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A BILL TO BE ENTITLED
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AN ACT
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relating to adoption of alternative payment method pilot programs |
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for the provision of health care services to certain state |
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employees and certain active and retired public school employees. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. EMPLOYEES RETIREMENT SYSTEM OF TEXAS--ACTIVE EMPLOYEES |
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SECTION 1.01. Chapter 1551, Insurance Code, is amended by |
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|
adding Subchapter K to read as follows: |
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SUBCHAPTER K. ALTERNATIVE PAYMENT METHOD PILOT PROGRAM FOR |
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PROVISION OF HEALTH CARE SERVICES |
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Sec. 1551.501. DEFINITIONS. In this subchapter: |
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(1) "Alternative payment system" includes: |
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|
(A) a global payment system; |
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|
(B) an episode-based bundled payment system; |
|
|
(C) a pay-for-performance payment system; and |
|
|
(D) a blended payment system. |
|
|
(2) "Blended payment system" means a system for |
|
|
compensating a physician or health care provider that includes one |
|
|
or more features of a global payment system, a pay-for-performance |
|
|
payment system, and an episode-based bundled payment system. |
|
|
(3) "Clinical integration" means a network of health |
|
|
care providers implementing an active and ongoing program to |
|
|
evaluate and modify practice patterns by the network's participants |
|
|
and create a high degree of independence and cooperation to control |
|
|
costs and ensure quality. |
|
|
(4) "Episode-based bundled payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on a flat payment for all services provided |
|
|
in connection with a single episode of medical care. |
|
|
(5) "Global payment system" means a system for |
|
|
compensating a physician or health care provider for arranging for |
|
|
or providing a defined set of covered health care services to |
|
|
participating enrollees for a specified period that is based on a |
|
|
predetermined payment per enrollee for the specified period, |
|
|
without regard to the quantity of services actually provided. |
|
|
(6) "Participating enrollee" means an employee or |
|
|
dependent enrolled in the pilot program. |
|
|
(7) "Pay-for-performance payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on the physician or health care provider |
|
|
meeting or exceeding certain defined performance measures. |
|
|
(8) "Pilot program" means the alternative payment |
|
|
method pilot program established under this subchapter. |
|
|
(9) "Plan year" means the period beginning on |
|
|
September 1 and ending the following August 31. |
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Sec. 1551.502. DEVELOPMENT AND IMPLEMENTATION OF PILOT |
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|
PROGRAM. (a) The board of trustees shall develop and implement a |
|
|
pilot program under which physicians and health care providers who |
|
|
provide health care services to certain employees who participate |
|
|
in the group benefits program under Section 1551.101 are |
|
|
compensated under an alternative payment system. The pilot program |
|
|
shall test alternatives to traditional fee-for-service payments |
|
|
made under the group benefits program. |
|
|
(b) The board of trustees shall administer the pilot program |
|
|
established under this subchapter and may adopt rules, plans, and |
|
|
procedures and enter into contracts and other agreements as it |
|
|
considers appropriate and necessary to administer this subchapter. |
|
|
(c) The board of trustees may limit participation in the |
|
|
pilot program to: |
|
|
(1) one or more regions of the state; or |
|
|
(2) one or more organized networks of physicians, |
|
|
hospitals, and other health care providers. |
|
|
(d) The board of trustees may examine and replicate |
|
|
innovative programs used in other states. |
|
|
(e) The pilot program implemented under this subchapter |
|
|
must be operated for at least one plan year. |
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|
Sec. 1551.503. STANDARDS; CLINICAL INTEGRATION. (a) In |
|
|
connection with the pilot program, the board of trustees shall |
|
|
adopt quality of care standards to ensure high-quality and |
|
|
effective health care services. The board of trustees shall |
|
|
implement policies to promote clinical integration of health care |
|
|
providers. |
|
|
(b) The board of trustees may adopt efficiency performance |
|
|
standards that may include the provision of bonuses to or the |
|
|
sharing of savings with physicians and other health care providers |
|
|
who provide health care services to participating enrollees that |
|
|
exceed the efficiency performance standards. |
|
|
Sec. 1551.504. ALTERNATIVE PAYMENT SYSTEM. (a) The board |
|
|
of trustees shall adopt a payment system under the pilot program |
|
|
that ensures: |
|
|
(1) the availability of a primary care physician or |
|
|
primary care health care provider for each participating enrollee; |
|
|
and |
|
|
(2) payment to such a primary care physician or |
|
|
primary care health care provider under an alternative payment |
|
|
system that appropriately compensates the primary care physician or |
|
|
primary care provider for the services provided. |
|
|
(b) The board of trustees may contract with appropriate |
|
|
entities, including qualified actuaries, to assist the board in |
|
|
determining appropriate payment rates for the pilot program. |
|
|
(c) The board of trustees may increase a payment rate |
|
|
adopted under this section as necessary to adjust the rate for |
|
|
inflation. |
|
|
SECTION 1.02. Section 1551.202, Insurance Code, is amended |
|
|
by adding Subsection (d) to read as follows: |
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|
(d) The board of trustees shall ensure that coverage |
|
|
provided to an enrollee participating in the pilot program |
|
|
implemented under Subchapter K meets the quality of care standards |
|
|
required under that subchapter and the basic coverage plan. |
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|
SECTION 1.03. The board of trustees of the Employees |
|
|
Retirement System of Texas shall develop the alternative payment |
|
|
method pilot program to be implemented under Subchapter K, Chapter |
|
|
1551, Insurance Code, as added by this Act, beginning September 1, |
|
|
2009. The board of trustees shall develop enrollment requirements |
|
|
for the pilot program not later than March 1, 2010, with |
|
|
participation and contributions for eligible enrollees beginning |
|
|
not later than September 1, 2010. |
|
|
SECTION 1.04. Not later than the 60th day before the date on |
|
|
which eligible employees may participate in the pilot program |
|
|
established under Subchapter K, Chapter 1551, Insurance Code, as |
|
|
added by this Act, the board of trustees of the Employees Retirement |
|
|
System of Texas shall provide written information to those |
|
|
employees that provides a general description of the requirements |
|
|
for the program as adopted under Subchapter K, Chapter 1551, |
|
|
Insurance Code, as added by this Act. |
|
|
SECTION 1.05. During the initial implementation of |
|
|
Subchapter K, Chapter 1551, Insurance Code, as added by this Act, |
|
|
and notwithstanding any bidding requirements or other requirements |
|
|
set forth in Chapter 1551, Insurance Code, as that chapter existed |
|
|
before amendment by this Act, the board of trustees of the Employees |
|
|
Retirement System of Texas may amend any agreement in effect on |
|
|
September 1, 2009, that it has entered into as necessary to comply |
|
|
with Subchapter K, Chapter 1551, Insurance Code, as added by this |
|
|
Act. |
|
|
SECTION 1.06. Not later than November 1, 2011, the board of |
|
|
trustees of the Employees Retirement System of Texas shall present |
|
|
a report to the governor, the lieutenant governor, the speaker of |
|
|
the house of representatives, and the members of each legislative |
|
|
committee having jurisdiction over insurance and health care for |
|
|
state employees. The report must: |
|
|
(1) describe the operation of the pilot program |
|
|
established under Subchapter K, Chapter 1551, Insurance Code, as |
|
|
added by this Act; |
|
|
(2) analyze the quality of health care provided to |
|
|
participating enrollees under the pilot program; |
|
|
(3) compare the per-patient cost under the pilot |
|
|
program to the cost per patient of a traditional fee-for-service |
|
|
program; and |
|
|
(4) make recommendations regarding the continuation |
|
|
or expansion of the pilot program. |
|
|
ARTICLE 2. TEACHER RETIREMENT SYSTEM OF TEXAS--RETIREES |
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|
SECTION 2.01. Chapter 1575, Insurance Code, is amended by |
|
|
adding Subchapter L to read as follows: |
|
|
SUBCHAPTER L. ALTERNATIVE PAYMENT METHOD PILOT PROGRAM FOR |
|
|
PROVISION OF HEALTH CARE SERVICES |
|
|
Sec. 1575.551. DEFINITIONS. In this subchapter: |
|
|
(1) "Alternative payment system" includes: |
|
|
(A) a global payment system; |
|
|
(B) an episode-based bundled payment system; |
|
|
(C) a pay-for-performance payment system; and |
|
|
(D) a blended payment system. |
|
|
(2) "Blended payment system" means a system for |
|
|
compensating a physician or health care provider that includes one |
|
|
or more features of a global payment system, a pay-for-performance |
|
|
payment system, and an episode-based bundled payment system. |
|
|
(3) "Clinical integration" means a network of health |
|
|
care providers implementing an active and ongoing program to |
|
|
evaluate and modify practice patterns by the network's participants |
|
|
and create a high degree of independence and cooperation to control |
|
|
costs and ensure quality. |
|
|
(4) "Episode-based bundled payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on a flat payment for all services provided |
|
|
in connection with a single episode of medical care. |
|
|
(5) "Global payment system" means a system for |
|
|
compensating a physician or health care provider for arranging for |
|
|
or providing a defined set of covered health care services to |
|
|
participating enrollees for a specified period that is based on a |
|
|
predetermined payment per enrollee for the specified period, |
|
|
without regard to the quantity of services actually provided. |
|
|
(6) "Participating enrollee" means a retiree or |
|
|
dependent enrolled in the pilot program. |
|
|
(7) "Pay-for-performance payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on the physician or health care provider |
|
|
meeting or exceeding certain defined performance measures. |
|
|
(8) "Pilot program" means the alternative payment |
|
|
method pilot program established under this subchapter. |
|
|
(9) "Plan year" means the period beginning on |
|
|
September 1 and ending the following August 31. |
|
|
Sec. 1575.552. DEVELOPMENT AND IMPLEMENTATION OF PILOT |
|
|
PROGRAM. (a) The trustee shall develop and implement a pilot |
|
|
program under which physicians and health care providers who |
|
|
provide health care services to certain retirees who participate in |
|
|
the group program under Subchapter D are compensated under an |
|
|
alternative payment system. The pilot program shall test |
|
|
alternatives to traditional fee-for-service payments made under |
|
|
the group program. |
|
|
(b) The trustee shall administer the pilot program |
|
|
established under this subchapter and may adopt rules, plans, and |
|
|
procedures and enter into contracts and other agreements as it |
|
|
considers appropriate and necessary to administer this subchapter. |
|
|
(c) The trustee may limit participation in the pilot program |
|
|
to: |
|
|
(1) one or more regions of the state; or |
|
|
(2) one or more organized networks of physicians, |
|
|
hospitals, and other health care providers. |
|
|
(d) The trustee may examine and replicate innovative |
|
|
programs used in other states. |
|
|
(e) The pilot program implemented under this subchapter |
|
|
must be operated for at least one plan year. |
|
|
Sec. 1575.553. STANDARDS; CLINICAL INTEGRATION. (a) In |
|
|
connection with the pilot program, the trustee shall adopt quality |
|
|
of care standards to ensure high-quality and effective health care |
|
|
services. The trustee shall implement policies to promote clinical |
|
|
integration of health care providers. |
|
|
(b) The trustee may adopt efficiency performance standards |
|
|
that may include the provision of bonuses to or the sharing of |
|
|
savings with physicians and other health care providers who provide |
|
|
health care services to participating enrollees that exceed the |
|
|
efficiency performance standards. |
|
|
Sec. 1575.554. ALTERNATIVE PAYMENT SYSTEM. (a) The |
|
|
trustee shall adopt a payment system under the pilot program that |
|
|
ensures: |
|
|
(1) the availability of a primary care physician or |
|
|
primary care health care provider for each participating enrollee; |
|
|
and |
|
|
(2) payment to such a primary care physician or |
|
|
primary care health care provider under an alternative payment |
|
|
system that appropriately compensates the primary care physician or |
|
|
primary care provider for the services provided. |
|
|
(b) The trustee may contract with appropriate entities, |
|
|
including qualified actuaries, to assist the trustee in determining |
|
|
appropriate payment rates for the pilot program. |
|
|
(c) The trustee may increase a payment rate adopted under |
|
|
this section as necessary to adjust the rate for inflation. |
|
|
SECTION 2.02. Subchapter D, Chapter 1575, Insurance Code, |
|
|
is amended by adding Section 1575.154 to read as follows: |
|
|
Sec. 1575.154. COVERAGE UNDER PILOT PROGRAM. The trustee |
|
|
shall ensure that coverage provided to an enrollee participating in |
|
|
the pilot program implemented under Subchapter L meets the quality |
|
|
of care standards required under that subchapter and the basic |
|
|
coverage plan. |
|
|
SECTION 2.03. The Teacher Retirement System of Texas shall |
|
|
develop the alternative payment method pilot program to be |
|
|
implemented under Subchapter L, Chapter 1575, Insurance Code, as |
|
|
added by this Act, beginning September 1, 2009. The trustee shall |
|
|
develop enrollment requirements for the pilot program not later |
|
|
than March 1, 2010, with participation and contributions for |
|
|
eligible enrollees beginning not later than September 1, 2010. |
|
|
SECTION 2.04. Not later than the 60th day before the date on |
|
|
which eligible retirees may participate in the pilot program |
|
|
established under Subchapter L, Chapter 1575, Insurance Code, as |
|
|
added by this Act, the Teacher Retirement System of Texas shall |
|
|
provide written information to those retirees that provides a |
|
|
general description of the requirements for the program as adopted |
|
|
under Subchapter L, Chapter 1575, Insurance Code, as added by this |
|
|
Act. |
|
|
SECTION 2.05. During the initial implementation of |
|
|
Subchapter L, Chapter 1575, Insurance Code, as added by this Act, |
|
|
and notwithstanding any bidding requirements or other requirements |
|
|
set forth in Chapter 1575, Insurance Code, as that chapter existed |
|
|
before amendment by this Act, the Teacher Retirement System of |
|
|
Texas may amend any agreement in effect on September 1, 2009, that |
|
|
it has entered into as necessary to comply with Subchapter L, |
|
|
Chapter 1575, Insurance Code, as added by this Act. |
|
|
SECTION 2.06. Not later than November 1, 2011, the Teacher |
|
|
Retirement System of Texas shall present a report to the governor, |
|
|
the lieutenant governor, the speaker of the house of |
|
|
representatives, and the members of each legislative committee |
|
|
having jurisdiction over insurance and health care for retired |
|
|
public school employees. The report must: |
|
|
(1) describe the operation of the pilot program |
|
|
established under Subchapter L, Chapter 1575, Insurance Code, as |
|
|
added by this Act; |
|
|
(2) analyze the quality of health care provided to |
|
|
participating enrollees under the pilot program; |
|
|
(3) compare the per-patient cost under the pilot |
|
|
program to the cost per patient of a traditional fee-for-service |
|
|
program; and |
|
|
(4) make recommendations regarding the continuation |
|
|
or expansion of the pilot program. |
|
|
ARTICLE 3. TEACHER RETIREMENT SYSTEM OF TEXAS--ACTIVE EMPLOYEES |
|
|
SECTION 3.01. Chapter 1579, Insurance Code, is amended by |
|
|
adding Subchapter H to read as follows: |
|
|
SUBCHAPTER H. ALTERNATIVE PAYMENT METHOD PILOT PROGRAM FOR |
|
|
PROVISION OF HEALTH CARE SERVICES |
|
|
Sec. 1579.351. DEFINITIONS. In this subchapter: |
|
|
(1) "Alternative payment system" includes: |
|
|
(A) a global payment system; |
|
|
(B) an episode-based bundled payment system; |
|
|
(C) a pay-for-performance payment system; and |
|
|
(D) a blended payment system. |
|
|
(2) "Blended payment system" means a system for |
|
|
compensating a physician or health care provider that includes one |
|
|
or more features of a global payment system, a pay-for-performance |
|
|
payment system, and an episode-based bundled payment system. |
|
|
(3) "Clinical integration" means a network of health |
|
|
care providers implementing an active and ongoing program to |
|
|
evaluate and modify practice patterns by the network's participants |
|
|
and create a high degree of independence and cooperation to control |
|
|
costs and ensure quality. |
|
|
(4) "Episode-based bundled payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on a flat payment for all services provided |
|
|
in connection with a single episode of medical care. |
|
|
(5) "Global payment system" means a system for |
|
|
compensating a physician or health care provider for arranging for |
|
|
or providing a defined set of covered health care services to |
|
|
participating enrollees for a specified period that is based on a |
|
|
predetermined payment per enrollee for the specified period, |
|
|
without regard to the quantity of services actually provided. |
|
|
(6) "Participating enrollee" means an employee or |
|
|
dependent enrolled in the pilot program. |
|
|
(7) "Pay-for-performance payment system" means a |
|
|
system for compensating a physician or health care provider for |
|
|
arranging for or providing health care services to participating |
|
|
enrollees that is based on the physician or health care provider |
|
|
meeting or exceeding certain defined performance measures. |
|
|
(8) "Pilot program" means the alternative payment |
|
|
method pilot program established under this subchapter. |
|
|
(9) "Plan year" means the period beginning on |
|
|
September 1 and ending the following August 31. |
|
|
Sec. 1579.352. DEVELOPMENT AND IMPLEMENTATION OF PILOT |
|
|
PROGRAM. (a) The trustee shall develop and implement a pilot |
|
|
program under which physicians and health care providers who |
|
|
provide health care services to certain employees who participate |
|
|
in the primary care coverage plan under Subchapter C are |
|
|
compensated under an alternative payment system. The pilot program |
|
|
shall test alternatives to traditional fee-for-service payments |
|
|
made under the group program. |
|
|
(b) The trustee shall administer the pilot program |
|
|
established under this subchapter and may adopt rules, plans, and |
|
|
procedures and enter into contracts and other agreements as it |
|
|
considers appropriate and necessary to administer this subchapter. |
|
|
(c) The trustee may limit participation in the pilot program |
|
|
to: |
|
|
(1) one or more regions of the state; or |
|
|
(2) one or more organized networks of physicians, |
|
|
hospitals, and other health care providers. |
|
|
(d) The trustee may examine and replicate innovative |
|
|
programs used in other states. |
|
|
(e) The pilot program implemented under this subchapter |
|
|
must be operated for at least one plan year. |
|
|
Sec. 1579.353. STANDARDS; CLINICAL INTEGRATION. (a) In |
|
|
connection with the pilot program, the trustee shall adopt quality |
|
|
of care standards to ensure high-quality and effective health care |
|
|
services. The trustee shall implement policies to promote clinical |
|
|
integration of health care providers. |
|
|
(b) The trustee may adopt efficiency performance standards |
|
|
that may include the provision of bonuses to or the sharing of |
|
|
savings with physicians and other health care providers who provide |
|
|
health care services to participating enrollees that exceed the |
|
|
efficiency performance standards. |
|
|
Sec. 1579.354. ALTERNATIVE PAYMENT SYSTEM. (a) The |
|
|
trustee shall adopt a payment system under the pilot program that |
|
|
ensures: |
|
|
(1) the availability of a primary care physician or |
|
|
primary care health care provider for each participating enrollee; |
|
|
and |
|
|
(2) payment to such a primary care physician or |
|
|
primary care health care provider under an alternative payment |
|
|
system that appropriately compensates the primary care physician or |
|
|
primary care provider for the services provided. |
|
|
(b) The trustee may contract with appropriate entities, |
|
|
including qualified actuaries, to assist the trustee in determining |
|
|
appropriate payment rates for the pilot program. |
|
|
(c) The trustee may increase a payment rate adopted under |
|
|
this section as necessary to adjust the rate for inflation. |
|
|
SECTION 3.02. Section 1579.103, Insurance Code, is amended |
|
|
to read as follows: |
|
|
Sec. 1579.103. PRIMARY CARE COVERAGE PLAN. (a) The |
|
|
coverage provided under the primary care coverage plan must be |
|
|
comparable in scope and, to the greatest extent possible, in cost to |
|
|
the coverage provided under Chapter 1551. |
|
|
(b) The trustee shall ensure that coverage provided to an |
|
|
enrollee participating in the pilot program implemented under |
|
|
Subchapter H meets the quality of care standards required under |
|
|
that subchapter and the primary care coverage plan. |
|
|
SECTION 3.03. The Teacher Retirement System of Texas shall |
|
|
develop the alternative payment method pilot program to be |
|
|
implemented under Subchapter H, Chapter 1579, Insurance Code, as |
|
|
added by this Act, beginning September 1, 2009. The trustee shall |
|
|
develop enrollment requirements for the pilot program not later |
|
|
than March 1, 2010, with participation and contributions for |
|
|
eligible enrollees beginning not later than September 1, 2010. |
|
|
SECTION 3.04. Not later than the 60th day before the date on |
|
|
which eligible employees may participate in the pilot program |
|
|
established under Subchapter H, Chapter 1579, Insurance Code, as |
|
|
added by this Act, the Teacher Retirement System of Texas shall |
|
|
provide written information to those employees that provides a |
|
|
general description of the requirements for the program as adopted |
|
|
under Subchapter H, Chapter 1579, Insurance Code, as added by this |
|
|
Act. |
|
|
SECTION 3.05. During the initial implementation of |
|
|
Subchapter H, Chapter 1579, Insurance Code, as added by this Act, |
|
|
and notwithstanding any bidding requirements or other requirements |
|
|
set forth in Chapter 1579, Insurance Code, as that chapter existed |
|
|
before amendment by this Act, the Teacher Retirement System of |
|
|
Texas may amend any agreement in effect on September 1, 2009, that |
|
|
it has entered into as necessary to comply with Subchapter H, |
|
|
Chapter 1579, Insurance Code, as added by this Act. |
|
|
SECTION 3.06. Not later than November 1, 2011, the Teacher |
|
|
Retirement System of Texas shall present a report to the governor, |
|
|
the lieutenant governor, the speaker of the house of |
|
|
representatives, and the members of each legislative committee |
|
|
having jurisdiction over insurance and health care for employees of |
|
|
public schools. The report must: |
|
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(1) describe the operation of the pilot program |
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established under Subchapter H, Chapter 1579, Insurance Code, as |
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added by this Act; |
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(2) analyze the quality of health care provided to |
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participating enrollees under the pilot program; |
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(3) compare the per-patient cost under the pilot |
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program to the cost per patient of a traditional fee-for-service |
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program; and |
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(4) make recommendations regarding the continuation |
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or expansion of the pilot program. |
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ARTICLE 4. EFFECTIVE DATE |
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SECTION 4.01. Except as otherwise provided by this Act, |
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this Act takes effect September 1, 2009. |
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* * * * * |