profiling of physicians, providers, medical groups, or
individual practice associations to also apply to quality
rating, requires health plans and insurers to make such
filings with their respective departments immediately upon
adoption, or within 30 days of making any changes, and
modifies the required content of such filings, as
specified, and also requires a health plan or insurer that
submitted a filing prior to January 1, 2011, to update the
filing by March 31, 2011, to comply with the bill's
CONTINUED
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requirements, and to reflect the health plan or insurer's
current policies and procedures.
ANALYSIS :
Existing law
1. Provides for the regulation of health plans and insurers
by the Department of Managed Health Care (DMHC) and the
California Department of Insurance (CDI), respectively.
2. Requires every plan and insurer, on or before July 1,
1999, to file with their respective departments, a
description of the policies and procedures related to
economic profiling used by the plan or insurer and its
medical groups and individual practice associations
(IPAs). In addition, requires changes to these policies
and procedures to be filed with DMHC and CDI.
3. Defines "economic profiling" as any evaluation of a
particular physician, provider, medical group, or IPA,
based in whole or in part on the economic costs or
utilization of services associated with medical care
provided or authorized by the physician, provider,
medical group, or IPA.
4. Defines "provider" to mean any professional person,
organization, health facility, or other person or
institution licensed by the state to deliver or furnish
health care services.
5. Requires the Director of DMHC and the Insurance
Commissioner to make these filings available to the
public upon request, with certain exceptions.
6. Requires health plans and insurers, or its contracting
medical group or IPA (as a condition of contract), to
provide, upon request, a copy of economic profiling
information to the profiled individual provider, group,
or association.
7. Requires the filing with DMHC and CDI, respectively, to
describe how these policies and procedures are used for
utilization review, peer review, incentive and penalty
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programs, and in provider retention and termination
decisions.
8. Requires the filing to indicate in what manner, if any,
the economic profiling system being used takes into
consideration risk adjustments that reflect case mix,
type and severity of patient illness, age of patients,
and other enrollee characteristics that may account for
higher- or lower-than-expected costs or utilization of
services.
This bill:
1. Expands the reporting requirements required of health
plans and health insurers, as specified, related to
economic profiling of physicians, providers, medical
groups, or IPAs to also apply to quality rating, as
defined.
2. Defines "quality rating" as any effort by a health plan
or insurer, or by an entity contracted by a health plan
or insurer, to develop, evaluate, rate, or designate a
particular physician, provider, medical group, or IPA
based, in whole or in part, on quality measurements and
claims data.
3. Requires filings of the policies and procedures related
to economic profiling or quality rating to be made to
the respective department immediately upon adoption of
the policies and procedures, and within 30 days of
adopting any changes.
4. Requires a plan or insurer that has made such a filing
prior to January 1, 2011 to update their filing by March
31, 2011, in order to meet requirements of this section
and to reflect its current policies and procedures.
5. Specifies that such filings should include a description
of how the policies and procedures are used to:
A. Designate or rate a particular physician,
provider, medical group, or IPAs within the plan or
insurer's existing network.
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B. To encourage patients to see only designated or
rated physician, provider, medical group, or IPA
within the existing network.
6. Requires such filings to include a description of the
manner and methodology used to share results from
economic profiling and quality rating with patients.
7. Requires such filings to indicate in what manner, if
any, the economic profiling or quality rating system
being used takes into consideration risk adjustments to
also reflect the accuracy and reliability of data relied
upon, and patient compliance that may account for
higher- or lower-than-expected cost, utilization, and
quality of services.
8. Makes other technical and clarifying changes.
Background
Physician rating programs . Programs to rate, grade, rank
or tier physicians based on cost, quality or other measures
are becoming more prevalent as the demand for greater
transparency and accountability in the nation's health care
system intensifies. Physicians may be rated in a variety
of ways by health plans, payers, hospitals or other
entities that have some control over their practices or
payments. Rating may be used to reward high-quality or
low-cost care, or to discourage patients from seeing poor
performers. According to a March 2010 New England Journal
of Medicine article on the related topic of physician cost
profiling, health plans have limited the number of
physicians who receive in-network contracts, offered
patients differential copayments to encourage them to visit
"high-performance physicians" (i.e., those providing
higher-quality, lower-cost services), paid bonuses to
physicians whose patterns of resource use are lower than
average, and publicly reported the relative costs of
physicians' services. In more and more communities and
settings, mechanisms to evaluate and differentiate
physicians are under development as a way to promote
clinical and economic value in health care expenditures.
As health plans and other entities have begun to publicly
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report information about physician quality and cost
efficiency, physicians are expressing greater concern about
the accuracy of the public information and the methods that
are used to create and disseminate this information. In
order to safeguard the interests of both patients and
physicians, policymakers have begun to regulate how
physicians are rated and how that information is presented
to consumers. Advocates of consumer-driven health care
hope that when consumers have solid data comparing
providers' quality of care and cost effectiveness, they
will make sound choices that will bring U.S. health care
costs down. On the other hand, physician ranking systems
built on inaccurate and incomplete data offer no benefit to
consumers, and unfairly penalize physicians who are
inappropriately placed in a lower tier.
The California Physician Performance Initiative (CPPI) .
Established in 2006, the CPPI is a physician rating project
aimed at measuring and reporting the quality of patient
care provided by individual Californian physicians. The
project is administered by the California Cooperative
Health Care Reporting Initiative (CCHRI), a group that
collaborates on quality issues, and whose members include
employer, consumer, health plan, and physician groups.
Start-up funding for CPPI was provided by the federal
Centers for Medicare and Medicaid Services, the California
HealthCare Foundation, the Pacific Business Group on
Health, and the pharmaceutical company, Merck.
The CPPI has mainly focused on measuring primary care
physicians and internists, but continues to expand to other
specialties, such as cardiologists, endocrinologists,
pulmonologists, gastroenterologists, and rheumatologists.
Its goal is to improve patient care and affordability by:
1. Reporting results to physicians to help them gauge how
well the care their patients receive meet national
standards of care;
2. Applying the performance results in ways to help
consumers and purchasers get better value when they
choose providers and use health care services; and,
3. Adopting performance measures and reporting methods
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using the best available science to set performance
standards.
The CPPI assesses physician performance using
evidence-based, clinical quality measures endorsed by
national standard-setting bodies, such as the National
Quality Forum (NQF) and the American Medical Association's
Physician Consortium on Performance Improvement. According
to CCHRI, the measures for 2008 and 2009 were related to
preventive care and chronic condition management, and were
based on medical claims data aggregated across California's
three largest commercial PPO health plans (Anthem Blue
Cross, Blue Shield of California, and United Healthcare)
and the Anthem Blue Cross and Blue Shield of California
commercial HMO health plans. Individual reports were sent
to over 13,000 physicians annually, and each physician was
asked to review and provide corrections to the data used in
their rating. In 2009, nearly 1,200 physicians submitted
corrections. CCHRI states that the initial data used to
produce the CPPI quality measures was found to be 93
percent complete and accurate, and physicians with
insufficient data for a particular performance measure were
not reported and scored for that measure.
According to the CCHRI website, Blue Shield of California
has notified its network physicians of the plan's intent to
use CPPI quality results to recognize top performing
physicians. This recognition is displayed in the plan
physician directory that is provided to health plan
members. Physicians are recognized for results that affirm
that a threshold number of patients have received the
designated service for a given quality measure. The
performance recognition is measure-specific - a physician
can merit recognition for any of the CPPI measures for
which they have reliable results. The other two CPPI
participating plans, Anthem Blue Cross and United
Healthcare, have not announced any plans to use CPPI
results at this time.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
SUPPORT : (Verified 6/30/10)
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California Medical Association (source)
American Congress of Obstetricians and Gynecologists,
District IX
California Chiropractic Association
Network of Ethnic Physician Organizations
Osteopathic Physicians & Surgeons of California
ARGUMENTS IN SUPPORT : The California Medical Association
(CMA), the sponsor of this bill, asserts that this bill
will help patients from being misled by health plans and
insurers whose current methods to rate physicians, with
respect to quality, are fraught with inaccuracy. CMA
states that shortcomings of such quality measurement
programs, like the CPPI, include, but are not limited to,
incompleteness of claims data, and statistically invalid
patient sample size. CMA further points out that many
insurers and plans, and other third-party entities, are
conducting physician quality ratings without the knowledge
or consent of physicians, who should be provided an
opportunity to review the data and methodology used to rate
them.
The Network of Ethnic Physician Organizations (NEPO), a
collaborative of over 50 ethnic physician organizations in
California, and the Osteopathic Physicians & Surgeons of
California (OPSC) support this bill, stating that, although
well intended, the CPPI is misleading to the public. NEPO
and OPSC asserts that several researchers from across the
nation have found that the majority of physicians do not
have cost profiles that meet common thresholds of
reliability. By requiring measurement and reporting
information to undergo more scrutiny before becoming
available to the public, NEPO and OPSC believes this bill
will result in the availability of more accurate and useful
physician practice information.
The American Congress of Obstetricians and Gynecologists,
District IX (ACOG) states that, in the rush to make quality
and economic accountability decisions in a field where
there can be great differences in what each patient needs,
one size fits all is not an appropriate approach. ACOG
asserts that AB 2533 tempers and modulates the efforts by
plans and insurers to use strict economic credentialing
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criteria and quality indicators to rate physicians, so as
to provide for an opportunity for regulatory input.
ASSEMBLY FLOOR :
AYES: Adams, Ammiano, Anderson, Arambula, Bass, Beall,
Bill Berryhill, Tom Berryhill, Blakeslee, Block,
Blumenfield, Bradford, Brownley, Buchanan, Caballero,
Charles Calderon, Carter, Chesbro, Conway, Cook, Coto,
Davis, De La Torre, De Leon, DeVore, Emmerson, Eng,
Evans, Feuer, Fletcher, Fong, Fuentes, Fuller, Furutani,
Gaines, Galgiani, Garrick, Gilmore, Hagman, Hall, Harkey,
Hayashi, Hernandez, Hill, Huber, Huffman, Jeffries,
Jones, Knight, Lieu, Logue, Bonnie Lowenthal, Ma,
Mendoza, Miller, Monning, Nava, Nestande, Niello,
Nielsen, V. Manuel Perez, Portantino, Ruskin, Salas,
Saldana, Silva, Smyth, Solorio, Audra Strickland,
Swanson, Torlakson, Torres, Torrico, Tran, Villines,
Yamada, John A. Perez
NO VOTE RECORDED: Norby, Skinner, Vacancy
CTW:do 8/3/10 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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