| 18 | | - | (b) As used in this section, "clinical pathway" means a structured plan of care for a defined group of patients with a particular disease or condition or who are undergoing a particular medical procedure or service, that is used by a health carrier to manage quality of care, standardize care processes or reduce or contain health care costs and "health carrier" has the same meaning as provided in section 38a-591a of the general statutes. |
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| 30 | + | (1) "Clinical pathway" means a structured plan of care for a defined group of patients with a particular disease or condition or who are undergoing a particular medical procedure or service, that is used by a health carrier to manage quality of care, standardize care processes or reduce or contain health care costs; |
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| 31 | + | |
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| 32 | + | (2) "Clinical practice guideline" means a recommendation for the performance or exclusion of a specific medical procedure or service, that is intended to optimize patient care and is derived through a systematic review of evidence and an assessment of the benefits and harms of alternative care options; |
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| 33 | + | |
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| 34 | + | (3) "Covered person" has the same meaning as provided in section 38a-591a of the general statutes; |
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| 35 | + | |
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| 36 | + | (4) "Financial incentive" means any monetary contribution or in-kind contribution or service or other thing of value, including, but not limited to, payment for the utilization of a clinical pathways program in medical decision-making, payment for using or not using a clinical pathway, eligibility to share in cost savings resulting from adherence to a clinical pathway or a health carrier's policy of considering a prescribing practitioner's participation in the health carrier's clinical pathways program, or lack thereof, in connection with such health carrier's decisions about terminating or renewing such prescribing practitioner's network participation; |
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| 37 | + | |
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| 38 | + | (5) "Health carrier" has the same meaning as provided in section 38a-591a of the general statutes; |
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| 39 | + | |
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| 40 | + | (6) "Participation in a clinical pathways program" means a prescribing practitioner's inclusion of formal consideration of a clinical pathway adopted for use by the health carrier in a therapeutic area; |
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| 41 | + | |
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| 42 | + | (7) "Prescribing practitioner" has the same meaning as provided in section 20-571 of the general statutes and is in-network; and |
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| 43 | + | |
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| 44 | + | (8) "Therapeutic area" means the disease, condition or particular procedure addressed by a clinical pathway. |
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| 45 | + | |
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| 46 | + | (b) (1) Each health carrier that adopts the use of a clinical pathway or clinical pathways program shall: |
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| 47 | + | |
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| 48 | + | (A) Ensure that each clinical pathway was developed in accordance with the following: |
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| 49 | + | |
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| 50 | + | (i) The clinical pathway was developed by (I) a multidisciplinary group of actively practicing physicians with clinical expertise in the therapeutic area, or (II) an organization generally recognized within the relevant medical community as a body with clinical expertise in the therapeutic area. A health carrier may collaborate with prescribing practitioners to include clinical pathways that are already established or integrated into such prescribing practitioners' treatment patterns, provided any such clinical pathway is in compliance with the requirements of this subparagraph; |
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| 51 | + | |
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| 52 | + | (ii) Prior to finalization, the clinical pathway was reviewed and endorsed by a formal, identified review panel of which (I) all panel members are actively practicing physicians within their respective medical specialties, and (II) a majority of panel members are board certified physicians in the relevant medical specialty; and |
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| 53 | + | |
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| 54 | + | (iii) Prior to finalization, the clinical pathway was subject to an opportunity for (I) review by stakeholders, including, but not limited to, prescribing practitioners and their professional societies, medical institutions or organizations, patients, patient advocacy groups and pharmaceutical and medical device manufacturers, and (II) public input to be considered in finalizing such clinical pathway; |
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| 55 | + | |
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| 56 | + | (B) Ensure that each clinical pathway specifies that (i) a prescribing practitioner participating in a clinical pathways program should make recommendations concerning the treatment, management or prevention of the relevant disease or condition for a specific patient in accordance with such prescribing practitioner's clinical judgment and the individual patient's needs, preferences and medical circumstances, including the use of any information provided by companion diagnostics or other diagnostic technologies, and (ii) such clinical pathway is not intended for use along with any financial incentive for a prescribing practitioner to adhere to specific treatments within the clinical pathway except in accordance with the provisions of subparagraph (B) of subdivision (2) of this subsection; |
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| 57 | + | |
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| 58 | + | (C) (i) Review and update, as appropriate, but not less than annually, each clinical pathway, except if a clinical pathway's therapeutic area is subject to rapid changes or a major development occurs in such therapeutic area, the health carrier shall review and update such clinical pathway on a more frequent regular basis, (ii) establish and maintain a procedure by which prescribing practitioners may seek a review or an update of a clinical pathway when a new treatment option becomes available, and (iii) disclose such procedure to prescribing practitioners; and |
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| 59 | + | |
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| 60 | + | (D) Provide prescribing practitioners with reasonable and readily available access to each clinical pathway. |
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| 61 | + | |
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| 62 | + | (2) No health carrier shall: |
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| 63 | + | |
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| 64 | + | (A) Adopt a clinical pathway that hinders education, research, patient screening or patient access to clinical trials; |
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| 65 | + | |
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| 66 | + | (B) Use a clinical pathway in conjunction with a financial incentive that is offered or provided to a prescribing practitioner and requires such practitioner to adhere to specific treatments within the clinical pathway for over eighty per cent of such practitioner's patients, unless (i) the health carrier maintains a procedure by which a prescribing practitioner may opt out from such adherence target when a new treatment becomes available but such clinical pathway has not yet been reviewed and updated to account for the new treatment, (ii) the health carrier maintains a program to track and evaluate health outcomes from such adherence target, and (iii) the health carrier has disclosed to prescribing practitioners the procedures described under subparagraphs (B)(i) and (B)(ii) of this subdivision; or |
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| 67 | + | |
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| 68 | + | (C) Offer or provide a financial incentive that rewards a prescribing practitioner for selecting a specific treatment, procedure or clinical pathway. |
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| 69 | + | |
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| 70 | + | (c) Each health carrier that adopts the use of a clinical pathway shall make publicly available for each such clinical pathway: |
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| 71 | + | |
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| 72 | + | (1) The scope of the clinical pathway, including the therapeutic area covered by such clinical pathway and any limitations on the patient population or treatment setting for which the clinical pathway was designed or other limitations on the scope of such clinical pathway; |
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| 73 | + | |
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| 74 | + | (2) The key clinical features of the clinical pathway, including the decision-making steps and key treatment recommendations to be made at each step; |
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| 75 | + | |
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| 76 | + | (3) The names, qualifications and any conflicts of interest of the physicians or organization that, pursuant to subparagraph (A) of subdivision (1) of subsection (b) of this section, developed the clinical pathway; |
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| 77 | + | |
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| 78 | + | (4) A listing of all panel members who participated in the review of such clinical pathway pursuant to subparagraph (B) of subdivision (1) of subsection (b) of this section. Such listing shall include the institutional affiliations, medical specialties and any conflicts of interest of such panel members; |
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| 79 | + | |
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| 80 | + | (5) The sources of evidence on which the clinical pathway is based. If the clinical pathway is based in part on a clinical practice guideline or similar document with recommendations on treatment, management or prevention of a particular disease or condition, but such clinical pathway uses a more narrow set of items or services than the underlying clinical practice guideline or similar document, the individuals or organization that developed the clinical pathway shall identify the differences between such clinical pathway and the underlying clinical practice guideline or similar document and explain why the clinical pathway excludes particular items or services; |
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| 81 | + | |
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| 82 | + | (6) A narrative summarizing the evidence on which the clinical pathway is based, including important issues the physicians or organization considered in interpreting the evidence and developing such clinical pathway; and |
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| 83 | + | |
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| 84 | + | (7) Information on the process for and timing of the health carrier's review and update of clinical pathways as required under subparagraph (C) of subdivision (1) of subsection (b) of this section. |
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| 85 | + | |
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| 86 | + | (d) Each health carrier that offers or provides a financial incentive to prescribing practitioners for participation in a clinical pathways program shall disclose to prospective covered persons, and annually to its covered persons and the Insurance Department, information about the clinical pathways such health carrier uses and any financial incentive such health carrier offers or provides to prescribing practitioners for participation in the health carrier's clinical pathways program. Such information shall include (1) a summary describing the clinical pathways used by the health carrier, (2) a statement that prescribing practitioners are offered a financial incentive to consider treatment for their patients in accordance with such clinical pathways, (3) for each clinical pathway for which the health carrier offers or provides a financial incentive to a prescribing practitioner, a description of such financial incentive or the manner in which amounts for shared cost savings are determined, (4) the Internet web site address where, or the process by which, a prospective covered person or a covered person may access the information set forth in subsection (c) of this section, (5) a specific description of the appropriate use criteria of each clinical pathway and a statement that the health carrier's practices concerning such clinical pathway conform to such appropriate use criteria, (6) the procedures by which a prescribing practitioner may opt out of a health carrier's adherence target pursuant to subparagraph (B) of subdivision (2) of subsection (b) of this section, and (7) contact information for prospective covered persons and covered persons to obtain additional information about the clinical pathways used, the financial incentives offered or provided or the prescribing practitioners to whom such financial incentives are offered or provided, by the health carrier. |
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| 87 | + | |
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| 88 | + | (e) Nothing in this section shall be construed to affect any of the rights afforded a covered person or a covered person's authorized representative under sections 38a-591a to 38a-591g, inclusive, of the general statutes. |
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| 89 | + | |
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| 90 | + | Sec. 2. Section 38a-507 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017): |
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| 91 | + | |
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| 92 | + | Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for the same or comparable services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform. Services covered under such policy and rendered by a chiropractor shall be subject to terms and conditions that are no less favorable than when such services are rendered by a physician. |
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| 93 | + | |
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| 94 | + | Sec. 3. Section 38a-534 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017): |
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| 95 | + | |
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| 96 | + | Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for the same or comparable services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform. Services covered under such policy and rendered by a chiropractor shall be subject to terms and conditions that are no less favorable than when such services are rendered by a physician. |
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