Bill HD.4601

HOUSE DOCKET, NO. 4601 FILED ON: 3/9/2016

HOUSE . . . . . . . . . . . . . . . No.

By Mr. Sannicandro of Ashland, a petition (subject to Joint Rule 12) of Tom Sannicandro relative to price transparency for certain health procedures. Health Care Financing.

The Commonwealth of Massachusetts

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In the One Hundred and Eighty-Ninth General Court
(2015-2016)

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An Act for health care price and quality transparency.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Section 8 of Chapter 12C of the General Laws is hereby amended by inserting at the end thereof the following:-

(f) In order to create quality and price transparency for all residents so they can make informed, values-based health care decisions and create incentives for providers to have high quality and low price, the center shall collect the following information from institutional providers and their parent organizations and any other affiliated entities, non-institutional providers and provider organizations:

(1) the location of each facility at which health care is performed for that entity;

(2) the names of every provider who practices at each location;

(3) the speciality or specialities of each provider at each location based on major service category;

(4) test, procedures, and care bundles offered at each location;

(5) chargemaster cost of each billable item at that location;

(6) whether the provider is accessible for people with disabilities.

(g) Cost information under subsection (f) shall be provided according to individual provider, not provider group or provider organization.

(h) The center shall create a comprehensive list of test, procedures, and care bundles for the purposes of reporting paragraph (4) of subsection (f) of section 8 of this chapter, paragraph (4) of subsection (e) of section 9 of this chapter, and paragraph (2) of subsection (f) of section 10 of this chapter, including but not limited to:

(1) Asthma

(2) Back Pain - Chiropractor Visit - Six Visits

(3) Back Pain - Epidural Steroid Injection

(4) Back Pain - Physical Therapy

(5) Carpal Tunnel Surgery

(6) Cataract Removal with Lens Implant

(7) Childbirth - Cesarean Delivery and Newborn Care

(8) Childbirth - Vaginal Delivery and Newborn Care

(9) Chiropractic Manipulation

(10) Cholesterol Test

(11) Colonoscopy - Preventive Screening

(12) Complete Blood Count - CBC Test

(13) CT Scan With Dye - Abdomen and Pelvis

(14) CT Scan Without Dye - Head or Brain

(15) CT Scan Without Dye - Maxillofacial - Face

(16) Electrocardiogram - EKG

(17) Gallbladder Removal - Laparoscopic

(18) Hemoglobin A1c Test

(19) Hernia Repair in Groin - Laparoscopic

(20) Knee Arthroscopy With ACL Surgery

(21) Knee Arthroscopy With Meniscus Surgery

(22) Knee Injection

(23) Knee Replacement

(24) Mammogram - Diagnostic - Digital

(25) Mammogram - Diagnostic - Film

(26) Mammogram - Preventive Screening - Digital

(27) Mammogram - Preventive Screening - Film

(28) MRI Scan With and Without Dye - Brain

(29) MRI Scan Without and With Dye - Lumbar Spine

(30) MRI Scan Without Dye - Brain

(31) MRI Scan Without Dye - Cervical Spine

(32) MRI Scan Without Dye - Knee

(33) MRI Scan Without Dye - Lumbar Spine

(34) MRI Scan Without Dye - Upper Extremity - Arm

(35) Office Visit - Primary Doctor - Established Patient - Moderate Complexity

(36) Office Visit - Primary Doctor - New Patient - Moderate Complexity

(37) Physical Therapy - Exercises

(38) Physical Therapy - Massage and Traction

(39) Physical Therapy - Nerve and Muscle Retraining

(40) Shoulder Arthroscopy with Rotator Cuff Repair

(41) Strep Throat Test

(42) Ultrasound - Abdomen

(43) Ultrasound - Pelvic - via Vagina

(44) Ultrasound - Pregnancy

(45) Upper Endoscopy

(46) Upper Endoscopy With Biopsy

(47) Urine Pregnancy Test

(48) Vaccine - Flu - Adult

(49) Vaccine - Shingles

(50) Vasectomy - Male Sterilization

(51) Weight Loss Surgery - Gastric Bypass

(52) Weight Loss Surgery - Laparoscopic Band

(53) Wellness Visit - Established Female Patient - Age 12-17

(54) Wellness Visit - Established Female Patient - Age 18-39

(55) Wellness Visit - Established Female Patient - Age 40-64

(56) Wellness Visit - Established Male Patient - Age 12-17

(57) Wellness Visit - Established Male Patient - Age 18-39

(58) Wellness Visit - Established Male Patient - Age 40-64

(59) Wellness Visit - Established Patient - Age 1-4

(60) Wellness Visit - Established Patient - Age 5-11

(61) Wellness Visit - Established Patient - Age Less Than 1

(62) Wellness Visit - Established Patient - Female Age 65 and Over

(63) Wellness Visit - Established Patient - Male Age 65 and Over

(64) Wellness Visit - New Female Patient - Age 12-17

(65) Wellness Visit - New Female Patient - Age 18-39

(66) Wellness Visit - New Female Patient - Age 40-64

(67) Wellness Visit - New Male Patient - Age 12-17

(68) Wellness Visit - New Male Patient - Age 18-39

(69) Wellness Visit - New Male Patient - Age 40-64

(70) Wellness Visit - New Patient - Age 1-4

(71) Wellness Visit - New Patient - Age 5-11

(72) Wellness Visit - New Patient - Age Less Than 1

(73) Wellness Visit - New Patient - Female Age 65 and Over

(74) Wellness Visit - New Patient - Male Age 65 and Over

(75) X-ray Chest - 2 Views

(76) X-ray Foot - 3 Views

(77) X-ray Lumbar Spine

(i) If any information from subsection (f) changes, the change shall be reported to to the center within 30 days.

SECTION 2. Section 9 of said Chapter 12C is hereby amended by inserting at the end thereof the following:-

(e) In order to create quality and price transparency for all residents so they can make informed, values-based health care decisions and create incentives for providers to have high quality and low price, the center shall collect the following information from provider organizations registered under section 11 of chapter 6D:

(1) the location of each facility at which health care is performed for that entity;

(2) the names of every provider who practices at each location;

(3) the speciality or specialities of each provider at each location based on major service category;

(4) test, procedures, and care bundles offered at each location;

(5) chargemaster cost of each billable item at that location;

(6) whether the provider is accessible for people with disabilities.

(f) Cost information under subsection (e) shall be provided according to individual provider, not provider group or provider organization.

(g) If any information from subsection (f) changes, the change shall be reported to to the center within 30 days.

SECTION 3. Section 10 of said Chapter 12C is hereby amended by inserting at the end thereof the following:-

(f) Health insurance carriers, health insurance companies, any public or private health care payers, self-insured groups, and any other organized payer of health care services shall provide the following information to the center:

(1) which providers it is contracted with under each plan it offers;

(2) any procedure that may be performed by each provider that would be covered by the insurance company’s plan;

(3) the negotiated price of each procedure covered under the insurance company’s plan for each provider it is contracted with;

(4) assuming a single office visit:

(A) what a patient’s co-pay is for each provider contracted under the plan, including differences that may exist in co-pays for different test, procedures, and care bundles performed by the provider,

(B) what a patient’s co-insurance cost is for each procedure that could be performed by each provider contracted with under the plan, including cost thresholds that may need to be met to determine the patient’s co-insurance,

(C) what portion of the patient’s expense is applied to their deductible for each procedure that could be performed by each provider contracted with under the plan, including cost thresholds that may need to be met to determine the portion of a patient’s expense that is applied to the deductible,

(D) all items, if medically necessary, the plan would cover from each provider, including but not limited to test, procedures, and care bundles, general health supplies, care, rehabilitative services or accommodations, or any other billable item.

(5) for drugs:

(A) what a patient’s co-pay is for each pharmacy contracted under the plan,

(B) what a patient’s co-insurance cost is for each pharmacy contracted with under the plan, including cost thresholds that may need to be met to determine the patient’s co-insurance,

(C) what portion of the patient’s expense is applied to their deductible for each pharmacy contracted with under the plan, including cost thresholds that may need to be met to determine the portion of a patient’s expense that is applied to the deductible,

(g) Cost information under subsection (f) shall be provided according to individual provider, not provider group or provider organization.

(h) If any information from subsection (f) changes, the change shall be reported to to the center within 30 days.

SECTION 4. Said Chapter 12C is hereby amended by striking out Section 20 in its entirety and replacing it with the following:-

Section 20.

(a) The center shall implement, operate, and maintain a health information website to provide quality and price transparency information to all residents. The website shall be designed to assist consumers in making informed health care decisions, including finding quality measures of providers, identifying locations of providers, and seeing cost information for test, procedures, and care bundles with different providers, including co-pay, co-insurance, and amount applied to their deductible.

(b) The website shall, on a single webpage, offer visitors the following search criteria:

(1) whether or not the patient has insurance;

(2) if the patient has insurance, the insurance company;

(3) if the patient has insurance with an insurance company offering multiple plans, the insurance plan;

(4) zip code or city in which the patient is seeking health care;

(5) provider name;

(6) provider type, including but not limited to addiction psychiatrist, adolescent medicine specialist, allergist, anesthesiologist, audiologist, board certified behavior analyst, cardiac electrophysiologist, cardiologist, cardiovascular surgeon, colon and rectal surgeon, critical care medicine specialist, dermatologist, developmental pediatrician, emergency medicine specialist, endocrinologist, family medicine physician, forensic pathologist, gastroenterologist, geriatric medicine specialist, gynecologist, gynecologic oncologist, hand surgeon, hematologist, hepatologist, hospitalist, hospice and palliative medicine specialist, hyperbaric physician, infectious disease specialist, internist, interventional cardiologist, medical examiner, medical geneticist, neonatologist, nephrologist, neurological surgeon, neurologist, nuclear medicine specialist, obstetrician, occupational medicine specialist, oncologist, ophthalmologist, orthopedic surgeon, otolaryngologist, pain management specialist, pathologist, pediatrician, perinatologist, physiatrist, plastic surgeon, primary care physician psychiatrist, pulmonologist, radiation oncologist, radiologist, reproductive endocrinologist, rheumatologist, sleep disorders specialist, spinal cord injury specialist, sports medicine specialist, thoracic surgeon, urologist, and vascular surgeon;

(7) procedure type, a list to be determined by the center as provided in subsection (h) of section 8 of this chapter, including the option to search by more than one procedure at a time;

(8) procedure billing code according to the most recent International Statistical Classification of Diseases and Related Health Problems, including the option to search by more than one billing code at a time;

(9) whether the provider is accessible for people with disabilities;

(c) The inputs from subparagraph (b) shall yield a results page. The results page shall include the following information in separate columns in an easy-to-read format:

(1) Name and address of provider;

(2) The quality measure set as outlined in section 14 of Chapter 12C of the General Laws;

(3) What insurance companies the provider is contracted with;

(4) What insurance plans the provider accepts;

(5) What test, procedures, and care bundles the provider performs, a list to be determined by the center as provided in subsection (h) of section 8 of this chapter;

(6) the total cost the insurance company would charge the patient for having the procedure with that provider, including separate columns for co-pay, co-insurance, and amount applied to deductible;

(7) If the patient has a personal profile, the patient’s total deductible on his plan and amount of the deductible that has been used;

(8) The chargemaster cost of the procedure;

(9) Whether the provider is accessible for people with disabilities.

(d) The website shall provide patients the option to create a secure, electronic personal profile where they can access their individual co-pay, co-insurance, and deductible information. The website shall meet all applicable federal and state privacy and security requirements, including requirements imposed by the Health Insurance Portability and Accountability Act of 1996, P.L.104-191, the American Recovery and Reinvestment Act of 2009, P.L. 111-5, 42 C.F.R. §§2.11 et seq. and 45 C.F.R. §§160, 162, 164 and 170.

(e) Any changes reported to the center under subsection (i) of section 8, subsection (g) of section 9, or subsection (h) of section 10 shall be changed on the website within 10 days of receiving the reported change.

(e) The website shall inform consumers that all information is only accurate within the past 40 days, and that they should check with their insurance company that the cost is correct, and with the provider to confirm the test, procedures, and care bundles are correct.

(f) The website shall inform patients that they may need preauthorization for services from their health insurance company.

(g) All data shall be available with a public API to encourage private sector innovation and development with the information on the website.

(h) The center shall conduct procurements and enter into contracts for the purchase and development of all hardware and software in connection with the creation and implementation of the website. The center may, in consultation with the council and the executive office, oversee the technical aspects of the development, dissemination and implementation of the website, including any modules, applications, interfaces or other technology infrastructure.

(i) The center may consult with all relevant parties, public or private, in exercising its duties under this section, including persons with expertise and experience in the development and dissemination of complex health care websites.

(j) The center shall develop and implement website infrastructure, including, without limitation, certificate storage, transmission gateways, auditing systems and any components necessary to connect the website to carriers’ electronic health systems.

(k) The Health Policy Commission shall issue a report on the effectiveness of the website in enabling values-based health care decisions by individual consumers and businesses two years following the creation of the website.

SECTION 5. Section 4 shall take effect four years after passage of this act.

SECTION 6. Section 11 of Chapter 176G of the General Laws is hereby amended by striking out, in line 12, the word “14” and replacing it with the following:-

Name:	District/Address:	Date Added:
Tom Sannicandro	7th Middlesex	3/9/2016