AN ACT Relating to clarifying the all payer claims database to improve health care quality and cost transparency by changing certain definitions regarding data, reporting and pricing of products, responsibility of the office and lead organization, and parameters for release of information; amending RCW 43.371.010, 43.371.020, 43.371.030, 43.371.040, 43.371.050, 43.371.060, and 43.371.070; and adding a new section to chapter 43.371 RCW.

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

Sec. 1.  RCW 43.371.010 and 2014 c 223 s 8 are each amended to read as follows:

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.

(1) "Authority" means the health care authority.

(2) "Carrier" and "health carrier" have the same meaning as in RCW 48.43.005.

(3) "Claims data" means the data required by RCW 43.371.030 to be submitted to the database, including billed, allowed and paid amounts, and such additional information as defined by the director in rule. (("Claims data" includes: (a) Claims data related to health care coverage and services funded, in whole or in part, in the omnibus appropriations act, including coverage and services funded by appropriated and nonappropriated state and federal moneys, for medicaid programs and the public employees benefits board program; and (b) claims data voluntarily provided by other data suppliers, including carriers and self-funded employers.))

(4) "Database" means the statewide all-payer health care claims database established in RCW 43.371.020.

(5) "Director" means the director of financial management.

(6) "Lead organization" means the organization selected under RCW 43.371.020.

(7) "Office" means the office of financial management.

Sec. 2.  RCW 43.371.020 and 2014 c 223 s 10 are each amended to read as follows:

(1) The office shall establish a statewide all-payer health care claims database to support transparent public reporting of health care information. The database must improve transparency to: Assist patients, providers, and hospitals to make informed choices about care; enable providers, hospitals, and communities to improve by benchmarking their performance against that of others by focusing on best practices; enable purchasers to identify value, build expectations into their purchasing strategy, and reward improvements over time; and promote competition based on quality and cost.

(2) Commencing no sooner than July 1, 2015, the director shall ((select))utilize a competitive process as set forth in subsection (4) of this section to select an organization for the initial contract term that is composed of health care purchasers, state licensed insurers, union trusts, providers, and consumers as a lead organization to coordinate and manage the database. The lead organization is responsible for internal governance, management, funding, and operations of the database. At the direction of the office, the lead organization shall:

(a) Collect claims data from data suppliers as provided in RCW 43.371.030;

(b) Design data collection mechanisms with consideration for the time and cost ((involved))incurred by data suppliers and others in submission, collection, and the benefits that measurement would achieve;

(c) Ensure protection of collected data and store and use any data with patient-specific or proprietary financial information in a manner that protects patient privacy and complies with this section;

(d) Consistent with the requirements of this chapter, make information from the database available as a resource for public and private entities, including carriers, employers, providers, hospitals, and purchasers of health care;

(e) Report performance on cost and quality pursuant to RCW 43.371.060 using, but not limited to, the performance measures developed under RCW 41.05.690;

(f) Develop protocols and policies, including prerelease peer review by data suppliers, to ensure the quality of data releases and reports;

(g) Develop a plan for the financial sustainability of the database and charge fees ((not to exceed five thousand dollars unless otherwise negotiated)) for reports and data files as needed to fund the database. Any fees must be approved by the office and ((must))should be comparable, accounting for relevant differences across data ((requesters and users))requests and uses; and

(h) Convene advisory committees with the approval and participation of the office, including: (i) A committee on data policy development; and (ii) a committee to establish a data release process consistent with the requirements of this chapter and to provide advice regarding formal data release requests. The advisory committees must include in-state representation from key provider, hospital, ((payer,)) public health, health maintenance organization, large and small private purchasers, ((and)) consumer organizations, and the two largest carriers supplying claims data to the database.

(3) The lead organization governance structure and advisory committees for this database must include representation of the third-party administrator of the uniform medical plan. A payer, health maintenance organization, or third-party administrator must be a data supplier to the all-payer health care claims database to be represented on the lead organization governance structure or advisory committees.

Sec. 3.  RCW 43.371.030 and 2014 c 223 s 11 are each amended to read as follows:

(1) ((Data suppliers must))The state medicaid program, public employees' benefits board programs, and all health carriers operating in this state must submit claims data to the database within the time frames established by the director in rule and in accordance with procedures established by the lead organization. The director may expand this requirement by rule to include any health plans or health benefit plans defined in RCW 48.43.005(26) (a) through (i) to accomplish the goals of this chapter set forth in RCW 43.371.020(1). Employer-sponsored self-funded health plans and Taft-Hartley trust health plans may voluntarily provide claims data to the database within the time frames and in accordance with procedures established by the lead organization.

(2) ((An entity that is not a data supplier but that chooses to participate in the database shall require any third-party administrator utilized by the entity's plan to release any claims data related to persons receiving health coverage from the plan.))Any data supplier used by an entity that voluntarily participates in the database must provide claims data to the lead organization upon request of the entity.

(3) ((Each data supplier))The lead organization shall submit an annual status report to the office regarding ((its)) compliance with this section. ((The report to the legislature required by section 2 of this act must include a summary of these status reports.))

Sec. 4.  RCW 43.371.040 and 2014 c 223 s 12 are each amended to read as follows:

(1) The claims data provided to the database, the database itself, including the data compilation, and any raw data received from the database are not public records and are exempt from public disclosure under chapter 42.56 RCW.

(2) Claims data obtained, distributed, or reported in the course of activities undertaken pursuant to or supported under this chapter are not subject to subpoena or similar compulsory process in any civil or criminal, judicial, or administrative proceeding, nor may any individual or organization with lawful access to data under this chapter be compelled to provide such information pursuant to subpoena or testify with regard to such data, except that data pertaining to a party in litigation may be subject to subpoena or similar compulsory process in an action brought by or on behalf of such individual to enforce any liability arising under this chapter.

Sec. 5.  RCW 43.371.050 and 2014 c 223 s 13 are each amended to read as follows:

(1) Except as otherwise required by law, claims or other data from the database shall only be available for retrieval in original or processed form to public and private requesters, other than the organization selected and acting as the lead organization under RCW 43.371.060, pursuant to this section and shall be made available within a reasonable time after the request. Each request for claims data must include, at a minimum, the following information:

(2) The lead organization may decline a request that does not include the information set forth in subsection (1) of this section, that does not meet the criteria established by the lead organization's data release advisory committee, or for reasons established by rule.

(3) Except as otherwise required by law, the office shall direct the lead organization to maintain the confidentiality of claims or other data it collects for the database that include proprietary financial information or direct ((and))or indirect patient identifiers. Any ((agency, researcher, or other person))entity that receives claims or other data ((under this section containing direct or indirect patient identifiers)) must also maintain confidentiality and may ((not))only release such claims ((or other data except as consistent with this section. The office shall oversee the lead organization's release of data as follows))data or any part of the claims data if:

(4) The lead organization shall, in conjunction with the office, create and implement a process to govern levels of access to and use of data from the database consistent with the following:

(a) Claims or other data that include proprietary financial information or direct ((or indirect)) patient identifiers, ((as specifically defined in rule,)) may be released only to the extent such information is necessary to achieve the goals of this chapter set forth in RCW 43.371.020(1) to:

(i) Federal, state, and local government agencies upon receipt of a signed data use and confidentiality agreement with ((the office and)) the lead organization. Federal, state, and local government agencies that obtain claims data pursuant to this section are prohibited from using such data in the purchase or procurement of health benefits for their employees; and

(ii) Researchers with approval of an institutional review board upon receipt of a signed data use and confidentiality agreement with ((the office and)) the lead organization. A researcher or research organization that obtains claims data pursuant to this section must agree in writing not to disclose such data or parts of the data set to any other party, including affiliated entities.

(b) Claims or other data that do not contain proprietary financial information or direct patient identifiers but that may contain indirect patient identifiers may be released to agencies, researchers, and other ((persons))entities as approved by the lead organization upon receipt of a signed data use agreement with the lead organization.

(c) Claims or other data that do not contain direct or indirect patient identifiers and proprietary financial information may be released upon request.

(7) Recipients of claims or other data under subsection (((2)(a) or (b)))(4) of this section must agree in a data use agreement or a confidentiality agreement to, at a minimum:

(a) Take steps to protect data containing direct and indirect patient ((identifying))identifiers or proprietary financial information as described in the agreement; ((and))

(b) Not redisclose the claims data except ((as authorized in the agreement consistent with the purpose of the agreement or as otherwise required by law.

(d) Store, destroy, or return claims data to the lead organization at the conclusion of the data use agreement.

Sec. 6.  RCW 43.371.060 and 2014 c 223 s 14 are each amended to read as follows:

(1)(a) Under the supervision of and through contract with the office, the lead organization shall prepare health care data reports using the database and the statewide health performance and quality measure set((, including only those measures that can be completed with readily available claims data)). Prior to the lead organization releasing any health care data reports that use claims data, the lead organization must submit the reports to the office for review ((and approval)).

(2)(a) Health care data reports that use claims data prepared by the lead organization ((that use claims data must assist))for the legislature and the public ((with))should promote awareness and ((promotion of)) transparency in the health care market by reporting on:

(i) Whether providers and health systems deliver efficient, high quality care; and

(ii) Geographic and other variations in medical care and costs as demonstrated by data available to the lead organization.

(b) Measures in the health care data reports should be stratified by demography, income, language, health status, and geography when feasible with available data to identify disparities in care and successful efforts to reduce disparities.

(c) Comparisons of costs among providers and health care systems must account for differences in ((acuity))the case mix and severity of illness of patients and populations, as appropriate and feasible, and must take into consideration the cost impact of subsidization for uninsured and ((governmental))government-sponsored patients, as well as teaching expenses, when feasible with available data.

(3) The lead organization may not publish any data or health care data reports that:

(a) Directly or indirectly ((identify))identifies individual patients;

(b) ((Disclose specific terms of contracts, discounts, or fixed reimbursement arrangements or other specific reimbursement arrangements between an individual provider and a specific payer))Discloses a carrier's proprietary financial information; or

(c) Compares performance in a report generated for the general public that includes any provider in a practice with fewer than ((five))four providers.

(4) The lead organization may not release a report that compares and identifies providers, hospitals, or data suppliers unless ((it)):

(a) It allows the data supplier, the hospital, or the provider to verify the accuracy of the information submitted to the lead organization, comment on the reasonableness of conclusions reached, and submit to the lead organization any corrections of errors with supporting evidence and comments within ((forty-five))thirty days of receipt of the report; ((and))

(b) It corrects data found to be in error within a reasonable amount of time; and

(c) The report otherwise complies with this chapter.

(5) The office and the lead organization may use claims data to identify and make available information on payers, providers, and facilities, but may not use claims data to recommend or incentivize direct contracting between providers and employers.

(6) The lead organization shall ((ensure that no individual data supplier comprises more than twenty-five percent of the claims data used in any report or other analysis generated from the database. For purposes of this subsection, a "data supplier" means a carrier and any self-insured employer that uses the carrier's provider contracts))distinguish in advance to the office when it is operating in its capacity as the lead organization and when it is operating in its capacity as a private entity. Where the lead organization acts in its capacity as a private entity, it may only access data pursuant to RCW 43.371.050.

Sec. 7.  RCW 43.371.070 and 2014 c 223 s 15 are each amended to read as follows:

(1) The director shall adopt any rules necessary to implement this chapter, including:

(a) Definitions of claim and data files that data suppliers must submit to the database, including: Files for covered medical services, pharmacy claims, and dental claims; member eligibility and enrollment data; and provider data with necessary identifiers;

(b) Deadlines for submission of claim files;

(c) Penalties for failure to submit claim files as required;

(d) Procedures for ensuring that all data received from data suppliers are securely collected and stored in compliance with state and federal law; ((and))

(e) Procedures for ensuring compliance with state and federal privacy laws;

(g) Procedures for data release.

(2) The director may not adopt rules, policies, or procedures beyond the authority granted in this chapter.

NEW SECTION.  Sec. 8.  A new section is added to chapter 43.371 RCW to read as follows:

(1) By December 1st of 2016 and 2017, the office shall report to the appropriate committees of the legislature regarding the development and implementation of the database, including but not limited to budget and cost detail, technical progress, and work plan metrics.

(2) Every two years commencing two years following the year in which the first report is issued or the first release of data is provided from the database, the office shall report to the appropriate committees of the legislature regarding the cost, performance, and effectiveness of the database and the performance of the lead organization under its contract with the office. Using independent economic expertise, the report must evaluate whether the database has advanced the goals set forth in RCW 43.371.020(1), as well as the performance of the lead organization. The report must also make recommendations regarding but not limited to how the database can be improved, whether the contract for the lead organization should be modified, renewed, or terminated, and the impact the database has had on competition between and among providers, purchasers, and payers.

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