Bill Text: MN SF2262 | 2011-2012 | 87th Legislature | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

---

Bill Title: Health provider peer grouping requirements modifications

Spectrum: Bipartisan Bill

Status: (Introduced - Dead) 2012-03-29 - Second reading [SF2262 Detail]

Download: Minnesota-2011-SF2262-Introduced.html

---

A bill for an act

relating to health; modifying requirements for provider peer grouping;
amending Minnesota Statutes 2010, sections 62U.04, subdivisions 1, 2, 4, 5;
256B.0754, subdivision 2; Minnesota Statutes 2011 Supplement, section 62U.04,
subdivisions 3, 9.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

    Section 1. Minnesota Statutes 2010, section 62U.04, subdivision 1, is amended to read:
    Subdivision 1. Development of tools to improve costs and quality outcomes.
    The commissioner of health shall develop a plan to create transparent prices, encourage
greater provider innovation and collaboration across points on the health continuum
in cost-effective, high-quality care delivery, reduce the administrative burden on
providers and health plans associated with submitting and processing claims, and provide
comparative information to consumers on variation in health care cost and quality across
providers. The development must be complete by January 1, 2010.

    Sec. 2. Minnesota Statutes 2010, section 62U.04, subdivision 2, is amended to read:
    Subd. 2. Calculation of health care costs and quality. The commissioner of health
shall develop a uniform method of calculating providers' relative cost of care, defined as a
measure of health care spending including resource use and unit prices, and relative quality
of care. In developing this method, the commissioner must address the following issues:
    (1) provider attribution of costs and quality;
    (2) appropriate adjustment for outlier or catastrophic cases;
    (3) appropriate risk adjustment to reflect differences in the demographics and health
status across provider patient populations, using generally accepted and transparent risk
adjustment methodologies and case mix adjustment;
    (4) specific types of providers that should be included in the calculation;
    (5) specific types of services that should be included in the calculation;
    (6) appropriate adjustment for variation in payment rates;
    (7) the appropriate provider level for analysis;
    (8) payer mix adjustments, including variation across providers in the percentage of
revenue received from government programs; and
    (9) for hospitals, appropriate cost adjustments to recognize the differences inherent
in hospitals that provide medical education, trauma services, neonatal intensive care, or
inpatient psychiatric services; and
(10) other factors that the commissioner determines are needed to ensure validity
and comparability of the analysis.

    Sec. 3. Minnesota Statutes 2011 Supplement, section 62U.04, subdivision 3, is
amended to read:
    Subd. 3. Provider peer grouping; system development; oversight committee.
    (a) The commissioner shall develop a peer grouping system for providers based on a
combined measure that incorporates both provider risk-adjusted cost of care and quality of
care, and for specific conditions as determined by the commissioner. In developing this
system, the commissioner shall consult and coordinate with health care providers, health
plan companies, state agencies, and organizations that work to improve health care quality
in Minnesota. For purposes of the final establishment of the peer grouping system, the
commissioner shall not contract with any private entity, organization, or consortium of
entities that has or will have a direct financial interest in the outcome of the system.
(b) The commissioner shall establish an oversight committee comprised of
representatives of health care providers, health plan companies, consumers, state
agencies, and organizations that work to improve health care quality in Minnesota. The
commissioner shall consult with the oversight committee in developing and administering
the peer grouping system, including but not limited to establishing peer groups,
selecting quality measures, and adopting patient attribution and quality and cost scoring
methodologies.
    Subd. 3a. Provider peer grouping; dissemination of data to providers. (b) By
no later than October 15, 2010, (a) The commissioner shall disseminate information
to providers on their total cost of care, total resource use, total quality of care, and the
total care results of the grouping developed under this subdivision 3 in comparison to an
appropriate peer group. Data used for this analysis must be the most recent data available.
Any analyses or reports that identify providers may only be published after the provider
has been provided the opportunity by the commissioner to review the underlying data,
including all relevant data fields from data used in the analysis that are necessary or
sufficient for the provider to verify that the data are accurate and complete, and submit
comments. Providers may shall be given any data for which they are the subject of the
data. The provider shall have 30 60 days to review the data for accuracy and initiate an
appeal as specified in paragraph (d) subdivision 3b.
    (c) By no later than January 1, 2011, (b) The commissioner shall disseminate
information to providers on their condition-specific cost of care, condition-specific
resource use, condition-specific quality of care, and the condition-specific results of the
grouping developed under this subdivision 3 in comparison to an appropriate peer group.
Data used for this analysis must be the most recent data available. Any analyses or reports
that identify providers may only be published after the provider has been provided the
opportunity by the commissioner to review the underlying data, including all relevant data
fields from data used in the analysis that are necessary or sufficient for the provider to
verify that the data are accurate and complete, and submit comments. Providers may shall
be given any data for which they are the subject of the data. The provider shall have 30
60 days to review the data for accuracy and initiate an appeal as specified in paragraph
(d) subdivision 3b.
    Subd. 3b. Provider peer grouping; appeals process. (d) The commissioner shall
establish an appeals a process to resolve disputes from providers regarding the accuracy
of the data used to develop analyses or reports. In addition to any informal process
established by the commissioner, a provider shall have the ability to appeal the peer group
to which the provider is assigned, the accuracy of the data used to calculate the peer
grouping system results, and the methodology used to calculate the provider's cost or
quality of care. When a provider appeals the accuracy of the data used to calculate the
peer grouping system results submits an appeal, the provider shall:
(1) clearly indicate the reason they believe the data used to calculate the peer group
system results are not accurate or reasons for the appeal;
(2) provide any evidence and, calculations, or documentation to support the reason
that data was not accurate for the appeal; and
(3) cooperate with the commissioner, including allowing the commissioner access to
data necessary and relevant to resolving the dispute.
If a provider does not meet the requirements of this paragraph subdivision, a provider's
appeal shall be considered withdrawn. The commissioner shall not publish peer grouping
results for a specific provider under paragraph (e) or (f) while that provider has an
unresolved appeal until the appeal has been resolved.
    Subd. 3c. Provider peer grouping; publication of information for the public.
    (e) Beginning January 1, 2011, the commissioner shall, no less than annually, publish
information on providers' total cost, total resource use, total quality, and the results of
the total care portion of the peer grouping process. The results that are published must
be on a risk-adjusted basis. (a) The commissioner may publicly release summary data
related to the peer grouping system as long as the data do not contain information or
descriptions from which the identity of individual hospitals, clinics, or other providers
may be discerned.
(f) Beginning March 30, 2011, the commissioner shall no less than annually publish
information on providers' condition-specific cost, condition-specific resource use, and
condition-specific quality, and the results of the condition-specific portion of the peer
grouping process. The results that are published must be on a risk-adjusted basis. (b) The
commissioner may publicly release analyses or results related to the peer grouping system
that identify hospitals, clinics, or other providers only if the following criteria are met:
(1) the results, data, and summaries, including any graphical depictions of provider
performance, have been distributed to providers at least 120 days prior to publication;
(2) the commissioner has provided an opportunity for providers to verify and review
data for which the provider is the subject or for which the cost or quality results have
been attributed to the provider;
(3) any depiction of differences among providers on the basis of quality is both
statistically significant and meaningfully relevant for consumer or purchaser decision
making;
(4) any provider with volumes that are too low for more than half of the quality
measures in a set of scored measures is excluded from reporting for that set of measures;
and
(5) the public report contains conspicuous disclaimers regarding patient populations
for which data are not available, such as out-of-state residents, uninsured residents, and
enrollees in health plans that failed to submit required data, and explaining that the peer
grouping report is experimental.
(g) (c) After publishing the first detailed report, the commissioner shall, no less
frequently than annually, publish information on providers' total cost, total resource use,
total quality, and the results of the total care portion of the peer grouping process, as well
as information on providers' condition-specific cost, condition-specific resource use,
and condition-specific quality, and the results of the condition-specific portion of the
peer grouping process. The results that are published must be on a risk-adjusted basis,
including case mix adjustments.
    Subd. 3d. Provider peer grouping; standards for dissemination and publication.
(a) Prior to disseminating data to providers under paragraph (b) or (c) subdivision 3a
or publishing information under paragraph (e) or (f) subdivision 3c, the commissioner,
in consultation with the oversight committee, shall ensure the scientific and statistical
validity and reliability of the results according to the standards described in paragraph (h)
(b). If additional time is needed to establish the scientific validity, timeliness, statistical
significance, and reliability of the results, the commissioner may delay the dissemination
of data to providers under paragraph (b) or (c) subdivision 3a, or the publication of
information under paragraph (e) or (f) subdivision 3c. If the delay is more than 60 days,
the commissioner shall report in writing to the chairs and ranking minority members
of the legislative committees with jurisdiction over health care policy and finance the
following information:
(1) the reason for the delay;
(2) the actions being taken to resolve the delay and establish the scientific validity
and reliability of the results; and
(3) the new dates by which the results shall be disseminated.
If there is a delay under this paragraph, The commissioner must disseminate the
information to providers under paragraph (b) or (c) subdivision 3a at least 90 120 days
before publishing results under paragraph (e) or (f) subdivision 3c.
(h) (b) The commissioner's assurance of valid, timely, statistically significant, and
reliable clinic and hospital peer grouping performance results shall include, at a minimum,
the following:
(1) use of the best available evidence, research, and methodologies; and
(2) establishment of an explicit minimum reliability threshold developed in
collaboration with the subjects of the data and the users of the data, at a level not below
nationally accepted standards where such standards exist; and
(3) publication of data that is not more than two years old.
In achieving these thresholds, the commissioner shall not aggregate clinics that are not
part of the same system or practice group. The commissioner shall consult with and
solicit feedback from the oversight committee and representatives of physician clinics
and hospitals during the peer grouping data analysis process to obtain input on the
methodological options prior to final analysis and on the design, development, and testing
of provider reports.

    Sec. 4. Minnesota Statutes 2010, section 62U.04, subdivision 4, is amended to read:
    Subd. 4. Encounter data. (a) Beginning July 1, 2009, and every six months
thereafter, all health plan companies and third-party administrators shall submit encounter
data to a private entity designated by the commissioner of health. The data shall be
submitted in a form and manner specified by the commissioner subject to the following
requirements:
    (1) the data must be de-identified data as described under the Code of Federal
Regulations, title 45, section 164.514;
    (2) the data for each encounter must include an identifier for the patient's health care
home if the patient has selected a health care home; and
    (3) except for the identifier described in clause (2), the data must not include
information that is not included in a health care claim or equivalent encounter information
transaction that is required under section 62J.536.
    (b) The commissioner or the commissioner's designee shall only use the data
submitted under paragraph (a) for the purpose of carrying out its responsibilities in this
section, and must maintain the data that it receives according to the provisions of this
section. following purposes:
(1) to carry out its responsibilities in this section, including supplying the data to
providers so they can verify their results of the peer grouping process and, if necessary,
submit comments or appeals;
(2) subject to the approval of the oversight committee established in subdivision
3, to release to state agencies or private research organizations for the purposes of
conducting research related to quality-of-care improvement and developing quality-of-care
improvement programs; and
(3) to release to the commissioner of human services upon request, for the purpose
of setting and auditing of the rates paid to managed care and county-based purchasing
plans under the prepaid medical assistance program and the MinnesotaCare program.
    (c) Data on providers collected under this subdivision are private data on individuals
or nonpublic data, as defined in section 13.02, except that the commissioner may
disclose data relevant to the provider. The provider must agree to maintain the data
according to its classification under chapter 13 and consistent with the procedures and
safeguards established by the commissioner under this paragraph. Notwithstanding the
definition of summary data in section 13.02, subdivision 19, summary data prepared
under this subdivision may be derived from nonpublic data. The commissioner or the
commissioner's designee shall establish procedures and safeguards to protect the integrity
and confidentiality of any data that it maintains.
    (d) The commissioner or the commissioner's designee shall not publish analyses or
reports that identify, or could potentially identify, individual patients.

    Sec. 5. Minnesota Statutes 2010, section 62U.04, subdivision 5, is amended to read:
    Subd. 5. Pricing data. (a) Beginning July 1, 2009, and annually on January 1
thereafter, all health plan companies and third-party administrators shall submit data
on their contracted prices with health care providers to a private entity designated by
the commissioner of health for the purposes of performing the analyses required under
this subdivision. The data shall be submitted in the form and manner specified by the
commissioner of health.
    (b) The commissioner or the commissioner's designee shall only use the data
submitted under this subdivision for the purpose of carrying out its responsibilities under
this section. following purposes:
(1) to carry out its responsibilities under this section, including supplying the data to
providers so they can verify their results of the peer grouping process and, if necessary,
submit comments or appeals; and
(2) to release to the commissioner of human services upon request, for the purpose
of setting and auditing of the rates paid to managed care and county-based purchasing
plans under the prepaid medical assistance program and the MinnesotaCare program.
    (c) Data collected under this subdivision are nonpublic data as defined in section
13.02 , except that the commissioner may disclose data relevant to the provider. The
provider must agree to maintain the data according to its classification under chapter
13 and consistent with the procedures and safeguards established by the commissioner
under this paragraph. Notwithstanding the definition of summary data in section 13.02,
subdivision 19 , summary data prepared under this section may be derived from nonpublic
data. The commissioner shall establish procedures and safeguards to protect the integrity
and confidentiality of any data that it maintains.

    Sec. 6. Minnesota Statutes 2011 Supplement, section 62U.04, subdivision 9, is
amended to read:
    Subd. 9. Uses of information. (a) For product renewals or for new products that
are offered, after 12 months have elapsed from publication by the commissioner of the
information in subdivision 3, paragraph (e) subdivision 3c, paragraph (b):
    (1) the commissioner of management and budget shall may use the information and
methods developed under subdivision 3 subdivisions 3 to 3d to strengthen incentives for
members of the state employee group insurance program to use high-quality, low-cost
providers;
    (2) all political subdivisions, as defined in section 13.02, subdivision 11, that offer
health benefits to their employees must may offer plans that differentiate providers on their
cost and quality performance and create incentives for members to use better-performing
providers;
    (3) all health plan companies shall may use the information and methods developed
under subdivision 3 subdivisions 3 to 3d to develop products that encourage consumers to
use high-quality, low-cost providers; and
    (4) health plan companies that issue health plans in the individual market or the
small employer market must may offer at least one health plan that uses the information
developed under subdivision 3 subdivisions 3 to 3d to establish financial incentives for
consumers to choose higher-quality, lower-cost providers through enrollee cost-sharing
or selective provider networks.
    (b) By January 1, 2011, the commissioner of health shall report to the governor
and the legislature on recommendations to encourage health plan companies to promote
widespread adoption of products that encourage the use of high-quality, low-cost providers.
The commissioner's recommendations may include tax incentives, public reporting of
health plan performance, regulatory incentives or changes, and other strategies.

    Sec. 7. Minnesota Statutes 2010, section 256B.0754, subdivision 2, is amended to read:
    Subd. 2. Payment reform. By no later than 12 months after the commissioner of
health publishes the information in section 62U.04, subdivision 3, paragraph (e) 62U.04,
subdivision 3c, paragraph (b), the commissioner of human services shall may use the
information and methods developed under section 62U.04 to establish a payment system
that:
    (1) rewards high-quality, low-cost providers;
    (2) creates enrollee incentives to receive care from high-quality, low-cost providers;
and
    (3) fosters collaboration among providers to reduce cost shifting from one part of
the health continuum to another.

    Sec. 8. EFFECTIVE DATE.
Sections 1 to 7 are effective July 1, 2012, and apply to all information provided or
released to the public or to health care providers, pursuant to Minnesota Statutes, section
62U.04, on or after that date.