Legislature(1993 - 1994)
03/14/1994 01:40 PM Senate HES
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* first hearing in first committee of referral
+ teleconferenced
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+ teleconferenced
= bill was previously heard/scheduled
CHAIRMAN RIEGER called the Senate Health, Education and Social Services (HESS) Committee to order at 1:40 p.m. He introduced SB 270 (COMPREHENSIVE HEALTH CARE) and SB 284 (COMPREHENSIVE HEALT ALT INSURANCE ACT) as the only business before the committee. He stated that the data collection aspect of both bills would first on the committee's agenda. NANCY USERA, Commissioner of the Department of Administration, deferred to Jay Livey who did most of the developmental work on the data collection section and who has a more in depth knowledge of that piece of SB 270. SENATOR DUNCAN asked if fiscal implications would be discussed today. CHAIRMAN RIEGER noted that the Department of Commerce and the Department of Administration are reviewing the fiscal notes together to make sure there are no inconsistencies in the approaches of the fiscal notes of both bills. They should have some information for the committee next week. Chairman Rieger said that fiscal implications could be addressed, but the specifics of the fiscal notes should be discussed when both departments come back with their information. SENATOR DUNCAN expressed the need for the departments to review other approaches to the fiscal notes. He did not believe that an objective fiscal note could come from the insurance industry who opposes such legislation as SB 284. NANCY USERA commented that it seems that everyone wants a common set of assumptions; to provide information that reflects the costs of these proposals. She agreed that there were different sets of assumptions. She said that she was open to suggestions. SENATOR DUNCAN stated that he was available for meeting. Number 095 JAY LIVEY, Deputy Commissioner of the Department of Health and Social Services, noted the presence of others who could also speak to health care data collection and its uses. He began with an overview of health care data collection. He explained that health data should be collected so that information regarding the type of person being served, the services they are receiving, the cost of those services, and the outcome of those services are available. From all that information, notions of improving or restructuring the services to decrease the costs and better the outcomes could be derived. Mr. Livey explained the three main sources of data. The first source of data is primary data elements which most states collect in order to do public health surveillance. Primary data elements include unintentional injuries, suicides, cancer deaths, infant mortality rates, etcetera. He identified the second source of data as the claims payment system which utilizes data from large organizations such as AETNA, who covers all state employees, and the Medicaid program. This could be used in policy analysis. He noted that currently, the Vital Statistics division of Public Health share information with Medicaid regarding women in prenatal care. Due to Alaska's small sample size, another year of data is needed to be statistically valid. He pointed out another problem with data collection would be determining how to link existing data bases so that policy makers can determine if the health care services being provided are the services needed. Number 165 The third level of data collection is additional data such as hospital discharge data which provides diagnosis information, demographic information, cost information, etcetera. Discharge data in Alaska is sketchy. Mr. Livey believed that in addition to information from the uniform claims form, this additional data would be helpful with health care reform. He presented the committee with a booklet of a health data form from Florida and its use of discharge data. He discussed information generated from the Maine Medical Assessment Foundation. He explained that Maine looked at outcome data from the point of view of regional statistics which can yield practice patterns of physicians. He explained that this information helps to determine ways to improve the system. Mr. Livey said that the data collection portion of SB 270 deals with adopting a uniform claims form, collecting and analyzing data regarding delivery of health care services in Alaska, and adopting regulations which define health care data. The type of data collection proposed in SB 270 is not comprehensive health data collection. He said that SB 270 attempts to define the roles of future health care data collection in order to achieve rationality and cooperative use of data already collected. He explained that the data collection he had discussed was not anticipated by SB 270 and is not reflected in the fiscal note of SB 270; however, SB 270 would provide a starting point for organization of the data collection systems. CHAIRMAN RIEGER asked if under SB 270 this would be coordinated through the Division of Insurance. JAY LIVEY said that data collection would be coordinated through the Health Commission. The information from the uniform claims form and how it is used and analyzed would be left to the deliberations of the Commission. CHAIRMAN RIEGER inquired of the language requiring that the Commission do the data collection. JAY LIVEY pointed out that section 44.19.621 under paragraph (1) and section 44.19.626 both specify that the Commission would do data collection. Number 259 SENATOR ELLIS asked why would they want to collect a small amount of data to decide what kind of data would be collected in the future. He said that the people in the department and those who worked on this issue for three years already know the kind of information that should be collected for the future. JAY LIVEY explained that the uniform claims form should be implemented in order to collect uniform data while saving some administrative costs. He felt that the data from the uniform claims form was needed to do further kinds of reform. There are still things to be learned about the health system. He did not feel that it would be a waste of time. SENATOR ELLIS said that SB 270 and its data collection was so limited. CHAIRMAN RIEGER asked if the discharge data, the third level of data, would be incorporated on the uniform claims form. JAY LIVEY said he did not know. That would be one of the issues the Commission would need to review. He pointed out that collecting such data would be a question of the extent that additional information could be included on the form. The costs of doing that versus the provider getting the data would have to be reviewed. CHAIRMAN RIEGER asked where Mr. Livey envisioned the actual collection of data; in the Commission or a department of the State. JAY LIVEY explained that he believed that the information from the form would be dumped into files for analysis. That information would be available to various people. Mr. Livey stated that the analysis would be done with existing resources, not by the Commission. DAVID WALSH, Director of the Division of Insurance, stated that the collection data would have minimal impact on the Division after the uniform claims form is developed. The key to data collection is the uniform claims form. CHAIRMAN RIEGER inquired of Mr. Walsh's thoughts regarding the third level of data, discharge data, being a part of the uniform claims form. DAVID WALSH imagined that the third level of data would be part of the form after things were running. He deferred to Mr. Livey regarding how crucial that data would be to the health analysis. Number 336 SENATOR DUNCAN directed the committee to page 14 of SB 284 which deals with health care data collection. He stated that a comprehensive data system was necessary in order to achieve universal coverage while controlling health care expenditures. The principle source of data in SB 284 is the claims clearinghouse. He believed that the comprehensive data care system should be a high priority in any comprehensive reform proposal which could be one of the differences in the two bills. The Corporation of SB 284 is charged with establishing the health care data system, and periodically monitoring and updating the system. He noted that lines 8-19 on page 14 of SB 284 list the type of data to be collected. Senator Duncan pointed out that section 21.58.270 addresses the statewide health care expenditure target. He also noted that in order for the statewide expenditure target to change, other data besides that listed on lines 8-19 must be collected. He acknowledged that a comprehensive data collection system would be costly, but must be done to have a good reform proposal. He discussed Vermont's approach to this same problem. In order to have a reform proposal that would work, a comprehensive data system must be in place which SB 284 recognizes from the beginning. He believed that there was a common consensus on the need for a comprehensive data system in order to have universal system with cost control; the difference would be on how and when that would be achieved. JAY LIVEY stated that those who use health care data say that in the long term they may want to go further with data collection than the common claims form. He explained that if the claims payment form basically provides information the provider takes to ensure payment then it may differ from information on the issues of diagnosis, treatment, and outcome which are also needed. He did agree that it was a good starting place and better than the current system. CHAIRMAN RIEGER asked if either bill contains provisions regarding confidentiality of this health information. JAY LIVEY pointed out that page 6, line 19 of SB 270 requires disclosure of medical information and continues on to page 7 describing the penalties for disclosure of that information. CHAIRMAN RIEGER inquired of the meaning of subsection (b) when it references AS 09.25.110 and 09.25.120 on line 28, page 6 of SB 270. Number 453 DAVID STEBING, Assistant Attorney General, said that he believed that was the Public Records Act. CHAIRMAN RIEGER expressed concern with that section because he would not want medical information to be part of the public record. DAVID STEBING recalled that medical information was well protected by the Public Records Act; medical records are an exception to disclosure. SENATOR DUNCAN referred to page 11, lines 24-30 of SB 284 which speaks to public disclosure of medical and financial information. Confidentiality of information from the uniform claims form should be maintained. JAY LIVEY said that they could review the citations. He explained that the intent of that section was to provide protection of the client and the data they furnish. CHAIRMAN RIEGER informed the committee of the fingerprint bill which goes into great detail about the release and use of that information. He felt that the release and use of medical information probably needs some work. JAY LIVEY noted the problems of collecting data from self insured firms. The ERISA bill said that the state does not have jurisdiction over those kinds of health programs or benefits, therefore, in order to collect that data federal waivers would be needed. He said that this would be an issue under either bill. He did acknowledge that the data could be given voluntarily, but the state cannot pass mandatory regulations. CHAIRMAN RIEGER asked if epidemiological information was being gathered on computers. AL ZANGRI, Chief of the Bureau of Vital Statistics, stated that currently epidemiological data is computerized. In response to Chairman Rieger, he said that it does not require huge computer systems for the data being collected. He noted that more data would necessitate more power, more computers. CHAIRMAN RIEGER asked if a mainframe would be needed if one had 500,000 data bases and 50 pieces of information per person. AL ZANGRI said no. A mini computer could store, access and use that amount of data; however, a mainframe would be needed to analyze that data. SENATOR DUNCAN asked if there were systems already set up that could be contracted for use to save money. AL ZANGRI believed that would be possible. Currently, the Division of Medical Assistance contracts computer services with an outside firm. SENATOR DUNCAN expressed the need to analyze such things as the possibility that the more information contracted, the cheaper it would be per individual. He asked if a data collection system as in SB 270 was used, would the legislature be approached the next session with recommendations. Number 542 JAY LIVEY explained that any health care reform strategy would have its own set of special data requirements. In a single payer system with expenditure limits, demographic data would need to be collected. In a pay or play system with a subsidy, other types of data may be needed to locate that subsidy. Any health care reform system would also need to review comprehensive data needs. He reiterated that the total cost of any health care reform is not reflected in the fiscal note of SB 270. NANCY USERA expressed concern with comparing the provisions of SB 270 and SB 284. SB 270 does not commit to comprehensive reform as SB 284 does; SB 270 begins the process. She expressed her preference to deal with the conceptual approaches of the bills rather than compare specific provisions. These two bills do two very different things due to the difference in their approaches. SENATOR DUNCAN agreed with Ms. Usera's statements. He said that he did not understand why any new data collection system was needed in SB 270 since Mr. Livey had outlined what was needed under a universal coverage, single payer system. He inquired of what the data collection would discover under SB 270 that is not already known. JAY LIVEY identified that Alaska has some unique data collection issues. The Commission would recommend how to integrate the various data systems. He did not believe that they know how to accomplish integration of the various data systems. SENATOR ELLIS stated that the data collection system under SB 270 would make sense if nothing was going to be done. He asserted that a more comprehensive, far reaching data collection system would be required if any type of reform is attempted. He noted that people from across the political spectrum feel that something must be done about the health care situation. TAPE 94-19, SIDE B Number 593 Senator Ellis concluded that the approach of SB 270 was acceptable if the purpose was to continue with the status quo. NANCY USERA clarified that under SB 270 data would be collected to determine how best to collect data. She explained that SB 270 would not be necessary if a spending plan for the 1995 fiscal year could be created in order to accomplish the entire reform. JAY LIVEY noted that not a lot of information is being collecting from claims payment information. Once everyone uses the uniform claims form, that information would be available in a uniform way. The information from the data collection of SB 270 would be available for day to day operations which is a benefit in itself. CHAIRMAN RIEGER asked if SB 270 addressed the publication of fees or the availability of price lists. NANCY USERA said no, but pointed out that there was a draft amendment in the House to SB 270. The amendment would suggest a provision of rate lists upon the request of the consumer. CHAIRMAN RIEGER asked if the amendment for SB 270 would be similar to the language on page 13, lines 13-19 of SB 284. NANCY USERA stated that the language in SB 284 requires that rates be reported by the provider to the Corporation. Ms. Usera indicated that subsection (a) of section 21.58.230 is similar to the proposed amendment for SB 270, but the amendment does not include a provision like subsection (b). In summary, the amendment would require disclosure of rates to the consumer upon request, but the provider is not required to report that information to the Commission. SENATOR DUNCAN clarified that SB 284 requires disclosure to the consumer and the Corporation. He noted that there was a major difference between the two bills regarding disclosure of rates. Number 528 SENATOR SALO pointed out that the last sentence of subsection (a) on page 13, line 18 of SB 284 seems to promote uniformity regarding what providers place on a price list. She inquired if the amendment to SB 270 addressed that issue. NANCY USERA said no. SENATOR DUNCAN agreed with Senator Salo's point of difference and also the fact that under the amendment to SB 270 disclosure occurs only upon the consumer's request. He did not believe that a comparison could be made with a price list from only one physician. NANCY USERA read the amendment to SB 270 regarding disclosure of provider fees, the fine, and the appeal process. She explained that this amendment was a consumer effort to increase consumer involvement and to contain administrative costs. CHAIRMAN RIEGER inquired of the possibility of Anti-Trust Exemptions standing in the way of the publication of rates. He asked if the publication of price lists would have to be linked to an Anti-Trust Exemption. NANCY USERA was not familiar with that issue; however, she assumed that since the Department of Law helped draft the legislation that issue had been reviewed. JAY LIVEY said that he thought the Anti-Trust Exemption was related to whether someone called another similar company and asked their rates before publishing their own rates. He deferred to David Stebing. DAVID STEBING did not know. CHAIRMAN RIEGER asked if the committee had a general consensus that the publication of fees was a useful provision. SENATOR ELLIS stated that this would be a form of informed consumerism which could be useful in controlling health care costs. He considered that this issue was used to dress up SB 270. There are many other ways that informed consumerism can be used regarding health reform. He did agree that the issue was worthy of discussion. SENATOR LEMAN did not have a problem with the publication of fees. He emphasized the need to realize what the list may be worth, no two procedures would be alike which could be reflected in the price list. Perhaps, an estimate comforts consumers. SENATOR DUNCAN agreed with Senator Ellis. He noted that under SB 284 the publication of fees would be used to control costs through peer review and sanctions. He explained that the publication of fees would even out prices due to peer review. The price lists were not intended to encourage shopping around per se. He pointed out that page 3 of SB 284 requires that health care providers shall comply and there has been no indication that this would be a problem with the Anti-Trust Exemption. Number 444 NANCY USERA did not believe that the publication of fees would be any different than calling an airline and inquiring of their prices. She did note that SB 270 does require an estimate for a specific procedure for a specific individual. CHAIRMAN RIEGER said that he would have the publication of fees and the Anti-Trust Exemption reviewed. He expressed his belief that asking for prices in a medical situation would be awkward, so publishing fees seems to help. SENATOR ELLIS asked what would change between the social dynamics of the physician and the patient. CHAIRMAN RIEGER reiterated the awkwardness of asking a physician how much a procedure costs. SENATOR ELLIS did not see anything in the bill that would alleviate that discomfort. CHAIRMAN RIEGER said that a price list may help in some situations. JAY LIVEY pointed out that the Resources and Access Task Force reviewed the funding services for health care. The Task Force discovered that a significant amount of out of pocket money is spent in Alaska which leads to a different dynamic when purchasing health care. He believed that the publication of fees would have the most impact on those individuals who pay out of their pocket for services. SENATOR SALO believed that for patients to become more participatory in the economic efficiency decisions would be beneficial. The posting of rates under SB 270 and SB 284 would be beneficial in helping the patient make decisions. She pointed out that under SB 284, the Corporation would decide what procedure prices should be published; however, under SB 270, only the twenty most common procedure prices would be published. She believed that in both bills, price lists would be a good provision because it may promote patients becoming move involved in their own care. CHAIRMAN RIEGER agreed that anything promoting price sensitivity would probably be useful. Number 398 SENATOR DUNCAN indicated that the problem with this provision is whether or not the publication is required or upon consumer request. He explained that under SB 270, the consumer would still have to ask which Chairman Rieger had thought awkward. Without standardized reporting and data there is nothing meaningful. He noted that under SB 284, one of the charges of the Corporation would be to pursue federal waivers in any area where there may be difficulty. The federal Anti-Trust law which could cause problems should be covered by the waiver process. SENATOR ELLIS said that the Anti-Trust issue should be taken care of under the federal reform. The application of waivers would be addressed and not necessary. CHAIRMAN RIEGER mentioned that on Wednesday the public health issue of SB 270 and SB 284 would be addressed.
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