2011 -- H 5276 SUBSTITUTE A AS AMENDED

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LC00079/SUB A

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2011

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A N A C T

RELATING TO STATE AFFAIRS AND GOVERNMENT -- PATIENT-CENTERED

MEDICAL HOME ACT

     Introduced By: Representatives Naughton, McNamara, Kennedy, E Coderre, and Walsh

     Date Introduced: February 08, 2011

     Referred To: House Corporations

It is enacted by the General Assembly as follows:

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     SECTION 1. Title 42 of the General Laws entitled "STATE AFFAIRS AND

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GOVERNMENT" is hereby amended by adding thereto the following chapter:

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     CHAPTER 14.6

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RHODE ISLAND ALL-PAYER PATIENT-CENTERED MEDICAL HOME ACT

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     42-14.6-1. Short title. – This chapter shall be known and may be cited as the “Rhode

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Island All-Payer Patient-Centered Medical Home Act.”

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     42-14.6-2. Legislative purpose and intent. – (a) The general assembly recognizes that

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patient-centered medical home (PCMH) is an approach to providing comprehensive primary care

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for children, youth and adults. The patient-centered medical home is a health care setting that

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facilitates partnerships between individual patients, and their personal physicians, physician

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assistants and advanced practice nurses, and when appropriate, the patient’s family. Care is

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facilitated by registries, information technology, health information exchange and other means to

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assure that patients get the indicated care when and where they need and want it in a culturally

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and linguistically appropriate manner. The goals of the patient-centered medical home are

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improved delivery of comprehensive primary care and focus on better outcomes for patients,

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more efficient payment to physicians and other clinicians and better value, accountability and

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transparency to purchasers and consumers. The patient-centered medical home changes the

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interaction between patients and physicians and other clinicians from a series of episodic office

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visits to an ongoing two-way relationship. The patient-centered medical home helps medical care

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providers work to keep patients healthy instead of just healing them when they are sick. In the

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patient-centered medical home patients are active participants in managing their health with a

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shared goal of staying as healthy as possible.

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     (b) The patient-centered medical home has the following characteristics:

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     (1) Emphasizes, enhances, and encourages the use of primary care;

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     (2) Focuses on delivering high quality, efficient, and effective health care services;

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     (3) Encourages patient-centered care, including active participation by the patient and

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family, or designated agent for health care decision-making, as appropriate in decision-making

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and care plan development, and providing care that is appropriate to the patient’s individual needs

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and circumstances;

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     (4) Provides patients with a consistent, ongoing contact with a personal clinician or team

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of clinical professionals to ensure continuous and appropriate care for the patient's condition;

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     (5) Enables and encourages utilization of a range of qualified health care professionals,

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including dedicated care coordinators, in a manner that enables providers to practice to the fullest

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extent of their license;

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     (6) Focuses initially on patients who have or are at risk of developing chronic health

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conditions;

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     (7) Incorporates measures of quality, resource use, cost of care, and patient experience;

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     (8) Ensures the use of health information technology and systematic follow-up, including

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the use of patient registries; and

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     (9) Encourages the use of evidence-based health care, patient decision-making aids that

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provide patients with information about treatment options and their associated benefits, risks,

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costs, and comparative outcomes, and other clinical decision support tools.

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     (c) The general assembly recognizes that Rhode Island is a national leader in all-payer

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patient-centered medical homes through a model developed by providers and financed through

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the voluntary participation of insurers. The continuation of this model, developed by the Rhode

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Island chronic care sustainability initiative, is recognized as critical to the future structure of the

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Rhode Island primary care delivery system. The general assembly also recognizes that the model

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created through this legislation is not the only model for patient-centered medical homes and in

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no way seeks to limit the innovation of providers and insurers in the future.

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     42-14.6-3. Definitions. – As used in this section, the following terms shall have the

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following meanings:

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     (1) "Commissioner" means the health insurance commissioner.

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     (2) "Health insurer" means all entities licensed, or required to be licensed, in this state

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that offer health benefit plans in Rhode Island including, but not limited to, nonprofit hospital

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service corporations and nonprofit medical service corporations established pursuant to chapters

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27-19 and 27-20, and health maintenance organizations established pursuant to chapter 27-41 or

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as defined in chapter 42-62, a fraternal benefit society or any other entity subject to state

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insurance regulation that provides medical care on the basis of a periodic premium, paid directly

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or through an association, trust or other intermediary, and issued, renewed, or delivered within or

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without Rhode Island.

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     (3) “Health insurance plan” means any individual, general, blanket or group policy of

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health, accident and sickness insurance issued by a health insurer (as herein defined). Health

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Insurance Plan shall not include insurance coverage providing benefits for:

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     (i) Hospital confinement indemnity;

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     (ii) Disability income;

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     (iii) Accident only;

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     (iv) Long-term care;

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     (v) Medicare supplement;

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     (vi) Limited benefit health;

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     (vii) Specified disease indemnity;

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     (viii) Sickness or bodily injury or death by accident or both; and

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     (ix) Other limited benefit policies.

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     (4) "Personal clinician" means a physician, physician assistant, or an advanced practice

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nurse licensed by the department of health.

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     (5) "State health care program" means medical assistance, RIteCare, and any other health

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insurance program provided through the office of health and human services (OHHS) and its

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component state agencies state health care program does not include any health insurance plan

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provided as a benefit to state employees or retirees.

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     (6) “Patient-centered medical home” means a practice that satisfies the characteristics

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described in section 42-14.6-2, and is designated as such by the secretary or through alternative

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models as provided for in section 42-14.6-7, based on standards recommended by the patient-

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centered medical home collaborative.

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     (7) “Patient-centered medical home collaborative” means a community advisory council,

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including, but not limited to, participants in the existing Rhode Island patient-centered medical

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home pilot project, and health insurers, physicians and other clinicians, employers, the state

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health care program, relevant state agencies, community health centers, hospitals, other providers,

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patients, and patient advocates which shall provide consultation and recommendations to the

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secretary and the commissioner on all matters relating to proposed regulations, development of

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standards, and development of payment mechanisms.

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     (8) “Secretary” means the secretary of the executive office of health and human services.

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     42-14.6-4. Promotion of the patient-centered medical home. – (a) Care coordination

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payments.

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     (1) The commissioner and the secretary shall convene a patient-centered medical home

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collaborative consisting of the entities described in subdivision 42-14.6-3(7). The commissioner

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shall require participation in the collaborative by all of the health insurers described above. The

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collaborative shall propose, by January 1, 2012, a payment system, to be adopted in whole or in

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part by the commissioner and the secretary, that requires all health insurers to make per-person

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care coordination payments to patient-centered medical homes, for providing care coordination

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services and directly managing on-site or employing care coordinators as part of all health

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insurance plans offered in Rhode Island. The collaborative shall provide guidance to the state

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health care program as to the appropriate payment system for the state health care program to the

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same patient-centered medical homes; the state health care program must justify the reasons for

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any departure from this guidance to the collaborative.

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     (2) The care coordination payments under this shall be consistent across insurers and

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patient-centered medical homes and shall be in addition to any other incentive payments such as

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quality incentive payments. In developing the criteria for care coordination payments, the

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commissioner shall consider the feasibility of including the additional time and resources needed

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by patients with limited English-language skills, cultural differences, or other barriers to health

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care. The commissioner may direct the collaborative to determine a schedule for phasing in care

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coordination fees.

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     (3) The care coordination payment system shall be in place through July 1, 2016. Its

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continuation beyond that point shall depend on results of the evaluation reports filed pursuant to

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section 42-14.6-6.

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     (4) Examination of other payment reforms. By January 1, 2013, the commissioner and the

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secretary shall direct the collaborative to consider additional payment reforms to be implemented

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to support patient-centered medical homes including, but not limited to, payment structures (to

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medical home or other providers) that:

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     (i) Reward high-quality, low-cost providers;

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     (ii) Create enrollee incentives to receive care from high-quality, low-cost providers;

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     (iii) Foster collaboration among providers to reduce cost shifting from one part of the

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health continuum to another; and

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     (iv) Create incentives that health care be provided in the least restrictive, most

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appropriate setting.

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     (5) The patient-centered medical home collaborative shall examine and make

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recommendations to the secretary regarding the designation of patient-centered medical homes, in

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order to promote diversity in the size of practices designated, geographic locations of practices

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designated and accessibility of the population throughout the state to patient-centered medical

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homes.

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      (b) The patient-centered medical home collaborative shall propose to the secretary for

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adoption, the standards for the patient-centered medical home to be used in the payment system,

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based on national models where feasible.

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     42-14.6-5. Annual reports on implementation and administration. – The secretary

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and commissioner shall report annually to the legislature on the implementation and

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administration of the patient-centered medical home model.

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     42-14.6-6. Evaluation reports. – (a) The secretary and commissioner shall provide to the

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legislature comprehensive evaluations of the patient-centered medical home model two (2) years

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and four (4) years after implementation. The evaluation must include:

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     (1) The number of enrollees in patient-centered medical homes in the collaborative and

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the health characteristics of enrollees;

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     (2) The number and geographic distribution of patient-centered medical home providers

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in the collaborative and the number of primary care physicians per thousand populations;

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     (3) The performance and quality of care of patient-centered medical homes in the

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collaborative;

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     (4) The estimated impact of patient-centered medical homes on access to preventive care;

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     (5) Patient-centered medical home payment arrangements, and costs related to

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implementation and payment of care coordination fees;

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     (6) The estimated impact of patient-centered medical homes on health status and health

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disparities; and

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     (7) Estimated savings from implementation of the patient-centered medical home model.

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     (b) Health insurers shall provide to the commissioner and secretary utilization, quality,

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financial, and other reports, specified by the commissioner and secretary, regarding the

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implementation and impact of patient-centered medical homes

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     42-14.6-7. Alternative models. – Nothing in this section shall preclude the development

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of alternative patient centered medical home models by an insurer for its group and/or individual

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policies, or by the secretary, the commissioner or other state agencies or preclude insurers, the

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secretary, the commissioner or other state agencies from establishing alternative models and

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payment mechanisms for persons who are enrolled in integrated Medicare and Medicaid

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programs, are enrolled in managed care long-term care programs, are dually eligible for Medicare

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and Medicaid, are in the waiting period for Medicare, or who have other primary coverage.

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     42-14.6-8. Regulations. – The secretary of health and human services and the health

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insurance commissioner shall develop regulations to implement this chapter.

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     SECTION 2. This act shall take effect upon passage.

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LC00079/SUB A

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO STATE AFFAIRS AND GOVERNMENT -- PATIENT-CENTERED

MEDICAL HOME ACT

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     This act would provide for the implementation and development of a model patient-

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centered medical home program as a new approach to providing comprehensive primary health

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care for children, youths, and adults in this state.

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     This act would take effect upon passage.

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LC00079/SUB A

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