SENATE FILE 117

BY  HATCH and BOLKCOM

A BILL FOR

An Act relating to health care and policy, and health care infrastructure and integration of public and private programs, and related matters, and including effective date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

DIVISION I

HEALTH CARE INFRASTRUCTURE —— 

DIVISION OF HEALTH POLICY
   Section 1.  Section 135.61, subsection 17, Code 2011, is amended by striking the subsection.
   Sec. 2.  Section 135.61, subsection 21, Code 2011, is amended to read as follows:
   21.  “Outpatient surgical facility” means a medical facility which as its primary function provides, through an organized medical staff and on an outpatient basis to patients who are generally ambulatory, that provides surgical procedures not ordinarily performed in a private physician’s office, but not requiring twenty-four hour hospitalization, and which is neither a part of a hospital nor the private office of a health care provider who there engages in the lawful practice of surgery in at least one dedicated, fully equipped operating room to patients who are admitted to and discharged from the facility within the same day, that meets staffing and equipment requirements necessary to ensure patient safety and quality care.“Outpatient surgical facility” includesa facility certified or seeking certification as an ambulatory surgical center, under the federal Medicare program or under the medical assistance program established pursuant to chapter 249A.
   Sec. 3.  Section 135.63, subsection 1, Code 2011, is amended to read as follows:
   1.  A new institutional health service or changed institutional health service shall not be offered or developed in this state without prior application to the department for and receipt of a certificate of need, pursuant to this division. The application shall be made upon forms furnished or prescribed by the department and shall contain such information as the department may require under this division. The application shall be accompanied by a fee equivalent to three-tenths of one percent of the anticipated cost of the project with a minimum fee of six hundred dollars and a maximum fee of twenty-one thousand dollars. The fee shall be remitted retained by the department to the treasurer of state, who shall place it in the general fund of the state for administration and fulfillment of the duties of the division. Revenues retained by the division under this section shall be considered repayment receipts as defined in section 8.2. Notwithstanding section 8.33, moneys retained by the department pursuant to this section are not subject to reversion to the general fund of the state. If an application is voluntarily withdrawn within thirty calendar days after submission, seventy-five percent of the application fee shall be refunded; if the application is voluntarily withdrawn more than thirty but within sixty days after submission, fifty percent of the application fee shall be refunded; if the application is withdrawn voluntarily more than sixty days after submission, twenty-five percent of the application fee shall be refunded. Notwithstanding the required payment of an application fee under this subsection, an applicant for a new institutional health service or a changed institutional health service offered or developed by an intermediate care facility for persons with mental retardation or an intermediate care facility for persons with mental illness as defined pursuant to section 135C.1 is exempt from payment of the application fee.
   Sec. 4.  Section 135.63, subsection 2, paragraph l, Code 2011, is amended by striking the paragraph.
   Sec. 5.  Section 135.63, subsection 2, paragraphs n and o, Code 2011, are amended to read as follows:
   n.  Hospice services provided by a hospital, notwithstanding any provision in this division to the contrary.
   o.  The change in ownership, licensure, or organizational structure, or designation of thetype of institutional health facility if the health services offered by the successor institutional health facility are unchanged. This exclusion is applicable only if the institutional health facility consents to the change in ownership, licensure, or organizational structure, or designation of the type of institutional health facility and ceases offering the health services simultaneously with the initiation of the offering of health services by the successor institutional health facility.
   Sec. 6.  Section 135.163, Code 2011, is amended to read as follows:
   135.163Health and long-term care access Division of health policy.
   1.  The A division of health policy is created in the department shall coordinate to integrate public and private efforts to develop in formulating and implementing a state health policy agenda to accomplish all of the following:
   a.  Develop and maintain an appropriate health care delivery infrastructure and a stable, well-qualified, diverse, and sustainable health care workforce in this state. The health care delivery infrastructure and the health care workforce shall address the broad spectrum of health care needs of Iowans throughout their lifespan including long-term care needs.
   b.  Establish a methodology and process to achieve cultural transformation that emphasizes health and wellness by removing barriers across the spectrum of personal, professional, and community constructs to empower individual behavioral and systemic change.
   c.  Provide for the collection, analysis, and use of cost and quality data to inform decisions by individual consumers, businesses, and policymakers in determining the most effective and efficient use of resources in arriving at economically sustainable health care outcomes.
   2.  The division administrator shall be a health economist. The administrator may utilize existing councils and workgroups as necessary and shall establish a technical advisory council to assist in the development of policy priorities and the strategic plan described in subsection 3. The technical advisory council shall include but is not limited to representatives of the university of Iowa college of public health and the university of Iowa public policy center, health planners, health care consumers, health care purchasers, state and local agencies that regulate entities involved in health care, health care providers, and health care facilities.
   3.  The department health policy division shall, at a minimum, do all of the following:
   1.  a.  Develop a strategic plan for health care delivery infrastructure and health care workforce resources in this state in accordance with section 135.164.  The division shall act as an ongoing resource to the health facilities council in evaluating and updating the certificate of need program.
   2.  b.  Provide for the continuous collection of data to provide a basis for health care strategic planning and health care policymaking decision making by individual consumers, businesses, and policymakers.
   3.  Make recommendations regarding the health care delivery infrastructure and the health care workforce that assist in monitoring current needs, predicting future trends, and informing policymaking.
   c.  Develop and implement a blueprint to make Iowa one of the healthiest states by the year 2014.
   Sec. 7.  Section 135.164, Code 2011, is amended to read as follows:
   135.164  Strategic plan.
   1.Development of a strategic plan.  The division shall develop a strategic plan for health care delivery infrastructure and health care workforce resources. The strategic plan shall describe the existing health care system, describe and provide a rationale for the desired health care system, provide an action plan for implementation of changes necessary to achieve the desired health care system, and provide methods to evaluate the system. The plan shall incorporate expenditure control methods and integrate criteria for evidence-based health care. The department division shall do all of the following in developing the strategic plan for health care delivery infrastructure and health care workforce resources:
   a.  Conduct strategic health planning activities related to preparation of the strategic plan.
   b.  Develop a computerized system for accessing, analyzing, and disseminating data relevant to strategic health planning. The department division may enter into data sharing agreements and contractual arrangements necessary to obtain or disseminate relevant data.
   c.  Conduct research and analysis or arrange for research and analysis projects to be conducted by public or private organizations to further the development of the strategic plan.
   d.  Establish a technical advisory committee to assist in the development of the strategic plan. The members of the committee may include but are not limited to health economists, representatives of the university of Iowa college of public health, health planners, representatives of health care purchasers, representatives of state and local agencies that regulate entities involved in health care, representatives of health care providers and health care facilities, and consumers.
   2.Guiding principles.  The strategic plan shall include statewide health planning policies and goals related to the availability of health care facilities and services, the availability of appropriate health care workforce resources, health and wellness promotion, the quality of care, and the cost of care. The policies and goals shall be based on the following principles:
   a.  That a strategic health planning process, responsive to changing health and social needs and conditions, is essential to the health, safety, and welfare of Iowans. The process shall be reviewed and updated as necessary to ensure that the strategic plan addresses all of the following:
   (1)  Promoting and maintaining the health of all Iowans.
   (2)  Providing accessible health care services through the maintenance of an adequate appropriate and sustainable supply of health facilities and an adequate a competent workforce reserve.
   (3)  Controlling excessive increases in costs.
   (4)  Applying specific quality criteria and population health indicators.
   (5)  Recognizing prevention and wellness as priorities in health care programs to improve quality and reduce costs and promoting prevention and wellness across all sectors to improve individual well-being and health outcomes, while reducing human and financial costs.
   (6)  Addressing periodic priority issues including disaster planning, public health threats, and public safety dilemmas.
   (7)  Coordinating health care delivery and resource development efforts among state agencies including those tasked with facility, services, and professional provider licensure; state and federal reimbursement; health service utilization data systems; and others.
   (8)  Recognizing long-term care as an integral component of the health care delivery infrastructure and as an essential service provided by the health care workforce.
   b.  That both consumers and providers throughout the state must be involved in the health planning process, outcomes of which shall be clearly articulated and available for public review and use.
   c.  That the supply of a health care service has a substantial impact on utilization of the service, independent of the effectiveness, medical necessity, or appropriateness of the particular health care service for a particular individual.
   d.  That given that health care resources are not unlimited, the impact of any new health care service or facility on overall health expenditures in this state must be considered.
   e.  That excess capacity of health care services and facilities places an increased economic burden on the public.
   f.  That the likelihood that a requested new health care facility, service, or equipment will improve health care quality and outcomes must be considered.
   g.  That development and ongoing maintenance of current and accurate health care information and statistics related to cost and quality of health care and projections of the need for health care facilities and services are necessary to developing an effective health care planning strategy.
   h.  That the certificate of need program as a component of the health care planning regulatory process must balance considerations of access to quality care at a reasonable cost for all Iowans, optimal use of existing health care resources, fostering of expenditure control, and elimination of unnecessary duplication of health care facilities and services, while supporting improved health care outcomes.
   i.  That strategic health care planning must be concerned with the stability of the health care system, encompassing health care financing, quality, and the availability of information and services for all residents.
   3.Components of the strategic plan.  The health care delivery infrastructure and health care workforce resources strategic plan developed by the department division shall include all of the following:
   a.Assessment and objectives.  A health care system assessment and objectives component that does all of the following:
   (1)  Describes stateand regional population demographics, health status indicators, and trends in health status and health care needs.
   (2)  Identifies key policy objectives for the state health care system related to access to care, health care outcomes, quality, and cost-effectiveness.
   b.Certificate of need determinations.  A health care facilities and services plan that assesses the demand for health care facilities and services to inform state health care planning efforts and direct certificate of need determinations for those facilities and services subject to certificate of need. The plan shall include all of the following:
   (1)  An inventory ofeach geographic region’s existing health care facilities and services.
   (2)  Projections of the need for each category of health care facility and service, including those subject to certificate of need.
   (3)  Policies to guide the addition of new or expanded health care facilities and services to promote the use of quality, evidence-based, cost-effective health care delivery options, including any recommendations for criteria, standards, and methods relevant to the certificate of need review process.
   (4)  An assessment of the availability of health care providers, public health resources, transportation infrastructure, and other considerations necessary to support the needed health care facilities and services in each region.
   (5)  An analysis of and recommended revisions to division VI of this chapter to direct certificate of need determinations in a manner that reflects the statewide health planning policies and goals specified in subsection 2. The analysis shall specifically address inclusions in and exclusions from the certificate of need process and whether the exclusions comport with the policies and goals specified in subsection 2.
   c.Data resources.  A health care data resources plan that identifies data elements necessary to properly conduct planning activities and to review certificate of need applications, including data related to inpatient and outpatient utilization and outcomes information, and financial and utilization information related to charity care, quality, and cost. The plan shall provide all of the following:
   (1)  An inventory of existing data resources, both public and private, that store and disclose information relevant to the health care planning process, including information necessary to conduct certificate of need activities. The plan shall identify any deficiencies in the inventory of existing data resources and the data necessary to conduct comprehensive health care planning activities. The plan may recommend that the department division be authorized to access existing data sources and conduct appropriate analyses of such data or that other agencies expand their data collection activities as statutory authority permits. The plan may identify any computing information technology infrastructure deficiencies that impede the proper storage, transmission, and analysis of health care planning data.
   (2)  Recommendations for increasing the availability of data related to health care planning to provide greater community involvement in the health care planning process and consistency in data used for certificate of need applications and determinations. The plan shall also integrate the requirements for annual reports by hospitals and health care facilities pursuant to section 135.75, the provisions relating to analyses and studies by the department pursuant to section 135.76, the data compilation provisions of section 135.78, and the provisions for contracts for assistance with analyses, studies, and data pursuant to section 135.83.
   d.  All-payer claims database plan.  A plan to establish an all-payer claims database to provide for the collection and analysis of claims data from multiple payers of health care. The plan shall establish the goals of the database which may include but are not limited to determining health care utilization patterns and rates; identifying gaps in prevention and health promotion services; evaluating access to care; assisting with benefit design and planning; analyzing statewide and local health care expenditures by provider, employer, and geography; informing the development of payment systems for providers; and establishing clinical guidelines related to quality, safety, and continuity of care. The plan shall identify a standard means of data collection, statutory changes necessary to the collection and use of the data, and the types of claims for which collection of data is required which may include but are not limited to eligibility data; provider information; medical data; private and public medical, pharmacy, and dental claims data; and other appropriate data. The plan shall also include an implementation and maintenance schedule including a proposed budget and funding plan and vision for the future.
   d.e.  Evaluation of trends.  An assessment of emerging trends in health care delivery and technology as they relate to access to health care facilities and services, quality of care, and costs of care. The assessment shall recommend any changes to the scope of health care facilities and servicescovered by the certificate of need program that may be warranted by these emerging trends. In addition, the assessment may recommend any changes to criteria used by the department to review certificate of need applications, as necessary.
   e.f.  Rural health care resources plan.  A rural health care resources plan to assess the availability of health resources in rural areas of the state, assess the unmet needs of these communities, and evaluate how federal and state reimbursement policies can be modified, if necessary, to more efficiently and effectively meet the health care needs of rural communities. The plan shall consider the unique health care needs of rural communities, the adequacy of the rural health care workforce, and transportation needs for accessing appropriate care.
   f.g.  Workforce resources plan.  A health care workforce resources plan to assure a competent, diverse, and sustainable health care workforce in Iowa and to improve access to health care in underserved areas and among underserved populations. The plan shall include the establishment of an advisory council to inform and advise the department and policymakers regarding issues relevant to the health care workforce in Iowa. The health care workforce resources plan shall recognize long-term care as an essential service provided by the health care workforce.
   h.  Provider payment system plan.  The provider payment system plan to provide recommendations to reform the health care provider payment system as an effective way to promote coordination of care, lower costs, and improve quality. The plan shall analyze and make recommendations regarding but not limited to accountable care organizations, a global payment system, or an episode of care payment system.
   i.  Blueprint for a healthy Iowa.  A blueprint for a healthy Iowa to provide a methodology and process for cultural transformation that emphasizes health and wellness by removing barriers across the spectrum of personal, professional, and community constructs to empower individual behavioral and systemic change. The blueprint shall provide for coordination of existing public and private health and wellness initiatives and shall include recommendations for replication of health and wellness initiatives for which evidence-based success has been demonstrated.
   j.  Long-term living plan.  A long-term living plan that reflects the intent specified in section 231F.1 in a manner that most effectively and efficiently meets the needs of Iowa’s population. The plan may include recommendations for modification of requirements for certificate of need determinations, health care workforce requirements, and funding to promote the specified intent.
   4.  The department shall submit the initial statewide health care delivery infrastructure and resources strategic plan to the governor and the general assembly by January 1, 2010, and shall submit an updated strategic plan to the governor and the general assembly every two years thereafter.
   4.  The division shall develop a timeline for completion and submission of the various components of the strategic plan to the governor and the general assembly and shall submit the proposed timeline to the governor and the general assembly by October 1, 2011. The components relating to certificate of need determinations, the all-payer claims database, and the provider payment system shall be completed and submitted to the governor and the general assembly by October 1, 2011. The division may contract with public or private entities to provide impartial, evidence-based research and analysis in developing these components of the strategic plan.
   Sec. 8.  EFFECTIVE UPON ENACTMENT.  This division of this Act, being deemed of immediate importance, takes effect upon enactment.

DIVISION II

MEDICATION THERAPY MANAGEMENT
   Sec. 9.  NEW SECTION.  8A.440  Medication therapy management.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Eligible employee” means an employee of the state including an employee of the state board of regents or institutions under the state board of regents for whom group health plans are established pursuant to chapter 509A providing for third-party payment or prepayment for health or medical expenses, and employees of a governmental subdivision for whom the governmental subdivision provides for third-party payment or prepayment for health or medical expenses.
   b.  “Medication therapy management” means a systematic process performed by a licensed pharmacist, designed to optimize therapeutic outcomes through improved medication use and reduced risk of adverse drug events, including all of the following services:
   (1)  A medication therapy review and in-person consultation relating to all medications, vitamins, and herbal supplements currently being taken by an eligible individual.
   (2)  A medication action plan, subject to the limitations specified in this section, communicated to the individual and the individual’s primary care physician or other appropriate prescriber to address safety issues, inconsistencies, duplicative therapy, omissions, and medication costs. The medication action plan may include recommendations to the prescriber for changes in drug therapy.
   (3)  Documentation and follow-up to ensure consistent levels of pharmacy services and positive outcomes.
   2.
  a.  The department shall continue to contract for the provision of medication therapy management services for eligible employees as initially required pursuant to 2010 Iowa Acts, chapter 1193, section 166, and shall amend the contract to include, beginning July 1, 2011, eligible employees who are employees of the state board of regents and institutions under the state board of regents and employees of governmental subdivisions, at the election of the governmental subdivision, who meet any of the following criteria:
   (1)  An individual who takes four or more prescription drugs to treat or prevent two or more chronic medical conditions.
   (2)  An individual with a prescription drug therapy problem who is identified by the prescribing physician or other appropriate prescriber, and referred to a pharmacist for medication therapy management services.
   (3)  An individual who meets other criteria established by the third-party payment provider contract, policy, or plan.
   b.  The department shall utilize an advisory committee comprised of an equal number of physicians and pharmacists to provide advice and oversight regarding the contract and evaluation processes. The department shall appoint the members of the advisory committee from designees of the Iowa pharmacy association, the Iowa medical society, and the Iowa osteopathic medical association.
   c.  The contract shall require the company to provide annual reports to the general assembly detailing the costs, savings, estimated cost avoidance and return on investment, and patient outcomes related to the medication therapy management services provided. The company shall guarantee demonstrated annual savings, including any savings associated with cost avoidance at least equal to the program’s costs with any shortfall amount refunded to the state. The department and the company shall agree on the terms, conditions, and applicable measurement standards associated with the demonstration of savings. The department shall verify that the demonstrated savings reported by the company were attained in accordance with the agreed upon measurement standards. The company shall be prohibited from using the company’s employees to provide the medication therapy management services and shall instead be required to contract with licensed pharmacies, pharmacists, or physicians.
   d.  The fees for pharmacist-delivered medication therapy management services shall be separate from the reimbursement for prescription drug product or dispensing services; shall be determined by each third-party payment provider contract, policy, or plan; and must be reasonable based on the resources and time required to provide the service.
   e.  A fee shall be established for physician reimbursement for services delivered for medication therapy management as determined by each third-party payment provider contract, policy, or plan, and must be reasonable based on the resources and time required to provide the service.
   f.  If any part of the medication therapy management plan developed by a pharmacist incorporates services which are outside the pharmacist’s independent scope of practice including the initiation of therapy, modification of dosages, therapeutic interchange, or changes in drug therapy, the express authorization of the individual’s physician or other appropriate prescriber is required.
   Sec. 10.  REPEAL.  2010 Iowa Acts, chapter 1193, section 166, is repealed.
   Sec. 11.  EFFECTIVE UPON ENACTMENT.  This division of this Act, being deemed of immediate importance, takes effect upon enactment.

DIVISION III

DIRECTIVES FOR INTEGRATION OF PUBLIC AND PRIVATE PROGRAMS
   Sec. 12.  PLAN FOR SEAMLESS PUBLIC AND PRIVATE PROGRAM INTEGRATION IN IOWA HEALTH BENEFIT EXCHANGE.  The department of human services, division of insurance of the department of commerce, department of public health, department of revenue, department of workforce development, and other appropriate agencies, shall develop a plan to meet the requirements of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, relating to a health benefit exchange. The plan shall address issues relating to eligibility determinations for Medicaid, hawk-i, and tax credit subsidies; information technology and process reengineering; necessary policy, statutory, and regulatory changes; financing; and tools and strategies necessary for implementation. The plan shall provide for integration and seamless operation of the eligibility system, which shall be housed within the department of human services, with the Iowa health benefit exchange, if created. The departments shall submit a joint plan to the joint appropriations subcommittee on health and human services by October 15, 2011.
   Sec. 13.  BENCHMARK PLAN DEVELOPMENT —— ANALYSIS OF INCLUSION OF BEHAVIORAL HEALTH BENEFITS.  The department of human services shall analyze how the inclusion of behavioral health benefits in a benchmark plan developed under the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, would impact the delivery and financing of behavioral health services in the state. The department shall report its findings to the joint appropriations subcommittee on health and human services no later than October 15, 2011.
   Sec. 14.  FEDERAL FUNDING OPPORTUNITIES.  The department of human services, department of public health, division of insurance of the department of commerce, and other affected state agencies shall pursue all federal funding opportunities under the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, including but not limited to funding relating to implementation funding for the health benefit exchange and eligibility system planning and implementation. The departments shall coordinate efforts to the maximum extent possible and shall report their activities on a monthly basis to the joint appropriations subcommittee on health and human services.
   Sec. 15.  EFFECTIVE UPON ENACTMENT.  This division of this Act, being deemed of immediate importance, takes effect upon enactment.
EXPLANATION
   This bill relates to health care and health policy.
   Division I of the bill relates to health care infrastructure and creates a division of health policy within the department of public health (DPH). The bill amends certificate of need exclusions relating to outpatient surgical facilities, hospitals, and nursing facilities. The bill also provides for retention of certificate of need fees by the department for administration of the program. Current law directs DPH to coordinate public and private efforts to develop and maintain an appropriate health care infrastructure and workforce. Current law also directs DPH to develop a strategic plan to address various components of the health care infrastructure and workforce. Current law directs DPH to utilize a technical advisory committee to assist in the development of the strategic plan.
   Under the bill, the division of health policy is created in DPH to fulfill the duties of the department in integrating public and private efforts in formulating and implementing a state health policy agenda that addresses the health care infrastructure and workforce, cultural transformation to emphasize health and wellness across all sectors, and the collection, analysis, and use of cost and quality data. The bill provides that the administrator of the division is to be a health economist and directs the division to establish a technical advisory council to assist the division in development of policy priorities and the strategic plan.
   The bill specifies the duties of the division relating to development of a strategic plan, collection of data, and development of a blueprint to make Iowa one of the healthiest states by the year 2014.
   The bill specifies the components of the strategic plan including the addressing of a health care system assessment and objectives; certificate of need determinations; data resources; an all-payer claims database; evaluation of trends; rural health care resources; workforce resources; a provider payment system; a blueprint for a healthy Iowa; and long-term living.
   The bill directs the division of health policy to develop a timeline for completion and submission of the components of the strategic plan to the governor and the general assembly. The bill directs the division to complete and submit the components relating to certificate of need determinations, the all-payer claims database, and the provider payment system to the governor and the general assembly by October 1, 2011. The bill authorizes the division to contract with public or private entities to provide impartial, evidence-based research and analysis in developing the components of the strategic plan.
   Division I takes effect upon enactment.
   Division II of the bill relates to medication therapy management. The bill directs that the pilot program for medication therapy management implemented on July 1, 2010, for eligible state employees is to be expanded and the contract for the program amended to include employees of the state board of regents or institutions under the state board of regents and employees of governmental subdivisions at the election of the governmental subdivision. The bill repeals the pilot program and codifies the newly expanded program. Division II takes effect upon enactment.
   Division III of the bill provides directives to state departments relative to provisions in the federal Patient Protection and Affordability Act.
   Division III directs the department of human services, division of insurance, department of public health, department of revenue, department of workforce development, and other appropriate agencies, to develop a plan to meet the requirements of the federal Act relating to a health benefit exchange. The plan is to address issues relating to eligibility determinations for Medicaid, hawk-i, and tax credit subsidies; information technology and process reengineering; necessary policy, statutory, and regulatory changes; financing; and tools and strategies necessary for implementation. The plan is to provide for integration and seamless operation of the eligibility system, which shall be housed within the department of human services, with the Iowa health benefit exchange, if created.
   Division III directs the department of human services to analyze how the inclusion of behavioral health benefits in a benchmark plan under the federal Patient Protection and Affordable Care Act would impact the delivery and financing of behavioral health services in the state. The department is to report its findings to the joint appropriations subcommittee on health and human services no later than October 15, 2011.
   Division III also directs the department of human services, department of public health, division of insurance, and other affected state agencies to pursue all federal funding opportunities under the federal Act including but not limited to funding relating to implementation funding for the health benefit exchange and eligibility system planning and implementation. The bill directs the departments to coordinate efforts to the maximum extent possible and to report their activities on a monthly basis to the joint appropriations subcommittee on health and human services.
   Division III takes effect upon enactment.