Chapter 260
2011 -- S 0770 SUBSTITUTE A AS
AMENDED
Enacted 07/09/11
A N A C T
RELATING TO
STATE AFFAIRS AND GOVERNMENT
Introduced By: Senator Elizabeth A. Crowley
Date Introduced: March 24, 2011
It is enacted by the General
Assembly as follows:
SECTION 1. Title 42 of the General Laws entitled "STATE
AFFAIRS AND
GOVERNMENT" is hereby
amended by adding thereto the following chapter:
CHAPTER
14.6
RHODE
ISLAND ALL-PAYER PATIENT-CENTERED MEDICAL HOME ACT
42-14.6-1.
Short title. – This chapter shall be known and
may be cited as the “Rhode
Island All-Payer Patient-Centered
Medical Home Act.”
42-14.6-2.
Legislative purpose and intent. – (a) The general assembly recognizes that
patient-centered medical home (PCMH) is an approach to providing
comprehensive primary care
for children, youth and adults. The patient-centered
medical home is a health care setting that
facilitates partnerships between individual patients, and their
personal physicians, physician
assistants and advanced practice nurses, and when appropriate,
the patient’s family. Care is
facilitated by registries, information technology, health
information exchange and other means to
assure that patients get the indicated care when and where they
need and want it in a culturally
and linguistically appropriate manner. The goals of the
patient-centered medical home are
improved delivery of comprehensive primary care and focus on
better outcomes for patients,
more efficient payment to physicians and other clinicians
and better value, accountability and
transparency to purchasers and consumers. The patient-centered
medical home changes the
interaction between patients and physicians and other clinicians
from a series of episodic office
visits to an ongoing two-way relationship. The
patient-centered medical home helps medical care
providers work to keep patients healthy instead of just healing
them when they are sick. In the
patient-centered medical home patients are active participants in managing
their health with a
shared goal of staying as healthy as possible.
(b) The
patient-centered medical home has the following characteristics:
(1) Emphasizes,
enhances, and encourages the use of primary care;
(2) Focuses on
delivering high quality, efficient, and effective health care services;
(3) Encourages
patient-centered care, including active participation by the patient and
family, or designated agent for health care decision-making,
as appropriate in decision-making
and care plan development, and providing care that is
appropriate to the patient’s individual needs
and circumstances;
(4) Provides patients
with a consistent, ongoing contact with a personal clinician or team
of clinical professionals to ensure continuous and
appropriate care for the patient's condition;
(5) Enables and
encourages utilization of a range of qualified health care professionals,
including dedicated care coordinators, in a manner that enables
providers to practice to the fullest
extent of their license;
(6) Focuses initially
on patients who have or are at risk of developing chronic health
conditions;
(7) Incorporates
measures of quality, resource use, cost of care, and patient experience;
(8) Ensures the use
of health information technology and systematic follow-up, including
the use of patient registries; and
(9) Encourages the
use of evidence-based health care, patient decision-making aids that
provide patients with information about treatment options and
their associated benefits, risks,
costs, and comparative outcomes, and other clinical
decision support tools.
(c) The general
assembly recognizes that
patient-centered medical homes through a model developed by providers
and financed through
the voluntary participation of insurers. The continuation
of this model, developed by the Rhode
Island chronic care sustainability initiative, is
recognized as critical to the future structure of the
created through this legislation is not the only model for
patient-centered medical homes and in
no way seeks to limit the innovation of providers and
insurers in the future.
42-14.6-3.
Definitions. – As used in this section, the
following terms shall have the
following meanings:
(1)
"Commissioner" means the health insurance commissioner.
(2) "Health
insurer" means all entities licensed, or required to be licensed, in this
state
that offer health benefit plans in
service corporations and nonprofit medical service
corporations established pursuant to chapters
27-19 and 27-20, and health maintenance organizations
established pursuant to chapter 27-41 or
as defined in chapter 42-62, a fraternal benefit society
or any other entity subject to state
insurance regulation that provides medical care on the basis of
a periodic premium, paid directly
or through an association, trust or other intermediary,
and issued, renewed, or delivered within or
without
(3) “Health insurance
plan” means any individual, general, blanket or group policy of
health, accident and sickness insurance issued by a health
insurer (as herein defined). Health
Insurance Plan shall not include insurance coverage
providing benefits for:
(i)
Hospital confinement indemnity;
(ii) Disability
income;
(iii) Accident only;
(iv)
Long-term care;
(v) Medicare
supplement;
(vi)
Limited benefit health;
(vii) Specified
disease indemnity;
(viii) Sickness or
bodily injury or death by accident or both; and
(ix) Other limited
benefit policies.
(4) "Personal
clinician" means a physician, physician assistant, or an advanced practice
nurse licensed by the department of health.
(5) "State
health care program" means medical assistance, RIteCare,
and any other health
insurance program provided through the office of health and
human services (OHHS) and its
component state agencies state health care program does not
include any health insurance plan
provided as a benefit to state employees or retirees.
(6) “Patient-centered
medical home” means a practice that satisfies the characteristics
described in section 42-14.6-2, and is designated as such by
the secretary, or through alternative
models as provided for in section 42-14.6-7, based on
standards recommended by the patient-
centered medical home collaborative.
(7) “Patient-centered
medical home collaborative” means a community advisory council,
including, but not limited to, participants in the existing
home pilot project, and health insurers, physicians and
other clinicians, employers, the state
health care program, relevant state agencies, community
health centers, hospitals, other providers,
patients, and patient advocates which shall provide
consultation and recommendations to the
secretary and the commissioner on all matters relating to
proposed regulations, development of
standards, and development of payment mechanisms.
(8) “Secretary” means
the secretary of the executive office of health and human services.
42-14.6-4.
Promotion of the patient-centered medical home. – (a)
Care coordination
payments.
(1) The commissioner
and the secretary shall convene a patient-centered medical home
collaborative consisting of the entities described in subdivision
42-14.6-3(7). The commissioner
shall require participation in the collaborative by all of
the health insurers described above. The
collaborative shall propose, by January 1, 2012, a payment system,
to be adopted in whole or in
part by the commissioner and the secretary, that requires
all health insurers to make per-person
care coordination payments to patient-centered medical
homes, for providing care coordination
services and directly managing on-site or employing care
coordinators as part of all health
insurance plans offered in
health care program as to the appropriate payment system for
the state health care program to the
same patient-centered medical homes; the state health care
program must justify the reasons for
any departure from this guidance to the collaborative.
(2) The care
coordination payments under this shall be consistent across insurers and
patient-centered medical homes and shall be in addition to any other
incentive payments such as
quality incentive payments. In developing the criteria for
care coordination payments, the
commissioner shall consider the feasibility of including the
additional time and resources needed
by patients with limited English-language skills,
cultural differences, or other barriers to health
care. The commissioner may direct the collaborative to
determine a schedule for phasing in care
coordination fees.
(3) The care
coordination payment system shall be in place through July 1, 2016. Its
continuation beyond that point shall depend on results of the
evaluation reports filed pursuant to
section 42-14.6-6.
(4) Examination of
other payment reforms. By January 1, 2013, the commissioner and the
secretary shall direct the collaborative to consider additional
payment reforms to be implemented
to support patient-centered medical homes including, but
not limited to, payment structures (to
medical home or other providers) that:
(i)
Reward high-quality, low-cost providers;
(ii) Create enrollee
incentives to receive care from high-quality, low-cost providers;
(iii) Foster
collaboration among providers to reduce cost shifting from one part of the
health continuum to another; and
(iv) Create
incentives that health care be provided in the least
restrictive, most
appropriate setting.
(5) The
patient-centered medical home collaborative shall examine and make
recommendations to the secretary regarding the designation of
patient-centered medical homes, in
order to promote diversity in the size of practices
designated, geographic locations of practices
designated and accessibility of the population throughout the
state to patient-centered medical
homes.
(b) The patient-centered
medical home collaborative shall propose to the secretary for
adoption, the standards for the patient-centered medical home
to be used in the payment system,
based on national models where feasible.
42-14.6-5.
Annual reports on implementation and administration. –
The secretary
and commissioner shall report annually to the legislature
on the implementation and
administration of the patient-centered medical home model.
42-14.6-6.
Evaluation reports. – (a) The
secretary and commissioner shall provide to the
legislature comprehensive evaluations of the patient-centered
medical home model two (2) years
and four (4) years after implementation. The evaluation
must include:
(1) The number of
enrollees in patient-centered medical homes in the collaborative and
the health characteristics of enrollees;
(2) The number and
geographic distribution of patient-centered medical home providers
in the collaborative and the number of primary care
physicians per thousand populations;
(3) The performance
and quality of care of patient-centered medical homes in the
collaborative;
(4) The estimated
impact of patient-centered medical homes on access to preventive care;
(5)
Patient-centered medical home payment arrangements, and costs
related to
implementation and payment of care coordination fees;
(6) The estimated
impact of patient-centered medical homes on health status and health
disparities; and
(7) Estimated savings
from implementation of the patient-centered medical home model.
(b) Health insurers
shall provide to the commissioner and secretary utilization, quality,
financial, and other reports, specified by the commissioner and
secretary, regarding the
implementation and impact of patient-centered medical homes.
42-14.6-7.
Alternative models. – Nothing in this section
shall preclude the development
of alternative patient centered medical home models by
an insurer for its group and/or individual
policies, or by the secretary, the commissioner or other state
agencies or preclude insurers, the
secretary, the commissioner or other state agencies from
establishing alternative models and
payment mechanisms for persons who are enrolled in integrated
Medicare and Medicaid
programs, are enrolled in managed care long-term care
programs, are dually eligible for Medicare
and Medicaid, are in the waiting period for Medicare, or
who have other primary coverage.
42-14.6-8.
Regulations. – The secretary of health and
human services and the health
insurance commissioner shall develop regulations to implement
this chapter.
SECTION 2. This act shall take effect upon passage.
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LC02313/SUB A
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