SENATE, No. 1279

SECTION 1. Section 16 of chapter 6A of the general laws, as appearing in the 2004 Official Edition, is hereby amended by adding at the end thereof, the following:

Statewide Strategy for Chronic Care Management

Section 1. DEFINITIONS

For the purposes of this chapter:

(1)  “Chronic care” means health services provided by a health care professional for an established clinical condition that is expected to last a year or more and that requires ongoing clinical management attempting to restore the individual to highest function, minimize the negative effects of the condition, and prevent complications related to chronic conditions.  Chronic conditions include, but are not limited to, diabetes, hypertension, cardiovascular disease, cancer, asthma, pulmonary disease, substance abuse, mental illness, spinal cord injury, and hyperlipidemia.

(2)  “Chronic care information system” means the electronic database developed under the Massachusetts eHealth Initiative for health that shall include information on all cases of a particular disease or health condition in a defined population of individuals.

(3)  “Chronic care management” means a system of coordinated health care interventions and communications for individuals with chronic conditions, including significant patient self-care efforts, systemic supports for the physician and patient relationship, and a plan of care emphasizing prevention of complications utilizing evidence-based practice guidelines, patient empowerment strategies, and evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

(4)  “Health care professional” means an individual, partnership, corporation, facility, or institution licensed or certified or authorized by law to provide professional health care services.

(5)  “Health risk assessment” means screening by a health care professional for the purpose of assessing an individual’s health, including tests or physical examinations and a survey or other tool used to gather information about an individual’s health, medical history, and health risk factors during a health screening.

(6)  “Massachusetts eHealth Initiative” means the Commonwealth’s plan for utilizing technology to manage health improvement through a public and private collaborative effort to improve quality and containing or reducing costs.  Among the features of the eHealth initiative is the development of a chronic care infrastructure, prevention of chronic conditions, and chronic care management program, and which includes an integrated approach to patient self-management, community development, health care system and professional practice change, and information technology initiatives.

Section 2.  MASSACHUSETTS e-HEALTH INITIATIVE; STRATEGIC PLAN

(a)  The secretary of health and human services, in cooperation with the commissioner of public health, is hereby authorized and directed to promote the development and implementation of a public-private partnership known as the Massachusetts e-Health Initiative, including the five-year strategic plan.

(b)(1)  The secretary is hereby further authorized and directed to establish and implement a strategic plan for the development of the statewide system of chronic care and prevention as described under this section. 

The secretary shall appoint a chronic care advisory committee to assist with the establishment and implementation of said strategic plan consisting of  the commissioner of public health, or his designee; the commissioner of the division of health care finance and policy, or his designee; the commissioner of insurance, or his designee; the commissioner of the division of medical assistance, or his designee; the executive director of the group insurance commission, or his designee; the executive director of the Massachusetts technology collaborative or his designee; the executive director of the Massachusetts eHealth collaborative, or his designee; the executive director of the commonwealth health insurance connector, or his designee; the director of the Health Safety Net Office, or his designee; the president of the Massachusetts medical society, or his designee; the president of the Massachusetts association of health plans, or his designee; the president of the Massachusetts hospital association, or his designee; the president of the institute for healthcare improvement, or his designee, the executive director of the Massachusetts coalition for the prevention of medical errors, or his designee; the president of the Massachusetts extended care federation, or his designee; the Executive Director of Health Care for All of Massachusetts, or his designee; a health care consumer; a representative of the complementary and alternative medicine profession; and a primary care professional serving low income or uninsured Massachusetts residents; and two individuals with demonstrated expertise in chronic care management or research. 

(2)  The chronic care advisory committee shall engage a broad range of health care professionals who provide services to health insurance plans, professional organizations, community and nonprofit groups, consumers, businesses, school districts, and state and local government in developing and implementing a five-year strategic plan. 

(c)(1)  The strategic plan shall include:

(A)  a description of the Massachusetts eHealth Collaborative model, which includes general, standard elements, patient self-management, community initiatives, and health system and information technology reform, to be used uniformly statewide by private insurers, third party administrators, and public programs;

(B)  a description of prevention programs and how these programs are integrated into communities, with chronic care management, and the Massachusetts eHealth Collaborative model;

(C)  a plan to develop and implement reimbursement systems aligned with the goal of managing the care for individuals with or at risk for conditions in order to improve outcomes and the quality of care, including, but not limited to the development of a system based on coordinated care management similar to the senior care options program established pursuant to section 9D of chapter 118E of the general laws;

(D)  the involvement of public and private groups, health care professionals, insurers, third party administrators, associations, and firms to facilitate and assure the sustainability of a new system of care;

(E)  the involvement of community and consumer groups to facilitate and assure the sustainability of health services supporting healthy behaviors and good patient self-management for the prevention and management of chronic conditions;

(F)  alignment of any information technology needs with the Massachusetts eHealth Initiative, the Massachusetts eHealth Collaborative, the Massachusetts Technology Collaborative, the Massachusetts Health Data Consortium, or other health care information technology initiatives;

(G)  the use and development of outcome measures and reporting requirements, aligned with existing outcome measures in consultation with the Cost and Quality Council established pursuant to section 16K of chapter 6A of the general laws, to assess and evaluate the system of chronic care;

(H)  target timelines for inclusion of specific chronic conditions to be included in the chronic care infrastructure and for statewide implementation of the Massachusetts eHealth Initiative;

(I)  identification of resource needs for implementation and sustaining the blueprint for health and strategies to meet the needs; and

(J)  a strategy for ensuring statewide participation no later than July 1, 2010 by insurers, third-party administrators, health care professionals, hospitals and other professionals, and consumers in the chronic care management plan, including common outcome measures, best practices and protocols, data reporting requirements, payment methodologies, and other standards.

(2)  The strategic plan shall be reviewed biennially by the chronic care advisory committee, and amended as necessary to reflect changes in priorities.  Amendments to the plan shall be reported to the general court in the report established under subsection (d) of this section.

(d)(1)  The secretary of health and human services shall report annually on the status of implementation of the Massachusetts blueprint for health to the joint legislative committee on public health, the joint legislative committee on mental health and substance abuse, the joint legislative committee on health care financing, and the House and Senate committees on ways and means.  The report shall include the number of participating insurers, health care professionals and patients; the progress for achieving statewide participation in the chronic care management plan, including the measures established under subsection (c) of this section; the expenditures and savings for the period; the results of health care professional and patient satisfaction surveys; the progress toward creation and implementation of privacy and security protocols; and other information as requested by the committees.  The surveys shall be developed in collaboration with the public health council and its chronic care advisory committee established under subsection (b) of this section.

Section 3.  CHRONIC CARE MANAGEMENT PROGRAM

(a)  The secretary of health and human services is hereby authorized and directed to establish a chronic care management program as provided for in this section, which shall be administered or provided by a private entity for individuals with one or more chronic conditions who are enrolled in MassHealth, the Commonwealth Care Health Insurance program or the Group Insurance Commission.  The program may provide mechanisms for collaboration with private, not for profit health plans to share information, strategies, and techniques within the privacy guidelines established by federal and state law and regulations.  The program shall not include individuals who are also eligible for Medicare, who are enrolled in the Senior Care Options Section 1115 waiver or who are in an institute for mental disease as defined in 42 C.F.R. § 435.1009. 

(b)  The secretary shall include a broad range of chronic conditions in the chronic care management program.

(c)  The chronic care management program shall be designed to include:

(1)  a method involving the health care professional in identifying eligible patients, including the use of the chronic care information system, an enrollment process which provides incentives and strategies for maximum patient participation, and a standard statewide health risk assessment for each individual;

(2)  the process for coordinating care among health care professionals;

(3)  the methods of increasing communications among health care professionals and patients, including patient education, self-management, and follow‑up plans;

(4)  the educational, wellness, and clinical management protocols and tools used by the care management organization, including management guideline materials for health care professionals to assist in patient-specific recommendations;

(5)  process and outcome measures to provide performance feedback for health care professionals and information on the quality of care, including patient satisfaction and health status outcomes;

(6)  payment methodologies to align reimbursements and create financial incentives and rewards for health care professionals to establish management systems for chronic conditions, to improve health outcomes, and to improve the quality of care, including case management fees, pay for performance, payment for technical support and data entry associated with patient registries, the cost of staff coordination within a medical practice, and any reduction in a health care professional’s productivity;

(7)  payment to the care management organization which would put the care management organization’s fee at risk if the management is not successful in reducing costs to the Commonwealth;

(8)  a requirement that the data on enrollees be shared, to the extent allowable under federal law, with the secretary in order to inform the health care reform initiatives enacted pursuant to the provisions of chapter 58 of the Acts of 2006;

(9)  a method for the care management organization to participate closely in the Massachusetts e-Health Initiative and other health care reform initiatives; and

(10)  participation in pharmacy best practices and cost-control program consistent with the quality initiative of the American Society of Health Systems Pharmacists and National Quality Indicators developed by the National Quality Forum and the MassHealth preferred drug list.

(d)  The secretary shall issue a request for proposals for the program established under this section.  Any contract under this section may allow the entity to subcontract some services to other entities if it is cost-effective, efficient, or in the best interest of the individuals enrolled in the program.

(e)  The secretary shall ensure that the chronic care management program is modified over time to comply with the Massachusetts eHealth Initiative strategic plan and to the extent feasible, collaborate in its initiatives.

Section 4.  PREVENTION AND CHRONIC CARE MANAGEMENT; EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES; IMPLEMENTATION PLAN

Notwithstanding  any other general or special law to the contrary, not later than January 1, 2009, the executive office of health and human services shall develop an implementation plan for prevention of chronic conditions and for chronic care management which at minimum meets the criteria and requirements of this section.  The implementation plan shall be revised periodically to reflect changes to the Massachusetts eHealth Initiative strategic plan.  In addition to the chronic care management, the executive office of health and human services may provide additional care coordination services to appropriate individuals as specified in its strategic plan.  The executive office of health and human services shall ensure that MassHealth, Medicaid waiver programs, and Commonwealth Care change the payment methodologies in order to align with the recommendation of the strategic plan.  The executive office of health and human services shall analyze and include a recommendation as to any waivers or waiver modifications needed to implement a chronic care management program.

Section 5.  PREVENTION AND CHRONIC CARE MANAGEMENT; STATE

             EMPLOYEES

The group insurance commission shall include in any request for proposals for the administration of the health benefit plans for public employees a request for a description of any chronic care management program provided by the entity and how the program aligns with the Massachusetts blueprint for health strategic plan.  The executive director shall also work with the secretary of health and human services or designee, and any organizations representing Massachusetts employees on how and when to align the state employees’ health benefit plan with the goals and statewide standards developed by the Massachusetts blueprint for health.