BILL REQ. #:  H-0709.2 

Read first time 01/18/11.   Referred to Committee on Health Care & Wellness.

     AN ACT Relating to establishing a public/private collaborative to improve health care quality, cost-effectiveness, and outcomes in Washington state; amending RCW 70.250.010 and 70.250.030; adding new sections to chapter 70.250 RCW; creating a new section; repealing RCW 70.250.020; and declaring an emergency.

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

NEW SECTION.  Sec. 1   (1) The legislature finds that:
     (a) Efforts are needed across the health care system to improve the quality and cost–effectiveness of health care services provided in Washington state and to improve care outcomes for patients.
     (b) Some health care services currently provided in Washington state present significant safety, efficacy, or cost-effectiveness concerns. Substantial variation in practice patterns or high utilization trends can be indicators of poor quality and potential waste in the health care system, without producing better care outcomes for patients.
     (c) State purchased health care programs should partner with private health carriers, third-party purchasers, and health care providers in shared efforts to improve quality, health outcomes, and cost-effectiveness of care.
     (2) The legislature declares that collaboration among state purchased health care programs, private health carriers, third-party purchasers, and health care providers to identify appropriate strategies that will increase the effectiveness of health care delivered in Washington state is in the best interest of the public. The legislature therefore intends to exempt from state antitrust laws, and to provide immunity from federal antitrust laws through the state action doctrine, for activities undertaken pursuant to efforts designed and implemented under this act that might otherwise be constrained by such laws. The legislature does not intend and does not authorize any person or entity to engage in activities or to conspire to engage in activities that would constitute per se violations of state and federal antitrust laws including, but not limited to, agreements among competing health care providers or health carriers as to the price or specific level of reimbursement for health care services.

Sec. 2   RCW 70.250.010 and 2009 c 258 s 1 are each amended to read as follows:
     The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
     (1) "Advanced diagnostic imaging services" means magnetic resonance imaging services, computed tomography services, positron emission tomography services, cardiac nuclear medicine services, ultrasound, and similar new imaging services.
     (2) "Authority" means the Washington state health care authority.
     (3) "Collaborative" means the Robert Bree collaborative established in section 3 of this act.
     (4) "Payor" means ((public purchasers and)) carriers licensed under chapters 48.21, 48.41, 48.44, 48.46, and 48.62 RCW.
     (((4) "Public purchaser" means the department of social and health services, the department of health, the department of labor and industries, the authority, and the Washington state health insurance pool)) (5) "Self-funded health plan" means an employer-sponsored health plan or Taft-Hartley plan that is not provided through a fully insured health carrier.
     (((5))) (6) "State purchased health care" has the same meaning as in RCW 41.05.011.

NEW SECTION.  Sec. 3   A new section is added to chapter 70.250 RCW to read as follows:
     (1) Consistent with the authority granted in RCW 41.05.013, the authority shall convene a collaborative, to be known as the Robert Bree collaborative. The collaborative shall identify health care services for which there are substantial variation in practice patterns or high utilization trends in Washington state, without producing better care outcomes for patients, that are indicators of poor quality and potential waste in the health care system. On an annual basis, the collaborative shall identify up to three health care services it will address.
     (2) For each health care service identified, the collaborative shall:
     (a) Analyze and identify evidence-based best practice approaches to improve quality and reduce variation in use of the service, including identification of guidelines or protocols applicable to the health care service. In evaluating guidelines, the collaborative should identify the highest quality guidelines based upon the most rigorous and transparent methods for identification, rating, and translation of evidence into practice recommendations.
     (b) Identify strategies to increase use of the evidence-based practice approaches identified under (a) of this subsection in both state purchased and privately purchased health care plans. Strategies considered should include, but are not limited to: Identifying goals for appropriate utilization rates and reduction in practice variation among providers; peer-to-peer consultation or second opinions; provider feedback reports; use of patient decision aids; reimbursement methodology changes; performance-based payment methodologies; clinical service authorization criteria; centers of excellence or other provider qualification standards; quality improvement systems; and service utilization and outcomes reporting, including public reporting. In developing strategies, the collaborative is encouraged to build its efforts upon similar efforts of the Puget Sound health alliance and the foundation for quality.
     (3) If the collaborative chooses a health care service for which there is substantial variation in practice patterns or a high utilization trend in Washington state, and a lack of evidence-based best practice approaches, it should consider strategies that will promote improved care outcomes, such as patient decision aids, provider feedback reports, centers of excellence or other provider qualification standards, and research to improve care quality and outcomes.
     (4) The administrator of the authority shall appoint eight members of the collaborative, who must include:
     (a) Three representatives of health carriers as defined in RCW 48.43.005, at least one of whom also serves as a third-party administrator for a self-funded employer sponsored health plan. The representatives must be chosen from among five nominees submitted by the association of Washington health plans;
     (b) Three physicians, at least one of whom is formally affiliated with a hospital system, chosen from among five nominees submitted by the Washington state medical association;
     (c) The medical director of the medical assistance program; and
     (d) The medical director of the department of labor and industries.
     (5) The governor shall appoint an additional member of the collaborative who must serve as the chair of the collaborative.
     (6) The collaborative may add additional members to its membership or establish clinical subcommittees on an ad hoc basis for the purpose of acquiring clinical expertise needed to accomplish the responsibilities designated under this act.
     (7) Permanent and ad hoc members of the collaborative or any of its subcommittees may not have personal financial conflicts of interest that could substantially influence or bias their participation. If a collaborative or subcommittee member has a personal financial conflict of interest with respect to a particular health care service being addressed by the collaborative, he or she shall disclose such an interest. The collaborative must determine whether the member should be recused from any deliberations or decisions related to that service.
     (8) The collaborative shall actively solicit federal or private funds and in-kind contributions necessary to complete its work in a timely fashion. No member of the collaborative or its subcommittees may be compensated for his or her service.

NEW SECTION.  Sec. 4   A new section is added to chapter 70.250 RCW to read as follows:
     (1) As part of its initial efforts, and by September 1, 2011, the collaborative shall:
     (a) Identify goals for the reduction in the rate of cesarean section deliveries and early induction of labor prior to thirty-nine weeks gestation in Washington state. In choosing goals, the collaborative shall rely upon measures identified by the United States department of health and human services healthy people 2010, the national quality forum, or other nationally recognized health care quality standard setting entities;
     (b) Identify high quality evidence-based practice guidelines and protocols that when used effectively, will bring practice patterns in Washington state closer to the goals identified under (a) of this subsection; and
     (c) Develop a multifaceted strategy to increase use of the guidelines and protocols identified under (b) of this subsection in both state purchased and privately purchased health care plans, which may include, but are not limited to, provider specific reporting of cesarean section and early induction rates, public reporting of hospital cesarean section and early induction rates, peer review or second opinions, and payment methodology incentives.
     (2)(a) As part of its initial efforts, and by January 1, 2012, the collaborative shall:
     (i) Identify evidence-based practice guidelines and protocols that, when used effectively, will improve the treatment of back pain in Washington state; and
     (ii) Develop a multifaceted strategy to increase use of the guidelines and protocols identified under (a) of this subsection in both state purchased and privately purchased health care plans, which may include, but are not limited to: Development of evidence-based quality indicators of care through formal focus groups of expert clinical and academic clinicians; assessment of and potential development of financial and nonfinancial incentive systems to increase use of guidelines, protocols, and quality indicators of care identified under this subsection; identification of the best quality metrics to determine outcomes of evidence-based best practice care for low back pain, including but not limited to use of metrics representing minimum clinically important outcomes; identification of best available evidence-based methods to coordinate and integrate care for persons with acute, subacute, and chronic low back pain; identification of potential methods to enhance delivery of evidence-based back pain care in community-based settings using interdisciplinary health services; and identification and development of pilot, web-based methods to track population-based outcomes and timely feedback of outcome information to health care providers to improve quality.
     (b) Considering the high variation in use, poor outcomes in some Washington state populations, the likelihood of reoperation and other adverse outcomes, and the cost of complex spinal surgery such as spinal fusion, the strategy identified in (a)(ii) of this subsection may also include a comparative effectiveness outcome study of spinal surgery, including lumbar fusion surgery for chronic back pain. This study may include participation of state purchased health care programs and private health plans. For the purposes of this study, participation of each spine surgery patient who meet study criteria and each requesting physician may be required as a condition of coverage for the surgery. The study per se, as an observational study, could include collection of data pertaining to baseline and follow-up health outcomes, adverse events, and costs, but would not itself mandate any additional treatments or interventions. All study procedures for this study must be approved by an institutional review board prior to the start of the study. Funding for this study must be obtained from nongeneral fund state sources.
     (3) The collaborative shall report its findings and recommendations related to cesarean section and elective induction of labor to the governor and the appropriate committees of the legislature by September 1, 2011.
     (4) The collaborative shall report its findings and recommendations related to the treatment of back pain to the governor and appropriate committees of the legislature by January 1, 2012.
     (5) The collaborative shall report its findings and recommendations related to additional health services areas to the governor and appropriate committees of the legislature by January 1st of each succeeding year.

Sec. 5   RCW 70.250.030 and 2009 c 258 s 3 are each amended to read as follows:
     (1) No later than September 1, 2009, all state purchased health care programs shall, except for state purchased health care services that are purchased from or through health carriers as defined in RCW 48.43.005, implement evidence-based best practice guidelines or protocols applicable to advanced diagnostic imaging services, and the decision support tools to implement the guidelines or protocols, identified under ((RCW 70.250.020)) section 3 of this act.
     (2) By January 1, 2012, all state purchased health care programs must implement the evidence-based practice guidelines or protocols and strategies identified under section 4 (1) and (2) of this act. If the collaborative fails to reach consensus within the time frames identified in this section and section 4 of this act, state purchased health care programs may pursue implementation of evidenced-based strategies on their own initiative.

NEW SECTION.  Sec. 6   RCW 70.250.020 (Work group -- Members--Duties -- Report -- Expiration of work group) and 2009 c 258 s 2 are each repealed.

NEW SECTION.  Sec. 7   This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately.