Text of
legislation filed by MMS for the 2015-16 session of the Massachusetts
Legislature:
SECTION 1. Section 2 of Chapter 32A is hereby
amended by inserting the following new definitions:
(j) “Quality”, the degree to which health services
for individuals and populations increase the likelihood of the desired health
outcomes and are consistent with current professional knowledge.
(k) “Cost efficiency”, the degree to which health
services are utilized to achieve a given outcome or given level of quality.
(l) “Physician performance evaluation”, a system
designed to measure the quality, and cost efficiency of a physician’s delivery
of care and shall include quality improvement programs, pay for performance
programs, public reporting on physician performance or ratings’ and the use of
tiering networks.
SECTION 2. Section 21 of Chapter 32A of the General
Laws, as appearing the 2010 Official Edition, is hereby amended by inserting at
the end thereof, the following:-
The commission shall not implement or contract with
a carrier as defined in section 1 of Chapter 1760 for the implementation of a
physician performance evaluation program as defined in section one unless the
program has the following minimum attributes:
(1) Public disclosure regarding the methodologies,
criteria and algorithms under consideration, 180 days before any performance
evaluations of physicians are applied;
(2) Meaningful input by independent practicing
physicians and biostatisticians in a timely fashion that will ensure the
measures being used are clinically important and understandable to patients and
physicians and the tools used for performance evaluations are fair and
appropriate;
(3) A mechanism to ensure data accuracy and validity
that includes a feedback cycle of not less than 120 days prior to the public
reporting of the data, which accepts corrections to errors from multiple
sources, including the physician being evaluated, assesses the causes of the error(s)
and improves the overall evaluation system;
(4) A mechanism to provide the physician being
evaluated with patient level drill downed information on any cost efficiency
measures used in the evaluation and patient lists for any quality measures that
are used in the evaluation that includes a list of patients counted towards each
quality measure, as well as the interventions for each patient that counted
towards that measure.
(5) Each quality measure shall have a reasonable
target set for each measure and shall not allow the target level to be
open-ended.
(6) If a quality measure is to be constructed across
multiple conditions then the measure shall be case mix adjusted.
(7) A consensus process shall be in place to provide
proper weighting of more important quality measures at a higher weight and the
equal weighting of all measure shall not be used as a default.
(8) Sample sizes used in the development of quality
measures should not be increased by adding the number of interventions and
number of opportunities across multiple health condition to create an adherence
ratio, without appropriate statistical adjustment of such a process. Adherence
must be assessed at a physician group practice level rather than at the
individual physician level.
(9) Sample sizes used in the development of cost
efficiency measures must be large enough to provide valid information.
(10) Information physicians are rated on must be
current to reflect physicians’ current practices of care for their patients, be
appropriately risk adjusted and include appropriate attribution, definition of
specialty and adjustments for unusual medical situations. Physicians should be
measured only on conditions appropriate to their specialties.
(11) Use of preventive care and under-use measures
should not be considered as part of cost efficiency measurements.
(12) Recommendations by which the physician can
improve the results of the evaluation reporting.
(13) An evaluation plan that uses assignment by
tiering shall include a uniform tier assignment protocol and shall have a
statistically significant difference in rating calculations in order to shift a
physician from one tier to another. Separate categories shall be created for physicians
for who cannot be evaluated in a statistically reliable manner. Said
categorization shall not result in higher co-payments for patients being
treated by physicians in these separate categories. Said plans shall also
employ a data driven process to determine which medical specialties to tier.
(14) Uniform tiering should be assigned to group
practices so as not to add additional administrative burdens to physicians’
practices.
(15) Accuracy regarding tiering is critical to avoid
the unintended consequences of limiting access to care and introducing risk
adversity. Information should be disseminated in such as fashion that results
are is both understandable and comprehensive enough to promote education and
quality improvement.
(16) Increasing data accuracy must be approached as
a continuous quality improvement (CQI) project aimed at improving the
evaluation system itself.
SECTION 3. No carrier as defined in Section 1 of
Chapter 1760 of the general laws shall establish a physician performance
evaluation program unless the program has the following minimum attributes:
(1) Public disclosure regarding the methodologies,
criteria and algorithms under consideration, 180 days before any performance
evaluations of physicians are applied;
(2) Meaningful input by independent practicing
physicians and biostatisticians in a timely fashion that will ensure the
measures being used are clinically important and understandable to patients and
physicians and the tools used for performance evaluations are fair and
appropriate;
(3) A mechanism to ensure data accuracy and validity
that includes a feedback cycle of not less than 120 days prior to the public
reporting of the data, which accepts corrections to errors from multiple
sources, including the physician being evaluated, assesses the causes of the error(s)
and improve the overall evaluation system; and
(4) A mechanism to provide the physician being
evaluated with patient level drill downed information on any efficiency
measures used in the evaluation and patient lists for any quality measures that
are used in the evaluation.
(5) Each quality measure shall have a reasonable
target set for each measure and shall not allow the target level to be
open-ended.
(6) If a quality measure is to be constructed across
multiple conditions then the measure shall be case mix adjusted.
(7) A consensus process shall be in place to provide
proper weighting of more important quality measures at a higher weight and the
equal weighting of all measure shall not be used as a default.
(8) Sample sizes used in the development of quality
measures should not be increased by adding the number of interventions and
number or opportunities across multiple health condition to create an adherence
ratio. Adherence must be assessed at a physician group practice level rather
than at the individual physician level.
(9) Recommendations by which the physician can
improve the results of the evaluation reporting.
(10) An evaluation plan that uses assignment by
tiering shall include a uniform tier assignment protocol and shall have a
statistically significant difference in rating calculations in order to shift a
physician from one tier to another. Separate categories shall be created for physicians
for who cannot be evaluated in a statistically reliable manner. Said
categorization shall not result in higher co-payments for patients being
treated by physicians in these separate categories. Said plans shall also
employ a data driven process to determine which medical specialties to tier.
(11) Uniform tiering should be assigned to group
practices so as not to add additional administrative burdens to physicians’
practices.
(12) Accuracy regarding tiering is critical to avoid
the unintended consequences of limiting access to care and introducing risk
adversity. Information should be disseminated in such as fashion that results
are is both understandable and comprehensive enough to promote education and
quality improvement.
(13) Increasing data accuracy must be approached as
a continuous quality improvement (CQI) project aimed at improving the
evaluation system itself.
SECTION 4. Subsection (b) of section 11 of chapter
176J of the General Laws is hereby amended by striking out the second sentence
and inserting in place thereof the following sentences:-
The commissioner shall determine by regulation
standard tiering criteria to be used by all carriers based on health outcomes,
quality performance as measured by the standard quality measure set and by cost
performance as measured by health status adjusted total medical expenses and
relative prices. The criteria shall require that all providers of the same type
who are participants in a particular Accountable Care Organization or Patient
Centered Medical Home, as defined in section 1 of chapter 6D, shall be
classified in the same tier.
SECTION 5. Section 11 of chapter 176J of the General
Laws is hereby amended by striking out subsection (c) and inserting in place
thereof the following subsection:–
(c) The commissioner shall promulgate by regulation
uniform criteria for determining network adequacy for a tiered network plan
based on the availability of sufficient network providers in the carrier’s
overall network of providers, including standards for adequate geographic
proximity of providers to members, taking into account distance, travel time and
availability of public transportation. In determining network adequacy, the
commissioner shall require that carriers classify providers into tiers so that
every member enrolled in a plan has reasonable access to at least one provider
in the lowest cost-sharing tier for every covered service.
SECTION 6. Section 11 of chapter 176J of the General
Laws is hereby amended by striking out subsection (f) and inserting in place
thereof the following subsection:–
(f) Carriers may: (i) reclassify provider tiers; and
(ii) determine provider participation in selective and tiered plans no more
than once per calendar year except that carriers may reclassify providers from
a higher cost tier to a lower cost tier or add providers to a selective network
at any time. If the carrier reclassifies provider tiers or providers
participating in a selective plan during the course of an account year, the
carrier shall provide affected members of the account with information
regarding the plan changes at least 30 days before the changes take effect. If
a member is in a course of treatment with a mental health provider who is
reclassified to a higher cost tier, the member shall be permitted to remain
with the provider with cost sharing at the previous lower cost tier for one
year following the reclassification.
Carriers shall provide information understandable to an average consumer
on their websites and though a toll-free telephone number that includes an
option of talking to a live person about any tiered or selective network plan, including
but not limited to, a searchable list of the providers participating in the
plan, the selection criteria for those providers and where applicable, the tier
in which each provider is classified. The information shall clearly distinguish
among different facilities of a provider if those facilities are in different
tiers or are excluded from a selective plan.
All promotional materials for tiered and selective plans must include a
readily understandable general explanation of the cost sharing and tiering
elements of the plan, and a prominent notice of the web site and toll-free
telephone number where a consumer may find more information about the cost
sharing and tiering elements. The commissioner shall monitor the web sites and
telephone response services for completeness, accuracy and understandability.
The commissioner may conduct consumer surveys and focus groups reviewing
carrier tiered and selective network plan web sites and telephone
response services, and shall issue guidelines for best practices.