Transparency and Accountability in Health Care Costs and Prices Act of 2020

I 116TH CONGRESS 2D SESSION H. R. 6004 To amend title XXVII of the Public Health Service Act to require the Secretary of Health and Human Services to establish a grant program for purposes of facilitating State efforts to establish or maintain all- payer claims databases, and for other purposes. IN THE HOUSE OF REPRESENTATIVES FEBRUARY 27, 2020 Mr. LIPINSKI introduced the following bill; which was referred to the Com- mittee on Energy and Commerce, and in addition to the Committee on Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XXVII of the Public Health Service Act to require the Secretary of Health and Human Services to establish a grant program for purposes of facilitating State efforts to establish or maintain all-payer claims databases, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; FINDINGS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Transparency and Accountability in Health Care Costs 5 and Prices Act of 2020’’. 6 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 6004 IH (b) FINDINGS.—Congress finds the following: 1 (1) According to official estimates published by 2 the Centers for Medicare & Medicaid Services, 3 Americans spent a total of $3.6 trillion on health 4 care in 2018, or $11,172 per person. 5 (2) Spending on hospital care services reached 6 $1.2 trillion in 2018 and rose by 4.5 percent from 7 the previous year. This growth occurred even as 8 Americans made fewer hospital visits because of 9 growth in hospital prices. 10 (3) Spending on physician visits and clinical 11 services reached $725.6 billion in 2018 and rose by 12 4.1 percent from the previous year. 13 (4) Spending on prescription drugs reached 14 $335 billion in 2018 and rose by 2.5 percent from 15 the previous year. 16 (5) According to a 2019 analysis of a subset of 17 commercial insurance claims by the independent, 18 non-partisan Health Care Cost Institute, prices for 19 common medical services could vary up to 25 times 20 between different metro areas and up to 39 times 21 for the same service within the same metro area. 22 (6) A 2015 analysis of a subset of commercial 23 insurance claims by Yale, University of Pennsyl- 24 vania, Carnegie Mellon, and MIT researchers found 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 6004 IH that even within one hospital, prices for certain com- 1 mon services like lower limb MRIs, knee replace- 2 ments, and colonoscopies could vary by 23.5 percent 3 on average depending on which insurer covered the 4 patient. 5 (7) Information about contracts between pro- 6 viders and insurers available to researchers, policy- 7 makers, and the public is limited or incomplete be- 8 cause these contracts frequently prohibit disclosure 9 of information about how providers are paid. 10 (8) All-payer claims databases (APCDs) are 11 large-scale databases increasingly adopted by States 12 to collect health care claims data across different 13 payers such as private insurers, government em- 14 ployee health plans, Medicare, and Medicaid. 15 (9) APCD data can be shared with vetted and 16 authorized users to make it easier to track trends in 17 health care prices, create tools for consumers to 18 check price and quality, assist employers and health 19 plans in making more informed decisions when de- 20 veloping employer-sponsored health plans, test new 21 ideas for holding down health care costs, and guide 22 policymakers in developing health care policy. 23 (10) In 2019, the independent, non-partisan 24 RAND Corporation published the first broad-based 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 6004 IH study reporting prices paid by private health plans 1 to hospitals identified by name. This important 2 study tracked important disparities in price trends 3 across the nation, with relative prices increasing rap- 4 idly from 2015 to 2017 for hospitals in some States, 5 while falling in others. This work was made possible 6 in part through the use of data from APCDs in New 7 Hampshire and Colorado. 8 (11) Since 2015, Oregon has used data from its 9 APCD to review insurers’ proposed premium rates, 10 including determining whether or not proposed pre- 11 miums are excessive. Oregon has also used its 12 APCD to create an annual report on hospital reim- 13 bursement variations from different insurers. 14 (12) Minnesota and Virginia have used data 15 from their APCDs to shine a spotlight on spending 16 for low-value—possibly even unnecessary—medical 17 services. 18 (13) Washington State has used data from its 19 APCD to create the Washington 20 HealthCareCompare tool that helps patients learn 21 about local prices for medical services at local doc- 22 tors’ offices, hospitals, and outpatient centers, and 23 puts those prices in context by highlighting what 24 kinds of prices can be considered typical, low, or 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 6004 IH high. Additional States that have developed price 1 transparency tools from their APCDs include New 2 Hampshire, Maine, Massachusetts, Colorado, Mary- 3 land, and Rhode Island. 4 (14) According to the APCD Council, a learn- 5 ing collaborative of public and private organizations 6 working on developing and establishing APCDs, at 7 least 18 States have enacted State laws establishing 8 APCDs. 9 (15) While many States have or are considering 10 establishing APCDs, current APCDs vary in the 11 types of data collected, the types of users allowed to 12 access the data, the types of data that can be pub- 13 lished, and how much authorized users are charged 14 to access the data. 15 (16) A 2016 Supreme Court decision, Gobeille 16 v. Liberty Mutual Insurance Co., prohibited States 17 from requiring claim submissions to APCDs from 18 large employers that pay for health benefits directly 19 instead of purchasing health coverage from insur- 20 ance companies. This limited the data that States 21 could mandate for inclusion in an APCD. 22 (17) Supporting the establishment of APCDs is 23 an important way to promote transparency and un- 24 derstanding of overall health care spending. 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 6004 IH (18) State APCDs should be encouraged to col- 1 lect data from more types of payers; make it easier 2 and more affordable for APCD data to be used to 3 assist patients and providers in making informed 4 choices about care; make it easier and more afford- 5 able for APCD data to be used for efforts to bring 6 health care cost growth under control and improve 7 insurance coverage; and permit their data to be used 8 to report provider-level prices. 9 SEC. 2. REQUIRING THE SECRETARY OF HEALTH AND 10 HUMAN SERVICES TO ESTABLISH A GRANT 11 PROGRAM FOR PURPOSES OF FACILITATING 12 STATE EFFORTS TO ESTABLISH OR MAINTAIN 13 ALL-PAYER CLAIMS DATABASES. 14 Part C of title XXVII of the Public Health Service 15 Act (42 U.S.C. 300gg–91 et seq.) is amended by adding 16 at the end the following new section: 17 ‘‘SEC. 2795. ALL-PAYER CLAIMS DATABASE GRANT PRO- 18 GRAM. 19 ‘‘(a) IN GENERAL.—Not later than 1 year after the 20 date of the enactment of this section, the Secretary shall 21 establish a grant program (in this section referred to as 22 the ‘program’) for purposes of awarding grants to States 23 to facilitate such States in establishing or maintaining an 24 all-payer claims database. 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 6004 IH ‘‘(b) USE OF FUNDS.—A State use funds from a 1 grant awarded under the program for any of the following: 2 ‘‘(1) To establish a State or regional all-payer 3 claims database or to maintain an existing such 4 database. 5 ‘‘(2) To expand the capabilities of an existing 6 such database (such as through improving the collec- 7 tion of data contained in such database or improving 8 the dissemination of such data). 9 ‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 10 under the program, a State (or compact of States) shall 11 submit to the Secretary an application at such time, in 12 such manner, and containing such information as the Sec- 13 retary may specify. Such information shall include the fol- 14 lowing: 15 ‘‘(1) A specification of how the State (or com- 16 pact of States) will ensure uniform data collection 17 through the all-payer claims database. 18 ‘‘(2) A description of privacy and security pro- 19 tections for data submitted to such database, includ- 20 ing a specification of how the State (or compact of 21 States) will ensure that— 22 ‘‘(A) no individually identifiable health in- 23 formation is disclosed to the public; 24 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 8 •HR 6004 IH ‘‘(B) access to such information is limited 1 to staff with appropriate security and privacy 2 training; 3 ‘‘(C) effective security standards for trans- 4 ferring such data or making such data available 5 to authorized uses of such database are main- 6 tained; 7 ‘‘(D) a process for providing access to such 8 data for such users is secure and maintains the 9 confidentiality of any individually identifiable 10 health information is established; 11 ‘‘(E) such database adheres to best secu- 12 rity practices relating to the management and 13 use of such data, consistent with any applicable 14 Federal law; and 15 ‘‘(F) users of such database are prohibited 16 from attempting to reidentify such data and pe- 17 nalized for any such attempt. 18 ‘‘(3) A specification of whether submission of 19 data to such database is (or will be) mandatory or 20 voluntary. 21 ‘‘(4) A specification of which type of entities 22 (such as group health plans, health insurance issues, 23 nonfederal governmental plans, and Federal health 24 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 9 •HR 6004 IH care programs) are (or will be) submitting such data 1 to such database. 2 ‘‘(5) A description of the types of claims in- 3 cluded in such database (such as medical claims, 4 pharmacy claims, and dental claims). 5 ‘‘(6) A description of the data release policy in 6 effect (or proposed to be put into effect) with respect 7 to data contained in such database, including a de- 8 scription of the type of users who are (or will be) au- 9 thorized to access such data (such as employers, em- 10 ployee organizations, health care providers, research- 11 ers, and policymakers). 12 ‘‘(7) Any other information determined appro- 13 priate by the Secretary. 14 ‘‘(d) AWARD PRIORITY.—In making grants under the 15 program, the Secretary shall prioritize applications sub- 16 mitted under subsection (c) that demonstrate any of the 17 following (with higher priority being given to applications 18 that demonstrate the greatest number of the following): 19 ‘‘(1) The all-payer claims database to be estab- 20 lished, maintained, or expanded through such grant 21 requires mandatory reporting of claims data to such 22 database. 23 ‘‘(2) Such database will transition to require 24 such mandatory reporting. 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 10 •HR 6004 IH ‘‘(3) Data contained in such database is (or will 1 be) easily accessible and affordable for users to ac- 2 cess. 3 ‘‘(4) Such database permits (or will permit) 4 such data to be viewed in a provider-specific manner. 5 ‘‘(5) A history of (or planned) partnerships 6 with users of such database to facilitate the use of 7 such data in— 8 ‘‘(A) informing individuals about the cost, 9 quality, and value of health care; 10 ‘‘(B) assisting health care providers, in- 11 cluding hospitals, in working with individuals to 12 make informed decisions regarding health care; 13 ‘‘(C) enabling health care providers, in- 14 cluding hospitals, and communities to improve 15 the furnishing of items and services and health 16 outcomes for individuals through comparisons 17 of such outcomes with other such providers and 18 hospitals; 19 ‘‘(D) enabling entities that pay for items 20 and services, including employers, employee or- 21 ganizations, group health plans, and health in- 22 surance issuers, to develop value-based pur- 23 chasing models and improve the quality and 24 cost of care furnished to employees or enrollees; 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H6004.IH H6004 pamtmann on DSKBC07HB2PROD with BILLS 11 •HR 6004 IH ‘‘(E) enabling group health plans and 1 health insurance issuers to evaluate network de- 2 sign, network construction, and the cost of care 3 furnished to enrollees; 4 ‘‘(F) facilitating State-led initiatives to 5 lower health care costs and improve health care 6 quality; or 7 ‘‘(G) promoting competition based on qual- 8 ity and cost. 9 ‘‘(e) PRIVACY REGULATIONS.—The Secretary shall 10 promulgate regulations specifying the extent and manner 11 to which any applicable Federal law or regulation relating 12 to privacy shall apply to activities carried out pursuant 13 to a grant made under the program and may issue any 14 additional regulation determined necessary by the Sec- 15 retary to ensure appropriate confidentiality of data associ- 16 ated with such activities. 17 ‘‘(f) DISCLOSURE OF DATA.—Any State (or compact 18 of States) receiving a grant under the program to estab- 19 lish, maintain, or expand an all-payer claims database 20 shall work to make all information contained in such data- 21 base available to the Director of the Congressional Budget 22 Office, the Comptroller General of the United States, the 23 Executive Director of the Medicare Payment Advisory 24 Commission, and the Executive Director of the Medicaid 25 VerDate Sep 11 2014 00:45 Mar 03, 2020 Jkt 099200 PO 0 [Text truncated for display. Full text available on Congress.gov.]