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Senate | April 24, 2013 | Committee Room | Senate Healthcare

Full MP3 Audio File

Thank you members of the committee, Ladies and Gentleman of the public. Welcome to our City Committee on Healthcare. I will start by saying that we will have Open to Public Comment on Senate Bill Four Seventy Three. You will need to sign up with the Sergeant at Arms in order to speak on that bill. Comments will be limited to two minutes per individual. As we begin today I want to start by recognizing our pages this week. We are going to start with Caleb Sanders Senator Daniel. Thank you. Natalie Brown Senator Pate. And Briggs Mantis Myself. Thank you. Hope your having a great week this week. Sergeant at Arms are Ashley Mccinns, Donna Blake, Billy Fritzer, Ed Kesler and Steve Wilson. Steve was here somewhere. Thank You. Members of the committee we will begin start by going through Senate Bill One Thirty Seven. We'll move through that so we can hold the remainder of the time for Four Seventy Three. Senator Tillman you will be recognized as ?? bill. Thank you for attending today. [SPEAKER CHANGES] Thank you Mr. Chairman. Its good to see this HHS committee. It's one that I've asked many many times not to be a part of. I can't understand it, Senator Hise I know you can I'm glad that I'm on education. I appreciate you hearing my bill first. This bill simply says that if you are a Medicaid provider in a pharmacy business you will not give away the prescription medication. What's going on in some places in the state is that providers, pharmacists are waiving the co-pay on prescription medications in order to get their business. And that is an unfair business practice. It does not comply with Federal law, this does. This makes them responsible if they do that. The penalty is possible loss of their license to do business with Medicaid and that would be a severe blow to anyone. There are possibilities of waiving it for someone that's truly in need. Those are exceptions rather than a rule. In most cases they are expected to pay and the pharmacist is expected to charge and collect on those Medicaid prescription drugs. That's basically all the bill does and I'd be glad to entertain questions if there are any. [SPEAKER CHANGES] Before we move to that PCS and Senator Pate will move to bring PCS before us. All those in favor say Aye. [SPEAKER CHANGES] Aye. [SPEAKER CHANGES] Opposed. The Ayes have it. We have the PCS before us. Any questions or comments? Senator Wade has moved for favorable report to the bill. Unfavorable is to the composed committee so ??. Unfavorable is to the original bill. Any other comments? Senator McKissick. [SPEAKER CHANGES] I apologize for running in a little bit late and first I want to commend you on having a good bill here Senator ??. Four Seventy Three. [SPEAKER CHANGES] Could you repeat that son? I didn't hear you. [SPEAKER CHANGES] I think it's a good bill. Good bill. I want to commend you on that. [SPEAKER CHANGES] Senator I will let you know that we are on Senate Bill One Thirty Seven. [SPEAKER CHANGES] So we've already gone through- [SPEAKER CHANGES] No. We are doing One Thirty Seven first and the remainder of the time will be on Four Thirty Seven. [SPEAKER CHANGES] I apologize, my thoughts were on the next bill. I didn't know we had changed the agenda. [SPEAKER CHANGES] Senator. Mr. Chairman. [SPEAKER CHANGES] Yes sir. [SPEAKER CHANGES] Senator McKissick is a great man. He's the only man I know that has a question about a bill while he's in the hall and he asked it when he got here but he's on the wrong bill today Senator. Very seldom will I catch you in one like that. [SPEAKER CHANGES] Any other comments on One Thirty Seven? Hearing none all those in favor committee ?? say Aye. [SPEAKER CHANGES] Aye [SPEAKER CHANGES] Opposed No? The Ayes have it. We will now move Senate Bill Four Seventy Three. Senator Rucho will be ?? the bill. We do have a committee substitute. Senator Rucho will move for the consideration of the post committee substitute. All those in favor say Aye. [SPEAKER CHANGES] Aye [SPEAKER CHANGES] Opposed? The bill before us Senator Rucho and Senator Brown. [SPEAKER CHANGES] Thank you Mr. Chairman. I know everybody's just waiting for this one. I think this is a good bill and I think it's had a lot of press and I think we'll do a lot of good things and I'm sure there will be a lot of questions so let me just try to get into it. Section One of the bill just establishes the health care cost-

production and transparency act is basically all that does. In part two of the bill creates new reporting requirements for hospitals and ambulatory surgical facilities on pricing for the fifty most common episodes of care in each of these facilities. It also requires these facilities make their policies on charity care and their annual expenditures on charity care, bad debt, and uncompensated care available to the general public, a posting on their premises and the internet. The bill charges the North Carolina health information exchange with publishing on its internet website the information reported by these facilities on the fifty most common episodes of care. Part three of the bill prohibits hospitals and A S C's, free standing radiology service facilities and physicians offices to provide outpatient radiology services from charging more than eighty percent of the full amount of certain outpatient radiology services for subsequent radiographs or are only provided to the patience once during the multiple radiology session. And I think most of you will remember there's been a lot of information on this about double billing on some of this and being charged twice for the set up fees basically. The next piece of the bill prohibits the U N C health care system and its affiliates and other schools of medicine, clinical programs, facilities and medical practices affiliated with one of the constiuent institutions of U N C to provide medical care to the general public from utilizing set off debt collection procedures to collect outstanding debts from tax refunds and lottery winnings of debtors. Only two are allowed to do that. There have been several bills that have been introduced to allow all of them to do it so I think that's going to be the debate. If you are going to allow two to do it, do you allow all of them to do it. We think we shouldn't allow any of them to do it. That the laws are there to collect and I'm sure we will have that debate. Part five of the bill establishes fair billing practices for hospitals and A S C's. These include readily understandable bills, notice before a bill is sent to collections, prompt refunds in the event of overpayment and the prohibition in the use of wage garnishments or for sale of primary residence to collect an unpaid bill. I think most patients, of course, I think if anybody's been to a hospital and you get a bill, if you can understand that bill you are better than I am. I think this will clean that up and try to get these to where you can at least understand what the charges are. And the last piece of the bill provides the department of health and human services may not contract with C C N C unless it makes specific changes to the board. So what we're trying to do is reorganize that board to, I think, give a broader input on the issues. That's pretty much what the bill does. [SPEAKER CHANGES] ?? [SPEAKER CHANGES] Thank you senator Brown and members of the health committee. This is another step that the general assembly, and specifically the senate, has taken- with moving forward last time we worked on health care reform cost with med mal reform and tort reform, now we're trying to put some light on the issue of the bills and as senator Brown eluded to, I know that I received one for a three hour service from my son's surgery. I probably would have needed a P H D in economics to understand it and that probably that would have been ??. So what we are trying to do is get to the point where the consumer, the patient, and the ones that are paying the bills, whether they are buying health insurance and the like, have the opportunity to understand and make comparison costs as if you were going to buy a product elsewhere. You walk into the store and say what's it cost me. Well then you will have a chance to do something similar to with health care so that's why it's important that we do move this forward. And I urge that you support the bill. I think we're going to let the staff go through ??. [SPEAKER CHANGES] ?? ?? as we speak. [SPEAKER CHANGES] Mister Adam. [SPEAKER CHANGES] Thank you mister chairman, senators Brown and ??, have asked me to go through the bill in detail. As you know, section one sets out the title of the act which is the health care cost reduction transparency act of twenty thirteen. We move in then to part two of the bill which is the transparency and health costs sections. Section one amends the purposes of the North Carolina H I E to- as one of it's purposes is going to provide current pricing information about the fifty most common episodes of care in each hospital and each

?? to a surgical facility on its internet website that is available to the public. [SPEAKER CHANGES] Mister chair, please translate the acronyms for us H I ?? information exchange, excuse me. This is an anacronym rich environment here. Section 3 goes on to direct the H I E to publish this data on its internet website. The second half section 3 part B essentially provides that C C N C who owns the North Carolina H I E can not sell the data or any analysis or product derived from the data to a third party. The information is kept in house. It is the property of the disclosing facilities and the state. Section 4 amends the North Carolina hospital licensure act and this is where the guts of the transparency portion are. A new 131 E 91 point one provides for disclosure on the fifty most common episodes of care. And an episode of care is defined as all acute care hospital services related to a health condition with a given diagnosis from the three day period proceding a patient's first admission to a hospital including readmissions through the thirty day period following the patient's discharge from the hospital for treatment of the health care condition. The term includes acute care, hospital services, services by heath care providers employed by the hospital, facility used by health care providers affiliated with the hospital, ancillary services, room and board, and pharmaceuticals dispensed by a hospital pharmacy or by a pharmacy owned or controlled by or under contract with the hospital. The medical care commission is directed to adopt rules establishing what those fifty most common episodes of care are. Beginning on march thirty first twenty fourteen, the hospitals are required to take this data and report, first of all the amount that would be charged to an uninsured patient for each of the fifty most common episodes of care if all charges are paid in full without having an insurer or other third party paying for any portion of those charges. They shall also report the average negotiated settlement on the amount charge to an uninsured patient. They are to report the total amount of medicaid reimbursements for each episode of care including claims and pro rata supplements, the total amount of medicare reimbursements for each episode of care and for the five largest health insurers providing payment to the hospital on behalf of insurers, the range of the total payments made for each of those fifty most common episodes of care, hospitals and ?? ?? have to redact the names and identifying information of the health insurers prior to providing that information. Last of all there is, to provide the total amount of payments made by the state health plan for each of the fifty most common episodes of care. Hospitals are also obligated to provide this information in writing to an individual who requests that within twenty four hours of receiving the patient's request. The North Carolina medical care commission is also charged with adopting rules to ensure that the new reporting requirements are implemented by January first, twenty fourteen. And that hospitals uniformly report these pricing information to the North Carolina H I E. The bill does provide that the reporting requirements of this section on transparency are not to be construed as requiring hospitals to participate in the voluntary state wide health information exchange network that is otherwise administered by the health information network. The other piece that the hospitals are required to disclose involves their charity care policies and amounts that are spent on that care starting in January one, twenty fourteen and annually there after each hospital must provide an annual disclosure to the public about its charity care policy and its annual expenditures on charity care bad debt and uncompensated care for the preceding calendar year. This information is to be posted on the premises of the hospital in a public area and available online on the website. Section five of the bill

Amends the Ambulatory Surgical Facility Licensure Act and provides parallel provisions for ambulatory surgical facilities. Section six of the bill directs DHHS to inform hospitals and Am-Surgs by July 1, of 2013, of the new reporting requirements pertaining to the episodes of care and charity care. Section seven excludes from the definition of competitive healthcare information, the information hospitals and Am-Surgs are required to report under sections four and five of the bill. Section Eight of the bill provides that information hospitals and Am-Surgs are required to report under four and five, that is included in the healthcare contract, is not confidential and is considered a public record under Chapter 132 of the General Statutes. Moving on to part three, part three deals with transparency in billing for outpatient radiological services. This is section nine of the bill. And this bill makes it unlawful for a provider of radiology services to charge more than eighty percent of the full amount of what are called technical components of an outpatient radiology imaging procedure, for subsequent radiographs performed on a patient during a multiple radiology session, if the provider only provides the technical components once during that multiple radiology session. Providers for this section include hospitals, ambulatory surgical facilities, free-standing radiology facilities, or a physician’s office, all which offer outpatient radiology services. Technical components, which are the things that are generally only provided once during a session, include clinical labor and supplies used by the hospital or Am-Surg to perform the imaging. Clinical labor includes greeting a patient, escorting and positioning the patient for the radiograph, educating the patient about the services to be performed, and obtaining the patient’s informed consent for the services and other things that are associated with the visit. Contracts, provisions and agreements that purport to require a patient to pay for these multiple charges are void and unenforceable. Moving on to part four of the bill, hospital debt collection, this is section ten of the bill. Section ten of the bill essentially says that UNC, or any school of medicine, clinical program, facility or practice affiliated with one of the constituent institutions of UNC, that provides medical care to the general public, will not be able to use set-off debt collection procedures to collect outstanding debts from debtors’ state tax refunds and lottery winnings. Part five of the bill, which is section eleven, eleven A, B, and C, is what we’ve designated the fair billing and collections act, and GS 131(E)-91 is amended, to provide that hospitals and ambulatory surgicals, first of all, non-itemized bills must contain a statement that a patient has a right to an itemized statement free of charge, and that the patient may request an itemized bill at any time within three years, or as long as the hospital or collections agency is asserting that the debt is still outstanding. All bills have to be readily understandable by a patient, if medical codes or terms are used, the bill must define those terms so that the patient can follow. If a patient has overpaid, a hospital or ambulatory surgical facility has sixty days to issue a refund after receiving notice of the overpayment. Patients are not to be billed for charges which would have been covered by their insurance had the facility submitted the claim or necessary information within the allotted timeframe given by the insurance company. Hospitals and ambulatory surgical facilities shall not refer an unpaid bill to a collections agency or other entity while a patient’s application for charity care is pending. Hospitals and ambulatory surgical facilities shall provide written notice to the patient thirty days before referring a bill to a collection agency. Facilities that contract with collections agencies or other entities shall require the collection agency to.

Inform the patient of the hospital or ambulatory surgical facilities, charity care, and financial assistance policies when engaging in collections activity. A hospital shall require a collections agency or other entity to obtain the written consent of the hospital or the ?? before filing a lawsuit to collect the debt, and finally, a hospital ambulatory surgical facility, collections agency entity, or other assignee of the facilities shall not use wage garnishment, a lien on a patient's primary residence, or otherwise force a sale of a primary residence as a means of collecting an unpaid bill. Section 11B simply provides a cross-reference to the provisions that I just went over in the ambulatory surgical facilities licensing act, because these other provisions are actually put in the hospital licensure act. Section 11C amends the insurance laws regarding, and requires health benefit plans to ensure that the patient is provided current and accurate information on providers' network status through their phone system or any online system. It also requires a healthcare provider to provide a patient or prospective patient on request information on the provider's network status with a particular health plan. Section 6 of the bill deals with CCNC governance, that's Community Care of North Carolina. This is section 12. Section 12 prohibits the Department of Health and Human Services from contracting with CCNC if the, if CCNC does not make certain adjustments to its bylaws, those bylaws include, and I'm on page 9 of the bill. I don't know if you want me to read them all, but they, they list the different parties that they would like to see represented on that board. A health actuary, two representatives of the provider community, a representative of the health insurance industry, someone with expertise in health information technology, a business owner or their designee. The board is also to be adjusted to have two persons appointed to the general assembly on the recommendation of the Pro Tem, president Pro Tem, at least one who shall be a business owner, two persons appointed by the Speaker of the House of Representatives, again one who shall be a business owner, and two persons appointed by the Governor, one of whom shall be a business owner. The provisions on the board also ask CCNC to ensure that no more than two members on its board directly benefit from the per member per month payments to providing to participating providers, to ensure that no more than 25% of the members of the board are providers or members of the provider community, and to ensure that no member or immediate family of a member of the board is a registered lobbyist, or is employed by a entity that lobbies on behalf of the healthcare provider, healthcare provider association. The board size is limited to thirteen members. [SPEAKER CHANGES] Thank, members of the committee, I want to first begin by just asking if there are any ?? that have any technical questions about the bill that would be directed to staff? Senator McKissick. [SPEAKER CHANGES] And I guess the first thing is, when it comes to determining the 50 most frequent medical procedures, is that gonna be unique for each particular hospital facility? Are they doing that based on what actually occurs at that particular hospital, or are they looking at a common group of 50 procedures which all these hospitals are identifying their cost and frequency related to, it wasn't clear to me from reading it and perhaps you could help me with that. [SPEAKER CHANGES] I think the North Carolina health information exchange is gonna help identify those. I think. [SPEAKER CHANGES] Actually it's the Medical Care Commission is supposed to identify the 50 most common, so it should be a uniform set for hospitals, and then a set for ambulatory surgical facilities. The Medical Care Commission is also to look and try to get a cross section of both medical and surgical procedures and diagnoses to include in that 50 most common episodes of care. [SPEAKER CHANGES] Mister chairman? If I may. [SPEAKER CHANGES] Senator Rucho. [SPEAKER CHANGES] Senator McKissick, it's designed to find the 50 that we can compare and contrast the cost and all the other things with it, and therefore the Medical Care Commission will help us determine what those 50 that would be best, helpful in achieving that information. [SPEAKER CHANGES] First, I think it's a great

idea what you’re doing in here, and I think it will really be like a bill of rights for patients to get this kind of information. Right now it really isn’t available so people can conduct an intelligent comparative analysis. Can I ask one quick follow up for the bill sponsors? And that is what have we done to work with small hospitals, because I know some small rural hospitals have somewhat limited staff and limited capacity. Are we allowing any special provisions for these smaller hospitals? Perhaps in rural areas. I think for the big boys, they’re going to be able to handle it all, but some of the smaller one will be faced with more challenging staff and resources. [SPEAKER CHANGES] Mr. Chair. [SPEAKER CHANGES] Senator McKissick, I have the same concerns. I have one of those and I think the more information we can get, I think the more that we can hopefully help those hospitals. I think this bill will get some information to allow us to do that. [SPEAKER CHANGES] Excellent and at an appropriate time, I’ll move for a favorable report. [SPEAKER CHANGES] Senators, can I give you a process of what I’m going through. Right now I wanted to see if we could get to staff for any technical questions about what the bill does. I know there’s a lot of interest and a lot of people are going to speak. We have two members of the of the community that want to speak, we’re going to hear from those and then we’ll open it up for questions and debate across, but at that time I anticipate I will limit members to one question and one follow up coming from those. We’ve got, in the time period allowed, I think that’s going to be very necessary to make sure this moves through. Staying on the area of technical questions, Senator Tucker, did you have… [SPEAKER CHANGES] Mr. Chair, I’ll...I’ve got a series of questions to ask. Perhaps I can get with staff later on, I’m not going to be able to do anything.I’ve got a whole page of questions to ask. You’ve seconded one, I just can’t do it justice with one question. Thank you sir. [SPEAKER CHANGES] And Senator Bingham. [SPEAKER CHANGES] Thank you, Mr. Chair. The 50 procedures that was mentioned. When can we get copies of that? Or get some information? I’m very interested in that, I appreciate the bill, but that’d be helpful in understanding this bill. [SPEAKER CHANGES] My understanding is that what we’re doing is requesting that from the Medical Cares Commission to come forward. That’s part of all of this collection of information. They will first determine what would be the ordinary 50 episode and then from that point forward there would be a data collection so we don’t have them yet because of the fact that this all part of the process of setting up a system with CNCC and the HIE and then subsequently asking the hospitals and the ambulatory facilities to provide that information based on the 50 that would be considered across the board basic procedures. [SPEAKER CHANGES] I understand. May I ask, when will we expect that? Are we talking about two months, six years, or… [SPEAKER CHANGES] Medical Care Commission is supposed to have those rules in place by January 1st 2014 [SPEAKER CHANGES] Senator Kinnaird. [SPEAKER CHANGES] I’ve just...think this an awfully big subject and I’m just wondering, are you intending to finish it up today or will this go over because many of the question I don’t know about two pages worth, but the question that he has might be questions that all of us would like to hear answered and I’m just wondering if this is maybe a little big for the next 20 minutes, especially since I know we’re going to hear from members of the public who are interested in this and so I’m just wondering are you intending only today? Or are you going to run over into another area. [SPEAKER CHANGES] Senator Kinnaird, and I will say with once a week meeting to draw this to a second meeting, there will be several bills that will not be eligible for crossover and doing so, it is my intent that we will finish this bill. It is also my understanding that this bill will be referred from here, most likely, to finance as it continues its direction. Senator Allran. [SPEAKER CHANGES] Mr. Chairman, may I ask a question that’s not so technical, or we still on the technical. [SPEAKER CHANGES] We’ll come back to those. [SPEAKER CHANGES] Okay, thank you. [SPEAKER CHANGES] Seeing no others, the two members that we have from. Senator Clark. [SPEAKER CHANGES] I know everybody does not want to hear from me on this topic today. On the common procedure, the first question is, how did we did decide to use episode of care as the unit of measure. [SPEAKER CHANGES] As best I can tell you, this

Not just like a procedure, the episode of care means coming into your pretreatment into a hospital ambulatory facility, through the entire treatment process and for a period of time afterwards. So there was the episode of care rather than a single procedure so that we can follow the patients progress and the costs that go with it. [SPEAKER CHANGES] Mr. Chair. [SPEAKER CHANGES] I believe episode of care is a term of art used in describing a block of procedures similar,. or I shouldn't say similar but there have been... [SPEAKER CHANGES] Ma'am I don't mean to interrupt and imply, I don't mean no disrespect, I absolutely know what an episode of care is and how it's defined. The question to be specific is how do we select that as the unit of measure. The reason being because most hospitals I will tell you in the state will not be able to comply with this on an episode of care direct measure because for one we probably have this three days before, 30 day limit. Half the episodes of care as defined, particularly in chronic care events, hypertension, dialysis, those things, can go 60 days or 180 days, so we'd be requiring or requesting partial payment information. Where a much better set would be for operations procedures or DRG codes for doing things on an impatient, outpatient basis we'll be using CPD hick pics [??] which are measured an compared right now and you can get very specific for comparison purposes. And then you've got the issues we talked about common procedures. I mean common too, is there going to be an acute care facility, community facility, is it going to be a tertiary care and academic medical center, what about specialty hospitals? They're doing different things for behavioral health, psych hospitals, children's hospitals, rehab facilities, it would vary by season as strange as it sounds. Outer banks with 19 beds is going to have a different set of common episodes of care or procedures in the summer so that we're... [SPEAKER CHANGES] Look, the one thing I will say first of all is episodes of care are common statewide and established for the year. They don't vary, they don't change, they are the 50 that are established and so seasonal factors will not change them within the internal. But I think - go ahead... [SPEAKER CHANGES] It was looked at in trying to stay consistent with medicare, and we had to have some kind of continuous thread through these systems, that's why it was chosen in that way. Can it be adjusted and refined a little bit? Of course, but that is the core thread that we want to have so we consistency to make those comparisons. [SPEAKER CHANGES] Senator [??]. [SPEAKER CHANGES] Mr. Chairman I have at least two questions and one amendment. Now, which is.. [SPEAKER CHANGES] Ask your technical question first. [SPEAKER CHANGES] It actually has to do with section six, identifying community care in North Carolina. Community care networks is a private non-profit corporation. We are directing the modification to their board for whatever reason, and I'm not saying - it seems to me that and I hate to use the word constitutional sometimes but we have a constitutional provision relating to our directing certain kinds of corporations to be established, we cannot do that other than by the general law. and doing this is creating some kind of composite and I'm just trying to figure out the mechanics of this and the appropriateness of [??] the context. [SPEAKER CHANGES] Senator Hartsell we're trying to utilize existing facility with CNCC and then they've already acquired HIE so they're all under that umbrella. And am I correct about that? That's part of the system, that's correct. And what we're trying to do is today CNCC is all based on providers. what we're trying to find is putting some people int here that pay the bills so that they can be part of that system and that's where we're making some requests as to the change of the board so that it could actually reflect what we're trying to do and that is to get to the core of what the cost is of healthcare, and this is what that effort is. [SPEAKER CHANGES] Mr. Chairman I understand that, my question has to do with compelling the structure in a constitutional context because we're actually taking a non-profit and requiring it to become a quasi [??] public agency, which we may want to do but I'm not - and it says it's by request or whatever and I'm just trying to figure out what that... [SPEAKER CHANGES] Mr. Chair.

Senator Hartsell, I, maybe it will help, it's not a, they're not directed to make these changes but if they want to continue to contract with DHHS, so it's, they're using the contract. It's not a direct, "you have to change," it's, "if you want to do business with the state this is what we want you to look like." [SPEAKER CHANGES] I understand that's what it says but that's about as much as a mandate as I've ever seen and my concern is, to the extent that it is that, does it violate the technical constitutional provision relating to our setting up private corporations, or however. That's my concern. [SPEAKER CHANGES] I would, to the others that support that it is, as much as it is that it is not, it is merely a directive to the department as to who they may contract with. [SPEAKER CHANGES] In the chaos we have with the department, this, setting this up is another, is a, I just, it's just a red flag is what I'm trying to- [SPEAKER CHANGES] I, Senator Hartsell, I understand and we can sure take a look at that but I think you see what we're trying to do and we'll just make sure we do it the right way. So we can take a look at that. [SPEAKER CHANGES] I will remind committee members we have a House Committee coming in at 12:00 so we're staying on technical questions in regards to the bill right now. We'll get to public then we'll get to the amendment and start moving so technical questions, Senator Stein. [SPEAKER CHANGES] I have one technical and one substantive, I hope that's alright, both dealing with the same subject. Part 6, this Community Care Board issue, is there, at what point does this have to happen? They're, they have contracts currently and I don't see in the effective date where section 12 is contemplated. It can't happen instantaneously, so that's my technical question. [SPEAKER CHANGES] I would assume the provision is effective when it becomes law, I would assume that it ... is actually implemented when contracts come up for renewal or other contracts are there to be let. [SPEAKER CHANGES] Okay, thank you. And my substantive comment on this is that CCNC works because it is a provider-based system. You get all the different providers together, creating a medical home for the patient and working cooperatively to achieve a good health outcome for the patient, and messing with the board might jeopardize the core of what that organization is and so I just want to flag that as, I can understand what your goal is about trying to get some more business representation, actuarial skills, on the board but you run the risk of undermining the entire organization by changing its composition. So it seems, at a minimum, you would want a director to be an advisory board of people who provide it to inform the newly constituted board if you continue along this path. [SPEAKER CHANGES] Thank you for the comments. When I look at the public speak-, Senator Tarte? [SPEAKER CHANGES] Do you mind if I ask a couple- [SPEAKER CHANGES] We'll come back. We're going to make sure that we're coming back to questions. Signed up for public speaking we first have Hugh Tilson. I will recommend him to speak for a time not to exceed two minutes. [SPEAKER CHANGES] Thank you, Mr. Chairman. My name is Hugh Tilson, Senior Vice President of the North Carolina Hospital Association. First of all, I want to say that we are for transparency and encourage and appreciative of the opportunity to work with the bill sponsors on the legislation. The bill, the PCS you have before you has addressed some of our concerns and we're grateful for the opportunity to work with you. With regard to transparency, Senator Bingham, you can go to the Hospital Association's website right now and get the top 35 DRG's on the inpatient basis in terms of charges and things like that. You can also go to our website and look at charity care policies, community benefits, and get a link to hospital financial assistance policies. I say all that by way of saying that we wish to continue to work with the bill sponsors and the members of the committee to address some technical concerns we have with regards to some specific things, many of which you all have already touched on. We want to be able to comply with whatever mandates the General Assembly imposes on us to be transparent even further than we already are. We're concerned that some of the provisions we may not be able to comply with and we look forward to working with you on that. Lastly, with regard to billing and collections piece, just want you to know the struggle that your community hospitals face as non-profit, community based organizations we have a duty to help those who honestly can't help themselves. We do that all day every day. We gave away a billion dollars worth of charity care last year, it's our mission, we're proud of that.

We also have a duty to the people who actually pay their health insurance to try to make sure we’re seeking payment from those who can pay, but choose not to pay and it’s a delicate balance. You’ve read about that in a lot of the media. I just want to let you know that every hospital in your community struggles with balance. To be there all day, every day, for those who legitimately need that service and can’t otherwise fend for themselves, but trying to work with those who can have the ability to pay, but choose not to pay. To make sure that we are collecting from them as reasonable as we can to minimize the cost that are put on to those who actually pay their health insurance bills. Again, appreciate very much the opportunity to work with ya’ll. We do have some technical questions and will look forward to the opportunity as this bill moves to address those. Thank you. [SPEAKER CHANGES] Next, finally we have Mark Flemming recognized for a period not to exceed two minutes. [SPEAKER CHANGES] Thank you, Mr. Chairman. Blue Cross/Blue Shield North Carolina, we also have been a leader and have been working hard on the issue of transparency. We are running TV ads on the issue. We have a website - letstalkcosts.com, encourage you to go to the site. On the issue, and we have enjoyed and appreciate working with the bill sponsors Senator Rucho and Senator Brown. Our transparency tool that is available for our 3.7 million members, they can go online right now and compare costs on a hundred non-emergency medical elective procedures at hospitals across North Carolina. Members can use that data and compare costs and make decisions on where they’re going to go to have their procedures done. We’ve just gotten a copy of this new PCS, we still do have some concerns with some of the language and we look forward to, and we’ll continue to look forward to working with the staff and the sponsors. On the third part of the bill on radiology, we do have some strong concerns about that language. We are currently in litigation on the appeals process on this radiology issue. We would strongly recommend that some of that language should be changed because of the impact that it could have on our litigation. If you will remember, this came about a couple years ago because of a reimbursement policy that we tried to implement on multiple billing on radiology issues, so again, we would look forward to working with the staff and the members to correct that part of the bill. [SPEAKER CHANGES] Thank you, Mr. Flemming. Appreciate it. Thank you, we have exhausted the members who would like to have spoke on the bill. I will begin then by recognizing Senator Hartsell who would like to send forth an amendment. [SPEAKER CHANGES] Mr. Chairman. The copies up front will need to be distributed, we don’t necessarily have our dashboards with us here at the moment that I’m aware of. I have the original. It’s a fairly simple amendment that I can explain fairly easily. [SPEAKER CHANGES] If we’ll suspend while they’re being handed out. [SPEAKER CHANGES] I’ll be glad to try to explain it while they’re… Mr. Chairman if you want me to. [SPEAKER CHANGES] Senator Hartsell to explain his amendment. [SPEAKER CHANGES] Thank you, Mr. Chair, members of the committee. What the amendment does is simply remove the section involving hospital debt collection for the UNC hospitals and essentially Pitt Memorial or ECU. The reason to do so, and I understand and I’ve mentioned this to Senator Rucho, and I had...

Can't say anything to Senator Brown. The rationale for removing them is that we need to put everybody in the same position. Well the fact of the matter is UNC Hospital and ECU are state agencies. They are hospitals of last resort in this state and they are different. And I would contend that - the argument that comes back - and it seems to me that if we don't prevent them to continue to do what they are doing now then we as a General Assembly are going to be subsidizing folks that we could otherwise pay from setoff debt collection with appropriation from the General Assembly and it seems to me it's appropriate to get the payees to pay it from the setoff debt collection otherwise. I'll say this from a personal experience. If one were to go downstairs to my office you would find a bill to me for some procedures that were done by my wife at UNC Hospitals a couple months ago. I have a dispute with them about what that is because I can't figure out whether they've said anything back and forth but the fact of the matter is I'll do what everybody else does and that's wait till the last minute, try to figure it out, contact them, say "Okay have you checked this? Have you checked that?" At some point it tends to be about a year before they ever get to it and we work it out maybe one way or another. But the fact of the matter is if I owe it it ought to get paid. And if it can be paid, and these are state hospitals just like other state agencies that utilize setoff debt collection, we ought to be able to permit them to do it and I submit that it's appropriate for us to permit them to continue to do what they're already doing or otherwise we're going to be subsidizing them in a similar fashion. [SPEAKER CHANGES] Members of the committee I'll respond to that amendment. We look at this seriously and we've also been approached - I think it was last year if I'm not mistaken - Newhanover County the hospital there asked if they could also get included into the ability to garnish the income tax refunds and I hope there are enough lottery winners out there to pay something but under that circumstance, garnishment is the most extreme type of bill collection and as Senator Hartzell alluded to, he's got a bill he's struggling with - I had a bill for 26,000 dollars and tried to make ?? of what was included in there especially for 3 hours worth of work in a outpatient setting - that was a lot of money I thought, but under the circumstances it is confusing and what our concern is that once as the time runs out as Senator Hartzell alludes to it gets to the point where they can't get to some agreement then that gets turned over to the ultimate collector and that is the Department of Revenue. At that point if Senator Hartzell owes 10,000 dollars according to that bill he doesn't have a chance to discuss the bill anymore it's a matter of putting the 10,000 dollars down and what we're saying is every hospital in the state of North Carolina who's also trying to take care of the patients should be treated the same and we if we allow the ECU and UNC hospital as Senator Hartzell say it may be, they're battling in a situation where they're competing with a number of other hospitals that are trying to do the same thing but they should follow the same rules as everyone else and if they find they get to a point where they can't get the bill resolved then it goes to normal debt collection and that's where it ought to be. They shouldn't be using the power of the Department of Revenue with a hammer to make those collections. It's not right it's not fair for the consumer and we do need to protect the consumer as much as protect the hospitals. [SPEAKER CHANGES] Thank you. We have 4 minutes and 40 seconds remaining. If I might just say, I understand exactly what Senator Rucho is saying and we disagree on other things, the fact of the matter is though these are hospitals of last resort, they're state agencies. There are processes for appeals for various other things and whether it goes to the collections office of the hospital or the Department of Revenue. There is a mechanism, it's actually not a garnishment, it's a process that's out there and I wish I had a 10,000 dollar refund that we could pay something and still argue about but I probably don't. I'm simply saying that they are different, they are state agencies, they are compelled by not just us but by the people of North Carolina to provide certain services and if they're eligible for these kinds of set offs then they ought to

Forget them. [SPEAKER CHANGES] Mr. Chairman real quick. Senator Hartzell I don't think you can convince all these other hospitals that that may be the case. Now it could be and it is I guess that you could argue that but I don't think you could argue - I don't think my hospital in Jacksville would tell you when that patient goes in that emergency room that they have that option to send them to UNC or ECU necessarily. They do but their first goal is gonna be to take care of that patient. And they don't have that same right. And I just think it puts everybody in the same playing field. [SPEAKER CHANGES] That the other hospitals don't have the educational requirements, I mean they may have some educational components. These 2 operations provide a lot of services through the education and the residents and all these other folks don't have and if we don't let the state agencies do their jobs we're gonna have to end up subsidizing with the other ways anyway and the people who are actually receiving the services may walk off scott and I don't think that's - [SPEAKER CHANGES] Senator Hartzell's move to the adoption of his amendment. All those in favor will say aye, all those opposed no. The no's have it and the amendment fails. Senator Tucker. [SPEAKER CHANGES] I'm sorry sir it's not enough time. Thank you. [SPEAKER CHANGES] Senator McKissick has moved for a favorable report on the bill unfavorable to the original committee substitute [SPEAKER CHANGES] If I could just say one thing. I have been contacted by my hospital, UNC. They're concerned over the multiple imaging and it's a little unclear and that's why I was hoping we could run this over. Since I have no time I just wanted to say that I have been contacted by the UNC hospitals with great concern over their multiple imaging schedules and I wish we were [SPEAKER CHANGES] Senator McKissick go ahead. [SPEAKER CHANGES] We made some adjustments to that piece of the bill and I think we should have handled at least a decent compromise. [SPEAKER CHANGES] Senator McKissick has moved the committee substitute unfavorable as the original bill. We will add to that a referral to finance for individuals. All those in favor, favorable report say aye. Opposed no. The ayes have it. Thank you.