BP BHEAD INT S [atlas:bill]

AN ACT Relating to the establishment of comprehensive quality assurance standards for health carriers; and adding new sections to chapter 48.43 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. The legislature finds that comprehensive quality assurance programs are essential to ensuring high quality health care for enrollees in health carriers. Since financial payments and incentive structures in health carriers may provide incentives to limit resources, restrict access to health care services, or otherwise affect and undermine the provision of quality health care services, quality assurance standards must be established. Comprehensive quality assurance standards will ensure that consumers receive the high quality health care that they expect when they enroll in a health carrier. The legislature also finds that the implementation of high quality assurance standards benefits Washington's business climate as well as consumers. Through the implementation of quality assurance standards, employers will be assured that the health care purchased for their employees meets certain minimum requirements. Public dissemination of health carrier annual evaluations will assist consumers and employers in choosing among health carriers.

NEW SECTION. Sec. 2. The department of health shall adopt comprehensive quality assurance standards that each health carrier must meet. These standards must be reviewed and modified as appropriate at least every three years. Standards must include:

(1) A requirement for an internal quality assurance system to apply to each health carrier and any entity with which it contracts for services;

(2) Performance and outcomes-based quality standards;

(3) A process to take remedial action to correct quality problems;

(4) A process for credentialing and recredentialing of providers;

(5) Uniform data collection and reporting requirements; and

(6) Other items required by the department of health.

NEW SECTION. Sec. 3. All health carriers shall implement a comprehensive quality assurance program designed to identify, evaluate, and remedy problems relating to access, continuity, and quality of care. Each health maintenance organization and health care service contractor's quality assurance system must comply with the standards adopted under section 1 of this act and must provide for:

(1) The designation of a corporate board, a committee, or a designated executive staff person responsible for program implementation and compliance;

(2) A detailed set of quality assurance objectives, with timetables, including assurance of adequate resources to deliver a full continuum of care and guaranteed geographic availability, cultural sensitivity, and planning for special needs populations;

(3) Health service delivery standards or practice guidelines aimed at curing, maintaining function, and improving quality of life, which are updated continuously with provider input, disseminated to providers, developed for the full spectrum of health carrier populations, based on reasonable scientific knowledge, focused on outcomes and access, and available to individual and group providers;

(4) Written guidelines for quality of care studies and monitoring, including evaluation of vulnerable populations;

(5) A methodology for identifying quality indicators relating to specific clinical or health service delivery areas that are objective, measurable, and based on current knowledge and clinical experience, including but not limited to the utilization of epidemiological data, chart reviews, patterns of care, patient surveys, spot checks, and continuous review by health professionals;

(6) The identification, evaluation, and remediation of problems relating to access, continuity, and quality of care, including a system for evaluating health outcomes consistent with current technology;

(7) A system to ensure compliance with all quality assurance standards by any entity providing services under any contractual agreements, including evidence that the health carrier will monitor compliance and require all remedial actions if necessary; and

(8) The reporting, within thirty days, of the occurrence of any of the following:

(a) The suspension, restriction, termination, or curtailment of training, employment, or the contract for the provision of services to enrollees for any reason relating to alleged mental or physical impairment, incompetence, malpractice, misconduct, or impairment of patient safety or welfare;

(b) The voluntary or involuntary resignation, termination of a contract for service, or withdrawal of privileges to avoid the imposition of disciplinary measures; or the receipt of information that any professional licensee or medical resident has been convicted of a crime; and

(c) The denial of staff privileges to a physician or the refusal to enter into or renew a contract with a physician for the provision of services if the reasons stated for denial or refusal are related to the alleged physical or mental impairment, incompetence, malpractice, misconduct, or impairment of patient safety or welfare.

NEW SECTION. Sec. 4. Annual audits of health carriers must be conducted annually. One or more independent quality assurance organizations shall be authorized to monitor and evaluate the quality of care and services furnished by health care services contractors and health maintenance organizations and utilization review entities. Requests for proposals must be issued for independent quality assurance organizations. Proposals submitted in response to such requests for proposals must be evaluated and one or more contracts awarded to one or more qualified and responsive organizations. Such quality assurance organizations may not be owned, operated, or controlled by any health carriers or utilization review company nor have a financial relationship with any such entity. Health carrier enrollees or participating providers may request that the independent quality assurance organization review all or any portion of a health carrier's quality assurance program, and the independent quality assurance organization may do so at any time.

NEW SECTION. Sec. 5. Annual evaluations must include the following:

(1) Compliance with performance and outcomes-based quality standards established in section 1 of this act;

(2) Appropriateness, accessibility, timeliness, and quality of care delivered by such providers;

(3) Coordination, management, and cost-effectiveness of care;

(4) Delivery of medically necessary covered services, including referrals for necessary services and capacity and scope of the network providers;

(5) Provision of all information to each enrollee in clear and coherent terms that are commonly used and in a culturally and linguistically appropriate and understandable manner, in light of the enrollees needs, circumstances, and language proficiency; and

(6) Any other requirement established by the department of health.

NEW SECTION. Sec. 6. Each health carrier shall collect and submit to the independent quality assurance organization or organizations conducting the evaluation, in a standardized format, patient care and patient satisfaction data including:

(1) Encounter and service utilization data including special care and chronic care utilization data;

(2) Emergency medical care utilization data;

(3) Outcome-based data;

(4) Grievance and appeals data;

(5) Disenrollment data, including reasons for disenrollment;

(6) Access data, including waiting times, travel times, patient-to-provider ratios, and unduplicated provider capacity; and

(7) Any other data required by the department of health.

NEW SECTION. Sec. 7. (1) The independent quality assurance organization shall analyze such data and report to the governor, the health care committees of the senate and the house of representatives, the department of health, and the public the results of its quality review and evaluation, including recommendations for remedial action, on at least an annual basis. A public or private entity who in good faith prepares a document of any kind that compares health carriers or carriers of any kind is immune from civil liability from claims based on the report, contents of the report, or the information filed by a health carrier.

(2) There is an absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the independent quality assurance organization's report, or the information filed by a health carrier, and contained the effective date of the information, if any.

(3) In the absence of reckless disregard for the truth proven by clear and convincing evidence, there is immunity from claims based on the independent quality assurance organization's report or the information filed by a health carrier.

NEW SECTION. Sec. 8. (1) Health carriers and utilization review entities that fail to ensure compliance with quality standards and reporting requirements may be subject to enforcement actions. Material violations of such standards and requirements may be punished by civil penalties.

(2) Repeated, material violations of quality standards and reporting requirements by a health carrier may be grounds for revocation of the health carrier's license.

(3) Prior to imposing any sanction, health carriers or utilization review entities must have an opportunity to be heard in connection with the violations alleged and sanctions imposed. Public comment must also be taken at the hearing.

NEW SECTION. Sec. 9. (1) The independent quality assurance organizations shall conduct and publish surveys of health carriers' enrollees and participating providers to assess satisfaction.

(2) Such surveys must differentiate between infrequent and frequent utilizers of health carrier services.

NEW SECTION. Sec. 10. Sections 1 through 9 of this act are added to chapter 48.43 RCW.