The TEACH STATES Act
Transparent Error Analysis, Candor, and Healthcare Standards to Encourage Adoption by the States Act
A Model Federal Medical Error Public Reporting Incentive and Patient Safety Protection Act
Section 1. Short Title
This Act may be cited as the Transparent Error Analysis, Candor, and Healthcare Standards to Encourage Adoption by the States Act, or the TEACH STATES Act.
Section 2. Congressional Findings and Constitutional Basis
Congress finds that:
- Serious medical errors resulting in death or injury requiring medical treatment are matters of national public health, patient safety, health care quality, and fiscal integrity.
- Federal health care programs, including Medicare, Medicaid, the Children’s Health Insurance Program, federally supported public health programs, health information technology programs, hospital preparedness programs, and quality-improvement programs, have a direct interest in reducing preventable patient harm.
- The federal government expends substantial funds to support state health care systems, public health infrastructure, hospital preparedness, Medicaid and CHIP administration, patient safety, and health care quality.
- A national floor for serious medical-error reporting, investigation, public learning, and protected safety analysis will improve patient safety and reduce preventable death, injury, waste, defensive medical practice, and avoidable public expense.
- Existing federal law recognizes that patient-safety information should receive privilege and confidentiality protections in order to encourage reporting and analysis of medical errors. The Patient Safety and Quality Improvement Act protects patient safety work product and encourages reporting, but the existing federal framework remains largely voluntary.
- Serious medical error should not remain a voluntary reporting matter when the consequence is death or injury requiring medical treatment.
- The purpose of this Act is to encourage, but not commandeer, States to adopt a serious medical-error public reporting and protected investigation system.
- Congress does not command any State legislature to enact or administer a federal regulatory program. Instead, Congress establishes clear, prospective, related, and limited conditions on certain federal health-system assistance.
- The conditions imposed by this Act are intended to satisfy the constitutional requirements for Spending Clause legislation: they promote the general welfare, are stated unambiguously, relate to the federal interest in health care quality and patient safety, do not require unconstitutional state action, and are limited so that the financial inducement remains encouragement rather than coercion.
- Congress intends this Act to follow the constitutional principles recognized in South Dakota v. Dole, while avoiding the coercion concerns identified in National Federation of Independent Business v. Sebelius.
Section 3. Definitions
For purposes of this Act:
3.1 “Secretary”
“Secretary” means the Secretary of Health and Human Services.
3.2 “State”
“State” means any State of the United States, the District of Columbia, Puerto Rico, Guam, American Samoa, the United States Virgin Islands, and the Northern Mariana Islands.
3.3 “Compliant State Medical Error Law”
“Compliant State Medical Error Law” means a State statute, regulation, or enforceable legal framework certified by the Secretary as substantially satisfying Section 5 of this Act.
3.4 “TEACH Act”
“TEACH Act” means a State law substantially equivalent to the Transparent Error Analysis, Candor, and Healthcare Learning Act, requiring immediate reporting, full investigation, public de-identified learning reports, discovery immunity for protected safety investigation material, preservation of original evidence, and loss of protection for cover-up.
3.5 “Covered Federal Health-System Assistance”
“Covered Federal Health-System Assistance” means federal funds payable to a State government, or to a State agency, for health care quality, health care administration, patient safety, public health infrastructure, health information technology, hospital preparedness, health-system oversight, Medicaid administration, CHIP administration, health care workforce safety programs, or health-system improvement.
Covered Federal Health-System Assistance includes, to the extent determined by the Secretary by regulation:
- Federal public health infrastructure grants;
- Federal hospital preparedness and health-system readiness grants;
- Federal patient-safety and health care quality grants;
- Federal health information technology grants payable to States;
- Federal Medicaid administrative matching funds;
- Federal CHIP administrative matching funds;
- Federal quality-improvement, oversight, and program-integrity grants payable to States; and
- Any other federal health-system assistance to States that the Secretary determines is directly related to patient safety, health care quality, public health reporting, or health-system oversight.
3.6 Funds Excluded from Covered Federal Health-System Assistance
Covered Federal Health-System Assistance does not include:
- Medicare benefit payments;
- Medicare payments to providers, suppliers, plans, or beneficiaries;
- Medicaid medical-assistance payments for covered services;
- CHIP child-health-assistance payments for covered services;
- Veterans Health Administration benefit payments;
- Indian Health Service direct care funds;
- Social Security benefits;
- Direct patient benefits;
- Direct provider reimbursement for patient care; or
- Any funds whose withholding would directly reduce a patient’s eligibility for, or receipt of, medically necessary care.
3.7 “Reportable Serious Medical Error”
“Reportable Serious Medical Error” means any known or reasonably suspected medical error, adverse medical event, preventable harm event, system failure, diagnostic failure, medication failure, procedural failure, device failure, communication failure, staffing failure, monitoring failure, discharge failure, or other health care-related event that results in:
- Death;
- Injury requiring medical treatment;
- Unplanned transfer to a higher level of care;
- Prolonged hospitalization;
- Emergency medical treatment caused by the event;
- Permanent or temporary loss of bodily function requiring medical treatment;
- Unplanned surgery, procedure, medication, transfusion, device intervention, or therapeutic intervention; or
- Any other event designated by the Secretary as reportable because of severity, preventability, recurrence risk, or public safety importance.
3.8 “Protected Patient Safety Investigation Material”
“Protected Patient Safety Investigation Material” means all analyses, findings, conclusions, interview statements, root-cause analyses, apparent-cause analyses, safety recommendations, drafts, deliberations, causal maps, internal memoranda, corrective-action deliberations, preventability assessments, and other materials created, assembled, obtained, or used primarily for a patient safety investigation required under a Compliant State Medical Error Law or under the federal default reporting program established by this Act.
3.9 “Original Medical Record or Independently Existing Evidence”
“Original Medical Record or Independently Existing Evidence” means medical records, billing records, discharge records, orders, medication administration records, laboratory records, imaging records, device logs, electronic health record audit trails, staffing records, policies, communications, physical evidence, and other information that exists independently of a patient safety investigation.
3.10 “Public Learning Report”
“Public Learning Report” means a de-identified public report describing a reportable serious medical error, its contributing factors, safety lessons, and corrective actions, without identifying patients, individual clinicians, reporters, witnesses, reviewers, or other natural persons.
3.11 “Cover-Up”
“Cover-up” means any knowing, reckless, or intentional act or omission designed to conceal, falsify, alter, destroy, suppress, delay, mischaracterize, or prevent reporting or investigation of a reportable serious medical error.
Cover-up includes, but is not limited to:
- Falsifying, altering, backdating, or destroying records;
- Directing or inducing any person to provide false or misleading information;
- Retaliating against a person for reporting a medical error or participating in an investigation;
- Failing to report a serious medical error as required by State or federal law;
- Knowingly submitting a materially false or misleading report;
- Concealing an ongoing hazard after actual or constructive notice of that hazard;
- Preventing patient or family participation required by law; or
- Failing to conduct or complete a required patient safety investigation.
Section 4. Federal Policy
It is the policy of the United States that:
- Every reportable serious medical error should be reported promptly;
- Every such event should be investigated fully and immediately;
- Every investigation should identify all converging human, technical, organizational, environmental, diagnostic, medication, device, staffing, communication, supervision, training, policy, and financial-pressure factors;
- De-identified safety lessons should be published for public learning;
- Protected patient safety investigation materials should be immune from civil discovery and evidentiary use;
- Original medical records and independently existing evidence should remain available under otherwise applicable law;
- Candor should be protected;
- Cover-up should be punished; and
- Federal funding should support States that adopt and enforce this patient-safety framework.
Section 5. Requirements for a Compliant State Medical Error Law
To receive full Covered Federal Health-System Assistance under this Act, a State shall adopt and enforce a Compliant State Medical Error Law.
A State law shall be certified as compliant if the Secretary determines that it substantially contains each of the following elements.
5.1 Mandatory Reporting
The State law shall require health care entities and health care personnel to report known or reasonably suspected reportable serious medical errors.
The State law shall require:
- Internal reporting within 24 hours after discovery;
- Reporting to the State health agency within 72 hours after discovery;
- Supplemental reporting when material new information becomes known; and
- Immediate notification to the State health agency if an ongoing hazard presents substantial risk to other patients.
5.2 Mandatory Preservation of Evidence
The State law shall require immediate preservation of original medical records and independently existing evidence, including medical records, device data, audit trails, medication records, staffing records, policies, communications, and physical evidence.
5.3 Mandatory Patient Safety Investigation
The State law shall require a prompt and complete patient safety investigation of each reportable serious medical error.
The investigation shall identify all contributing factors, including clinical, diagnostic, medication, communication, equipment, device, staffing, training, supervision, policy, workflow, electronic health record, environmental, leadership, production-pressure, and financial-pressure factors.
5.4 Patient and Family Participation
The State law shall require a health care entity to offer the patient, patient representative, or family a reasonable opportunity to provide information relevant to the investigation.
5.5 Disclosure to Patient or Patient Representative
The State law shall require plain-language disclosure to the patient or patient representative that:
- A serious adverse event or suspected medical error occurred;
- An investigation has begun;
- The patient or patient representative may provide information;
- Corrective steps are being considered or taken; and
- A de-identified public learning report will be published when complete.
5.6 Public Medical Error Learning Registry
The State law shall require a publicly accessible online medical-error learning registry.
The registry shall publish de-identified public learning reports searchable by event type, care setting, specialty, medication, device, diagnosis, procedure, workflow, contributing factor, and corrective action.
5.7 Required Contents of Public Learning Reports
The State law shall require each public learning report to include, in de-identified form:
- General care setting;
- General event type;
- General nature of the harm;
- Plain-language description of what happened;
- Contributing factors identified;
- Safeguards that failed or were absent;
- Corrective actions taken or planned;
- Schedule for corrective action;
- Method for verifying completion and effectiveness; and
- Broader safety lessons for other health care entities.
5.8 Privilege and Immunity from Discovery
The State law shall provide that Protected Patient Safety Investigation Material is privileged, confidential, immune from discovery, immune from subpoena, inadmissible in evidence, and unavailable for use in civil litigation, administrative proceedings, arbitration, professional disciplinary proceedings, credentialing disputes, employment proceedings, or public-records requests.
5.9 Protection of Findings
The State law shall specifically immunize from discovery and evidentiary use all findings, conclusions, causal analyses, root-cause analyses, preventability assessments, safety recommendations, corrective-action analyses, witness statements made for the investigation, drafts, deliberations, and internal communications created for the patient safety investigation.
5.10 Preservation of Original Evidence
The State law shall provide that original medical records and independently existing evidence do not become privileged merely because they are reviewed, copied, preserved, discussed, or analyzed during a protected patient safety investigation.
5.11 No Waiver
The State law shall provide that privilege and confidentiality are not waived by:
- Reporting to a State agency;
- Reporting to a federal agency;
- Reporting to a patient safety organization;
- Disclosing information to the patient or patient representative;
- Publishing a de-identified public learning report;
- Disclosing protected material to contractors, consultants, experts, insurers, reinsurers, attorneys, auditors, accrediting bodies, or quality-improvement organizations for patient safety purposes; or
- Using protected material for internal education, quality improvement, credentialing, peer review, or corrective action.
5.12 Cover-Up Exception
The State law shall provide that cover-up is not protected.
A health care entity or person who engages in cover-up shall be subject to civil penalties, regulatory sanctions, referral to licensing authorities, and loss of privilege to the limited extent necessary to prove the cover-up after in camera judicial review.
5.13 Anti-Retaliation Protection
The State law shall prohibit retaliation against any person who reports a medical error, participates in an investigation, refuses to participate in cover-up, discloses an ongoing substantial patient-safety risk, or assists a patient or family in providing information.
5.14 Enforcement
The State law shall authorize meaningful civil penalties, corrective-action orders, audits, compliance reviews, referral to licensing boards, and public aggregate reporting.
5.15 Annual Statewide Patient Safety Report
The State law shall require the State health agency to publish an annual aggregate report summarizing:
- Number and type of reportable serious medical errors;
- Care settings involved;
- Common contributing factors;
- Recurrent hazards;
- Corrective-action categories;
- Compliance trends;
- Enforcement actions; and
- Recommendations for statewide patient-safety improvement.
Section 6. State Certification
6.1 Submission
Each State seeking full Covered Federal Health-System Assistance shall submit to the Secretary a certification that the State has enacted and is enforcing a Compliant State Medical Error Law.
6.2 Contents of Certification
The certification shall include:
- The text of the State law and implementing regulations;
- Description of the State reporting system;
- Description of the State medical-error learning registry;
- Description of enforcement procedures;
- Description of privilege and discovery protections;
- Description of patient and family disclosure procedures;
- Description of anti-retaliation protections;
- Data on implementation, reporting, and publication; and
- Any additional information required by the Secretary.
6.3 Review
The Secretary shall approve, conditionally approve, or disapprove a State certification within 180 days after submission.
6.4 Substantial Compliance
The Secretary may certify a State law that is substantially equivalent to the requirements of this Act, even if the State uses different terminology, procedures, agencies, or enforcement mechanisms.
6.5 Conditional Approval
The Secretary may conditionally approve a State for up to two fiscal years if the State has enacted a substantially compliant law and is making good-faith progress toward implementation.
Section 7. Funding Condition and Withholding
7.1 Condition on Federal Funds
Beginning with the first fiscal year that begins at least two years after enactment of this Act, a State shall not receive 5% of its otherwise payable Covered Federal Health-System Assistance unless the Secretary certifies that the State has adopted and is enforcing a Compliant State Medical Error Law.
7.2 Scope of Withholding
The withholding under this section shall apply only to Covered Federal Health-System Assistance.
The withholding shall not apply to:
- Direct patient benefits;
- Medicaid medical-assistance payments for covered services;
- CHIP child-health-assistance payments for covered services;
- Medicare payments;
- Direct provider reimbursement for patient care;
- Veterans Health Administration patient-care payments;
- Indian Health Service direct care funds; or
- Any amount whose withholding would directly reduce a patient’s eligibility for, or receipt of, medically necessary care.
7.3 Maximum Withholding
The maximum annual withholding under this Act shall be 5% of Covered Federal Health-System Assistance otherwise payable to the State for that fiscal year.
7.4 Notice
Before withholding funds, the Secretary shall provide the State with:
- Written notice of noncompliance;
- Specific reasons for the determination;
- A description of required corrective action;
- At least 180 days to cure the noncompliance; and
- Opportunity for administrative review.
7.5 Good-Faith Reduction
The Secretary may reduce the withholding to not less than 1% for a fiscal year if the State demonstrates good-faith progress toward compliance.
7.6 Waiver for Extraordinary Circumstances
The Secretary may waive withholding for one fiscal year if extraordinary circumstances prevent compliance and the State submits an acceptable corrective-action plan.
7.7 Restoration of Funds
Withheld funds may be restored to the State if the State achieves certification within the same fiscal year, subject to regulations issued by the Secretary.
7.8 Use of Withheld Funds
Funds withheld under this Act shall remain available to the Secretary for:
- Patient safety implementation grants;
- Federal default reporting and registry activities;
- Grants to health care entities in noncompliant States to implement reporting systems;
- Grants to States seeking to become compliant;
- Technical assistance;
- Research on medical-error prevention; and
- Public education on patient safety.
Section 8. Federal Default Reporting Program
8.1 Establishment
The Secretary shall establish a Federal Medical Error Reporting and Learning Program for use in States that are not certified under this Act.
8.2 Voluntary Provider Participation
A health care entity in a noncertified State may participate in the federal default program by reporting reportable serious medical errors to the Secretary or to a federally listed patient safety organization designated by the Secretary.
8.3 Federal Public Learning Registry
The Secretary shall maintain a federal public learning registry for de-identified public learning reports received under the federal default program.
8.4 Federal Privilege
Protected Patient Safety Investigation Material submitted, created, assembled, or analyzed under the federal default program shall receive the privilege and confidentiality protections provided by this Act.
8.5 No Preemption of Stronger State Law
The federal default program shall not preempt a State law that provides equal or greater public reporting, investigation, privilege, confidentiality, anti-retaliation, or enforcement protections.
Section 9. Federal Privilege and Immunity
9.1 General Rule
Protected Patient Safety Investigation Material created, assembled, obtained, maintained, submitted, or analyzed under a Compliant State Medical Error Law or the federal default reporting program is privileged and confidential.
9.2 Discovery and Subpoena Protection
Protected Patient Safety Investigation Material shall not be:
- Subject to subpoena;
- Subject to discovery;
- Subject to civil investigative demand;
- Subject to public-records disclosure;
- Admitted into evidence;
- Used for impeachment;
- Used as a basis for expert testimony;
- Used to prove negligence, causation, standard of care, liability, damages, notice, foreseeability, recklessness, professional misconduct, or institutional fault; or
- Used in any civil, administrative, arbitration, licensing, credentialing, employment, or professional disciplinary proceeding.
9.3 Protection of Findings
All findings, conclusions, contributing-factor analyses, root-cause analyses, preventability assessments, safety recommendations, corrective-action deliberations, and implementation analyses are absolutely privileged and immune from discovery and evidentiary use, except as expressly provided in this Act.
9.4 Protection of Statements
Statements made for purposes of a patient safety investigation by health care personnel, patients, patient representatives, family members, witnesses, reviewers, consultants, or investigators are privileged and immune from discovery and evidentiary use.
9.5 Protection of Public Learning Reports
A de-identified public learning report may be used for public health, research, policy, education, and safety improvement, but shall not be admissible in civil litigation or administrative proceedings to prove negligence, causation, standard of care, liability, damages, notice, foreseeability, recklessness, or professional misconduct.
9.6 Original Evidence Preserved
Nothing in this Act shall prevent discovery or use of original medical records or independently existing evidence, subject to otherwise applicable law.
Section 10. Cover-Up Exception
10.1 No Protection for Cover-Up
Nothing in this Act protects cover-up.
10.2 Motion Required
A party seeking disclosure of Protected Patient Safety Investigation Material to prove cover-up must file a motion supported by specific facts establishing a substantial basis to believe that cover-up occurred.
10.3 In Camera Review
Before ordering disclosure, the court shall conduct an in camera review.
10.4 Standard for Disclosure
The court may order disclosure only if it finds by clear and convincing evidence that:
- Cover-up occurred;
- The material sought is directly relevant to proving the cover-up;
- The information cannot reasonably be obtained from nonprivileged sources;
- Disclosure is narrowly tailored; and
- A protective order will adequately protect confidentiality.
10.5 Limited Disclosure
Any disclosure ordered under this section shall be limited to the materials directly necessary to prove cover-up and shall not constitute general waiver of privilege.
10.6 Criminal Conduct
Nothing in this Act immunizes criminal conduct, intentional patient harm, intentional falsification, intentional destruction of evidence, fraud, obstruction of justice, or retaliation.
Section 11. Anti-Retaliation
11.1 Prohibited Retaliation
No health care entity, State agency, employer, insurer, contractor, or other person may retaliate against any person because that person:
- Reports a serious medical error;
- Participates in a patient safety investigation;
- Provides information to a State or federal agency;
- Refuses to participate in cover-up;
- Discloses an ongoing substantial patient-safety risk; or
- Assists a patient or family in providing information.
11.2 Remedies
A person subjected to retaliation may bring a civil action for:
- Reinstatement;
- Restoration of privileges;
- Back pay;
- Front pay;
- Compensatory damages;
- Injunctive relief;
- Attorney fees and costs; and
- Any other appropriate relief.
Section 12. Patient Privacy and De-Identification
12.1 HIPAA Compliance
Nothing in this Act authorizes disclosure of protected health information in violation of HIPAA or other federal privacy law.
12.2 De-Identification
Public learning reports shall be de-identified before publication.
12.3 Prohibition on Re-Identification
No person may knowingly attempt to re-identify a patient, patient representative, family member, clinician, reporter, witness, reviewer, investigator, or other natural person from a public learning report.
12.4 Penalties
The Secretary may impose civil monetary penalties for knowing re-identification or attempted re-identification.
Section 13. Technical Assistance and Grants
13.1 Implementation Grants
The Secretary may award grants to States to support:
- Drafting and enactment of compliant laws;
- Creation of medical-error learning registries;
- Reporting-system technology;
- Training of health care personnel;
- Patient and family disclosure programs;
- Anti-retaliation enforcement;
- Investigation workforce development;
- Human-factors and systems-safety analysis; and
- Publication of de-identified safety lessons.
13.2 Priority
The Secretary shall give priority to States that:
- Enact compliant laws early;
- Demonstrate high-quality public learning reports;
- Protect candor while preserving original evidence;
- Enforce anti-retaliation provisions;
- Penalize cover-up; and
- Share data with federal patient safety databases.
Section 14. Rulemaking
The Secretary shall issue regulations to implement this Act, including regulations governing:
- Certification procedures;
- Definition of Covered Federal Health-System Assistance;
- Withholding calculation;
- Notice and cure procedures;
- State reporting standards;
- Public learning registry standards;
- De-identification requirements;
- Privilege and confidentiality procedures;
- Federal default reporting;
- Grant administration;
- Data security;
- Anti-retaliation enforcement;
- Cover-up referral procedures; and
- Coordination with the Patient Safety and Quality Improvement Act.
Section 15. Administrative Review
15.1 State Review
A State may seek administrative review of a certification denial, conditional approval, or withholding determination.
15.2 Final Agency Action
A final decision by the Secretary after administrative review shall constitute final agency action for purposes of judicial review.
15.3 Limited Scope
Judicial review shall be limited to whether the Secretary’s decision was arbitrary, capricious, an abuse of discretion, contrary to law, or unsupported by substantial evidence.
Section 16. Relationship to Existing Federal Law
16.1 Patient Safety and Quality Improvement Act
This Act supplements and does not diminish the Patient Safety and Quality Improvement Act, 42 U.S.C. §§ 299b-21 through 299b-26, or 42 C.F.R. Part 3.
16.2 No Reduction of Existing Privilege
Nothing in this Act shall be construed to reduce any privilege, confidentiality, immunity, peer-review protection, quality-improvement protection, or patient-safety protection available under federal or State law.
16.3 Stronger State Laws Preserved
Nothing in this Act preempts a State law that provides stronger medical-error reporting, public learning, investigation, privilege, anti-retaliation, enforcement, or cover-up penalties.
16.4 Federal Floor
This Act establishes a federal floor for States seeking full Covered Federal Health-System Assistance.
Section 17. Non-Commandeering Construction
This Act shall be construed as an exercise of Congress’s power to provide for the general welfare by attaching clear, prospective, related, and limited conditions to federal funds.
Nothing in this Act shall be construed to command a State legislature to enact a law, to command a State executive officer to administer a federal program, or to require a State to participate in any federal program.
A State remains free to decline certification and accept the funding consequences described in this Act.
Section 18. Severability
If any provision of this Act, or the application of any provision to any person, State, entity, or circumstance, is held invalid, the remainder of the Act and the application of the remaining provisions shall not be affected.
If the 5% withholding is held excessive as applied to any State or funding category, the Secretary shall apply the maximum lower percentage permitted by law, not to exceed 5%.
Section 19. Effective Dates
19.1 Rulemaking
The Secretary shall issue proposed regulations within 12 months after enactment and final regulations within 24 months after enactment.
19.2 State Certification
States may submit certifications beginning 18 months after enactment.
19.3 Funding Condition
The funding condition in Section 7 shall apply beginning with the first fiscal year that begins at least 36 months after enactment.
19.4 Federal Default Program
The federal default reporting program shall begin not later than 36 months after enactment.
Section 20. Construction Against Coercion
This Act shall be construed to avoid unconstitutional coercion of the States.
If a court determines that the withholding of 5% of Covered Federal Health-System Assistance is coercive as applied to any State, funding stream, or circumstance, the Secretary shall reduce the withholding to the highest constitutionally permissible percentage.
No provision of this Act shall be construed to authorize withholding of funds in a manner that directly denies medical care, coverage, or benefits to patients.
Section 21. Sense of Congress
It is the sense of Congress that:
- Medical error should be treated as a public-safety event before it is treated as a private litigation event;
- The public interest is served when serious medical errors are reported immediately, investigated fully, and converted into public de-identified lessons;
- Litigation fear should not prevent hospitals, physicians, nurses, pharmacists, and other health care personnel from speaking candidly about the causes of patient harm;
- Original medical records and independently existing evidence should remain available under ordinary law;
- Safety findings, root-cause analyses, witness statements made for safety investigation, corrective-action deliberations, and public learning reports should not be turned into litigation weapons;
- Cover-up, falsification, retaliation, destruction of evidence, and knowing concealment of ongoing hazards should never receive protection; and
- Candor should be protected, public learning should be mandatory, and concealment should be punished.
Drafting Note
The most aggressive version would withhold 5% of all federal health care funds to a State. That would be constitutionally riskier after NFIB v. Sebelius. The safer version above withholds 5% only from related state-administered health-system, quality, safety, public-health, and administrative funds, while protecting direct patient benefits and provider reimbursements.
This structure is intended to mirror the Dole model: clear notice, related funds, limited percentage, no direct command to legislate, and no loss of direct patient care benefits.
