HEALTH CARE COST CONTAINMENT COUNCIL [28 PA. CODE CHS. 911 AND 912] Severity Methodology [29 Pa.B. 332] The Health Care Cost Containment Council (Council), under the authority of section 5(b) of the Pennsylvania Health Care Cost Containment Act (35 P. S. § 449.5(b)), proposes to amend §§ 911.1, 911.3, 911.4, 912.1, 912.3 and 912.31. The proposed amendments remove specific reference to a particular methodology currently used by the Council to afford the Council flexibility in selecting an alternative methodology for measuring provider quality and provider service effectiveness.
Purpose
The purpose of the proposed amendments is to give the Council greater flexibility in responding to the marketplace than the present regulations allow. The proposed amendments will enable the Council to change its vendor if the vendor fails to meet its contractual requirements.
Summary of Proposed Amendments
The proposed amendments remove specific reference to the MedisGroups methodology to afford the Council flexibility in selecting a methodology for measuring provider quality and provider service effectiveness.
Affected Parties
All data sources in this Commonwealth are currently required to use the MedisGroups methodology.
Paperwork Requirements
The proposed amendments will not impose additional paperwork on the private sector, the general public or the Commonwealth and its political subdivisions.
Fiscal Impact
The proposed amendments will have no fiscal impact on the regulated community, the State or local governments.
Effective Date
The proposed amendments will be effective upon publication of final-form regulations in the Pennsylvania Bulletin.
Sunset Date
The Council continually monitors its regulations. Therefore, no sunset date has been assigned.
Public Comment/Contact Person
Written comments, suggestions or objections will be accepted for 30 days after publication of the proposed amendments in the Pennsylvania Bulletin. Comments should be addressed to Marc P. Volavka, Executive Director, Health Care Cost Containment Council, Suite 400, 225 Market Street, Harrisburg, PA 17101.
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on January 5, 1999, the Council submitted a copy of the proposed rulemaking to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. In addition to submitting the proposed amendments, the Council has provided IRRC and the Committees with a copy of a detailed Regulatory Analysis Form, prepared by the Council. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, if IRRC has objections to any portion of the proposed amendments, it will notify the Council within 10 days of the close of the Committees' review period. The notification shall specify the regulatory review criteria which have not been met by that portion. The Regulatory Review Act specifies detailed procedures for review by the Council, the Governor and the General Assembly prior to final publication of the amendments.
MARC VOLAVKA,
Executive DirectorFiscal Note: 100-14. No fiscal impact; (8) recommends adoption.
Annex A TITLE 28. HEALTH AND SAFETY PART VI. HEALTH CARE COST CONTAINMENT COUNCIL CHAPTER 911. DATA SUBMISSION AND COLLECTION Subchapter A. STATEMENT OF POLICY § 911.1. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * [MedisGroups--A computerized system that calculates patient morbidity and patient severity according to a methodology developed by Mediqual Systems, Inc.
Patient morbidity--A score indicating the presence or absence of a major or minor morbidity as measured by MedisGroups defined methodology.]
Patient severity--A [score from 0 to 4 reflecting the] measure of severity of illness as defined by [MedisGroups methodology] the Council using [key] appropriate clinical findings, such as physician examinations, radiology findings, laboratory findings and pathology findings or any other relevant clinical factors.
* * * * * § 911.3. Council adoption of [MedisGroups derived index for patient severity upon admission and morbidity] methodology.
[The MedisGroups methodology for determining patient severity upon admission and patient morbidity is the nationally recognized methodology of quantifying and collecting data on provider quality and provider service effectiveness for purposes of sections 5 and 6 of the act (35 P. S. §§ 449.5 and 449.6). The following four options are acceptable to the Council:
(1) A hospital may purchase the full MedisGroups license, which includes information and services beyond the Council's requirements for calculating admission severity and morbidity.
(2) A hospital may purchase an abridged MedisGroups license, which includes only information and services required to provide the Council with patient severity upon admission and morbidity.
(3) A hospital may purchase a service contract for the abridged version from a provider licensee--for example, another hospital--of the full version of MedisGroups.
(4) A hospital may purchase a service contract with a nonprovider licensee of abridged Medis- Groups.]
Under section 6(d) of the act (35 P. S. § 449.6), the Council will adopt a methodology required to collect and report provider quality and provider service effectiveness. Periodically, the Council will review the methodology and, if a change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to the appropriate data sources within 30 days and at least 180 days before the change is to be implemented.
§ 911.4. Adoption of data elements to be reported to the Council.
* * * * * TABLE A PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM DATA ELEMENTS Field Data Element Definition * * * * * [21a Patient Severity Upon Admission A score from 0 to 4 reflecting the severity of illness as defined by MedisGroups methodology using key clinical findings, such as physical examination, radiology findings, laboratory findings, and pathology findings. 21b Patient Morbidity A score indicating the presence or absence of a major or minor morbidity as measured by MedisGroups defined methodology.] * * * * * CHAPTER 912. DATA REPORTING REQUIREMENTS Subchapter A. GENERAL PROVISIONS § 912.1. Legal base and purpose.
* * * * * [(c) The Council hereby adopts the MedisGroups' methodology for determining patient morbidity and patient severity upon admission to a hospital for purposes of quantifying and collecting data on provider quality and provider service effectiveness. The MedisGroups' methodology is available to hospitals either as the full MedisGroups' system or the MedisPA system.]
§ 912.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * [MedisGroups--A computerized system that calculates patient morbidity and patient severity according to a methodology developed by MediQual Systems, Inc.
MedisPA--The abridged version of MedisGroups using the MedisGroups' methodology.
Patient morbidity--A score indicating the presence or absence of a major or minor morbidity as measured by MedisGroups' defined methodology.
Patient severity--A score from 0 to 4 reflecting the severity of illness as defined by MedisGroups' methodology using key clinical findings, such as physician examinations, radiology findings, laboratory findings and pathology findings.]
* * * * * Subchapter B. PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM SUBMISSION SCHEDULES EXCEPTIONS § 912.31. Principle.
The Council may, within its discretion and for good reason, grant exceptions to sections within this chapter when the policy and objectives of this chapter and the act are otherwise met. [Failure of MediQual, Inc. to perform shall be reason for the Council to grant an exception to hospitals under § 912.22(1)(iii) and (2) (relating to data element submission schedules).]
[Pa.B. Doc. No. 99-80. Filed for public inspection January 15, 1999, 9:00 a.m.]
