STATE OF OKLAHOMA

2nd Session of the 52nd Legislature (2010)

SENATE BILL 1358	By:	Adelson

AS INTRODUCED

An Act relating to insurance; directing certain insurers to adopt a physician performance reporting program; requiring and providing for certain ratings examiner; requiring certain review; directing certain results to be accessible; requiring certain report and recommendations; requiring certain measures; directing use of certain software; requiring certain description; requiring appropriate risk adjustment; providing for certain physician attribution; requiring certain disclosure; directing certain display; directing certain reporting to physicians; permitting certain corrections and additional information; requiring appeals process for physicians; requiring certain notice and explanation for physicians; prohibiting certain changes; requiring use of most current data in certain measures; providing for certain aggregated data; directing application of act; authorizing the Insurance Commissioner to promulgate rules; providing for codification; and providing an effective date.

BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.1 of Title 36, unless there is created a duplication in numbering, reads as follows:
On or before January 1, 2012, any insurer, as defined by Section 103 of Title 36 of the Oklahoma Statutes, which offers individual or group health benefit plans in this state shall adopt a physician performance reporting program to measure and tier physicians.
SECTION 2.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.2 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  To assure compliance with this act and to facilitate the collection and presentation to consumers and physicians of information about the insurer’s processes and methodologies used in its physician performance reporting program, the insurer shall retain the services of an oversight monitor to be known as the ratings examiner.
B.  The ratings examiner shall be a national standard-setting organization or shall be associated with a national standard-setting organization.  For purposes of this subsection, a “national standard-setting organization” shall be national in scope, independent, and an Internal Revenue Code Section 501(c)(3) organization, and shall have existing standards and collection processes that comply with the transparency and accuracy requirements of this act.
C.  The insurer shall maintain in good standing a review of its physician performance measures and reporting process by the ratings examiner.  The review conducted by the ratings examiner shall encompass all of the requirements specified by this act.  The insurer shall also obtain review by the ratings examiner of such additional national standardized review processes as may be necessary to assure compliance with this act, including fully disclosing the insurer’s procedures for consumer and physician grievance or appellate rights.
D.  The insurer shall make the results of such review processes prominently accessible in all locations that describe the physician performance reporting program.
E.  The ratings examiner shall report and make recommendations annually to the Insurance Commissioner regarding the details of the methodologies used and the extent to which they reflect national standards and compliance with this act.
SECTION 3.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.3 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  A physician performance reporting program shall only measure quality of performance and cost-efficiency.
B.  In information for consumers and in public reporting, measures of cost-efficiency should be used in conjunction with measures of quality of performance.  The insurer shall not conduct rankings based solely on cost-efficiency, but shall consider quality dimensions.  Specifically, the insurer shall disclose to what extent the rankings and selection process are based on cost-efficiency and on quality.  To the extent that the insurer presents a combined score or rating using cost-efficiency and quality, the insurer shall disclose the specific measures for each category and their relative weight in determining a combined score.
C.  In evaluating physician quality and cost-efficiency, the insurer shall seek to achieve the goals of safe, timely, effective, efficient, equitable and patient-centered care, to the extent possible.  The insurer shall seek to include patient experience as a measure of patient-centeredness and shall use measures to determine quality of performance that are based on nationally recognized evidence-based and/or consensus-based clinical recommendations or guidelines.  Where available, the insurer shall use measures endorsed by the National Quality Forum or other entities whose work in the area of physician quality performance is generally accepted in the health care industry.  Where National Quality Forum-endorsed measures are unavailable, the insurer shall use measures endorsed by the Ambulatory Care Quality Alliance (AQA) and accreditors.  Where National Quality Forum, AQA, or accreditors’ measures are unavailable, or data to calculate the measures are unavailable to the insurer, measures shall be based on other nationally-recognized guidelines.  The basis and data used, and its relative weight or relevance to the overall rating, shall be fully disclosed.
D.  The insurer shall agree to support the development and use of any standardized quality and cost-efficiency measures which may be required by the Insurance Commissioner.
E.  In evaluating physician cost-efficiency performance, the insurer shall use appropriate and comprehensive episode-of-care software and shall ensure that any appropriate risk adjustment occurs pursuant to Section 5 of this act.  In measuring physician cost-efficiency, the insurer shall compare physicians within the same specialty within the same appropriate geographical market.  The basis and data used, and its relative weight or relevance to the overall rating, shall be fully disclosed.
SECTION 4.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.4 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The insurer shall describe the statistical basis for the number of patients for each disease state or specialty and use accurate, reliable and valid measurements of a physician’s quality performance.
B.  The insurer shall describe the statistical basis for the number of patient episodes of care and use accurate, reliable and valid measurements of a physician’s cost-efficiency performance.
SECTION 5.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.5 of Title 36, unless there is created a duplication in numbering, reads as follows:
In determining a physician’s performance for quality and cost-efficiency, the insurer shall use appropriate risk adjustment to account for the characteristics of the physician’s patient population, such as case mix, severity of the patient’s condition, co-morbidities, outlier episodes and other factors.
SECTION 6.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.6 of Title 36, unless there is created a duplication in numbering, reads as follows:
In deciding physician attribution for quality measurement, the insurer shall determine which physician or physicians should be held reasonably accountable for a patient’s care and shall fully disclose the methodology used for such attribution.
SECTION 7.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.7 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The insurer shall disclose to consumers:
1.  Where its physician performance ratings are found;
2.  That physician performance ratings are only a guide to choosing a physician and that such ratings have a risk of error and should not be the sole basis for selecting a doctor;
3.  Information explaining the physician ranking system, including the basis upon which physician performance is measured, and the basis for determining that a physician is not currently rated due to insufficient data or a pending appeal;
4.  Any limitations of the data the insurer uses to measure physician performance;
5.  How physicians are selected for inclusion or exclusion in a physician performance-reporting program;
6.  Details on the factors and criteria used in the insurer’s rating system, specifically its quality performance measures, cost-efficiency measures and other methodologies;
7.  How the perspectives of consumers, consumer advocates, employers, labor, and/or physicians were incorporated in the development of the physician-reporting program; and
8.  How the consumer may register a complaint with the insurer and the ratings examiner about the program.
B.  The insurer shall directly and prominently display this information on its website and other appropriate locations in accordance with standards and a template to be provided by the ratings examiner.
SECTION 8.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.8 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The insurer shall report the detailed data and methodologies to physicians in an independent and easily accessible manner, including measures and other criteria, that the insurer used to determine physician quality and cost-efficiency ratings and inclusion or exclusion in a physician performance reporting program.
B.  The insurer shall also explain to physicians that they have the right to correct errors and seek review of data, quality and cost-efficiency performance ratings and inclusion or exclusion from any physician performance-reporting program.  The insurer shall also inform physicians that they may submit additional information, including information obtained in medical charts, for consideration.
C.  The insurer shall also provide a reasonable, prompt, and transparent appeals process for physicians.
D.  At least forty-five (45) days before making available to consumers any new or revised quality or cost-efficiency evaluations or any new or revised inclusions or exclusions from any program created pursuant to this act, the insurer shall provide physicians with:
1.  Notice of the proposed change;
2.  An explanation of and access to the data used for a particular physician;
3.  Methodology and measures used to assess physicians, including attribution; and
4.  An explanation of the physician’s right to make corrections and an appeal.
E.  If a physician makes a timely appeal, the insurer shall make no change in the physician’s quality and cost-efficiency rankings or designation until the appeal is completed.  The ratings examiner shall have oversight and review of the physician appeals process.
SECTION 9.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.9 of Title 36, unless there is created a duplication in numbering, reads as follows:
A.  The insurer shall use the most current claims or other data to measure physician performance, consistent with the time period needed to attain adequate sample sizes and to comply with the requirements of this act.  The insurer shall strive to ensure that the data it relies upon is accurate, including a consideration of whether some medical record verification is appropriate and necessary.
B.  As part of its reporting to the ratings examiner, the insurer shall provide the ratings examiner a plan to use aggregated data, validated as appropriate, as a supplement to test its own claims data.
SECTION 10.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.10 of Title 36, unless there is created a duplication in numbering, reads as follows:
This act shall apply to insurers which offer group hospital or medical insurance coverage plans, not-for-profit hospital or medical service or indemnity plans, prepaid health plans, health maintenance organization plans, preferred provider organization plans, the State and Education Employees Group Insurance Plan, coverage provided by a Multiple Employer Welfare Arrangement (MEWA), or any other analogous benefit arrangement.  The act shall not apply to insurers or other entities which only offer short-term, accident, fixed indemnity, or specified disease policies, disability income contracts, limited benefit or credit disability insurance, workers' compensation insurance coverage, state Medicaid program coverage, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which are required by law to be contained in any liability insurance policy or equivalent self-insurance.
SECTION 11.     NEW LAW     A new section of law to be codified in the Oklahoma Statutes as Section 6582.11 of Title 36, unless there is created a duplication in numbering, reads as follows:
The Insurance Commissioner may promulgate rules as necessary to implement the provisions of this act.
SECTION 12.  This act shall become effective November 1, 2010.

52-2-2732	ARE	1/5/2010 9:32:32 AM