BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                      



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          |SENATE RULES COMMITTEE            |                   AB 415|
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                                 THIRD READING


          Bill No:  AB 415
          Author:   Logue (R), et al.
          Amended:  8/15/11 in Senate
          Vote:     21

           
           SENATE HEALTH COMMITTEE  :  8-0, 06/29/11
          AYES:  Hernandez, Strickland, Alquist, Anderson, Blakeslee, 
            De León, DeSaulnier, Wolk
          NO VOTE RECORDED:  Rubio

           SENATE BUS., PROF. & ECON. DEVELOP. COMM.  :  9-0, 07/06/11
          AYES:  Price, Emmerson, Corbett, Correa, Hernandez, Negrete 
            McLeod, Vargas, Walters, Wyland

           SENATE APPROPRIATIONS COMMITTEE  :  9-0, 08/25/11
          AYES:  Kehoe, Walters, Alquist, Emmerson, Lieu, Pavley, 
            Price, Runner, Steinberg

           ASSEMBLY FLOOR  :  76-0, 06/01/11 - See last page for vote


           SUBJECT  :    Healing arts:  telehealth

           SOURCE  :     Author


           DIGEST  :    This bill enacts the Telehealth Advancement Act 
          of 2011.  This bill repeals and recasts existing laws 
          related to the delivery of health care services via 
          telemedicine and replaces the term telemedicine with 
          telehealth. 

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           ANALYSIS  :    Existing law:

            1.  Establishes the Medical Board of California to 
              exercise licensing, regulation and disciplinary 
              functions in accordance with the Medical Practice Act.  
              Defines, in the Medical Practice Act, telemedicine as 
              the practice of health care delivery, diagnosis, 
              consultation, treatment, transfer of medical data, and 
              education using interactive audio, video, or data 
              communications. 

            2.  Establishes the Telemedicine Development Act of 1996 
              (TDA), which broadly defines telemedicine as the use of 
              information technology to deliver medical services and 
              information from one location to another, and imposes 
              several requirements governing the delivery of health 
              care services through telemedicine. 

            3.  Requires the health care practitioner who has 
              ultimate authority over the care or primary diagnosis 
              of the patient to obtain verbal and written informed 
              consent from the patient or the patient's legal 
              representative prior to the delivery of health care via 
              telemedicine, except when the patient is not directly 
              involved in the telemedicine interaction (e.g., health 
              care practitioners consulting with one another), in an 
              emergency situation when a patient is unable to give 
              informed consent, and the patient is under the 
              jurisdiction of the California Department of 
              Corrections and Rehabilitation or any other 
              correctional facility. 

            4.  Establishes an informed consent procedure 
              (specifically for telemedicine) that requires at least 
              all of the following information be given to the 
              patient or the patient's legal representative verbally 
              and in writing:  a) The patient or the patient's legal 
              representative retains the option to withhold or 
              withdraw consent at any time without affecting the 
              right to future care or treatment or program benefits; 
              b) A description of the potential risks, consequences, 
              and benefits of telemedicine; c) All existing 
              confidentiality protections apply; d) All existing laws 
              regarding patient access to medical information and 

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              copies of medical information and copies of medical 
              records apply; and, e) Prohibits dissemination of any 
              patient identifiable images or information from the 
              telemedicine interactions to researchers or other 
              entities from occurring without consent. 

            5.  Requires a patient or the patient's legal 
              representative to sign a written statement prior to the 
              delivery of health care via telemedicine, indicating 
              that the patient or the patient's legal representative 
              understands the written information provided pursuant 
              to 4) above and that this information has been 
              discussed with the health care practitioner, or his or 
              her designee. 

            6.  Makes the patient's written consent statement part of 
              the patient's medical record. 

            7.  Makes failure to comply with #3 to #6 above 
              unprofessional conduct, but not a misdemeanor, as 
              specified. 

            8.  Establishes procedures for physicians to obtain 
              verbal and/or written informed consent for specified 
              treatments and procedures, such as hysterectomies, 
              psychosurgery, electroconvulsive therapy, and assisted 
              oocyte production. 

            9.  Prohibits health plans and health insurers from 
              requiring face-to-face contact between a health care 
              provider and a patient for services appropriately 
              provided through telemedicine, subject to all terms and 
              conditions of the contract agreed upon between the 
              enrollee or subscriber and the plan or insurer. Applies 
              this prohibition to health plan contracts with the 
              Medi-Cal Managed Care Program only to the extent 
              telemedicine services are covered by and reimbursed 
              under the Medi-Cal fee-for-service program, and 
              Medi-Cal contracts with health plans are amended to add 
              coverage of telemedicine services and make any 
              appropriate capitation rate adjustments. 

            10. Prohibits health plans and health insurers from being 
              required to pay for consultation provided by the health 

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              care provider by telephone or facsimile machines. 

            11. Defines, for the purposes of Medi-Cal, 
              "teleophthalmology and teledermatology by store and 
              forward" as transmission of medical information to be 
              reviewed at a later time and at a distant site by a 
              physician who is trained in ophthalmology or 
              dermatology, where the physician at the distant site 
              reviews the medical information without the patient 
              being present in real time. 

            12. Prohibits, under the Confidentiality of Medical 
              Information Act, licensed or certified health care 
              professionals, clinics and health facilities, health 
              plans, and contracting entities, as defined, from 
              disclosing or using a patient's medical information for 
              any purpose not necessary to provide health care 
              services to the patient and related administrative 
              functions, without first obtaining authorization from 
              the patient or the patient's representative, as 
              specified, with exceptions. 

          This bill:

          1.Removes various requirements imposed by health care 
            service plans, health insurers, and Medi-Cal for patients 
            to receive health care services through telehealth and 
            would amend the informed consent requirements prior to 
            the delivery of health care via telehealth.

          2.Repeals the definition of telemedicine, which means the 
            practice of health care delivery, diagnosis, 
            consultation, treatment, transfer of medical data, and 
            education using interactive audio, video, or data 
            communications, not including by means of a telephone 
            conversation nor an electronic mail message between a 
            health care practitioner and patient.

          3.Defines telehealth as the mode of delivering health care 
            services and public health via information and 
            communication technologies to facilitate the diagnosis, 
            consultation, treatment, education, care management, and 
            self-management of a patient's health care while the 
            patient is at the originating site and the health care 

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            provider is at a distant site.

          4.Repeals the requirement that prior to the delivery of 
            health care via telemedicine, the health care 
            practitioner must obtain verbal and written informed 
            consent from the patient, as specified, and the 
            requirement that a patient must sign a written statement 
            prior to the delivery of health care via telemedicine. 
            The written statement is made part of the patient's 
            medical record. Instead, this bill would require a health 
            care practitioner to obtain verbal consent from the 
            patient prior to the provision of health care services 
            via telehealth and to document that verbal consent was 
            given in the medical record.

          5.Prohibits the department from requiring that a health 
            care provider document a barrier to an in-person visit 
            prior to paying for services provided via telehealth to a 
            Medi-Cal beneficiary.

          6.Repeals the prohibition for paying for a service provided 
            by telephone or facsimile and would instead prohibit the 
            department from limiting the type of setting where 
            services are provided for the patient. 

          7.Prohibits health plans and insurers from requiring that 
            in-person contact occur between a health care provider 
            and a patient before payment is made for the services 
            appropriately provided through telehealth, subject to the 
            terms of the relevant contract.

          8.Repeals the prohibition for paying for a service provided 
            by telephone or facsimile and would instead prohibit them 
            from limiting the type of setting where services are 
            provided for the patient or by the health care provider. 
            These provisions would apply to plans contracting with 
            DHCS to provide Medi-Cal managed care and would repeal 
            the requirements that telemedicine could only be used (a) 
            for telemedicine services that are reimbursed by the 
            Medi-Cal fee-for-service program and (b) that Medi-Cal 
            contracts with health plans are amended to add coverage 
            of telemedicine services and to make any appropriate 
            capitation rate adjustment. 


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          9.Repeals the existing January 1, 2013, sunset date on the 
            use of teleopthalmology and teledermatology by store and 
            forward technology and would update and define 
            terminology related to telehealth and current practice.

           Background
           
          Telehealth is a mode of delivering health care services and 
          public health using information and communication 
          technologies that enable the diagnosis, consultation, 
          treatment, education, care management, and self-management 
          of patients.  It includes telemedicine, which is the 
          diagnosis and treatment of illness or injury, and 
          telehealth services can range from diagnosis, treatment, 
          assessment, monitoring, communications, and education.  
          Currently, telehealth services are primarily delivered in 
          three ways:  

                 Video conferencing, which is used for real-time 
               patient-provider consultations, provider-to-provider 
               discussions, and language translation services; 
                 Patient monitoring, in which electronic devices 
               transmit patient health information to health care 
               providers; and
                 Store and forward technologies, which 
               electronically transmit pre-recorded videos and 
               digital images, such as X-rays, video clips, and 
               photos, between primary care providers and medical 
               specialists.

          Telehealth is commonly used to address the problems of 
          inadequate provider distribution and is used in the 
          development of health systems in rural and medically 
          underserved areas.  It has the potential to reduce costs, 
          improve quality, change the conditions of practice and 
          improve access to health care services.

          In February 2011, the Center for Connected Health Policy 
          (CCHP) issued a report with 13 recommendations to update 
          California's TDA.  The revisions to existing law that this 
          bill contemplates are based on the following 
          recommendations from the CCHP report:

                 Update the term "telemedicine" used in current law 

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               to "telehealth," to reflect changes in technologies, 
               settings, and applications for medical and other 
               purposes;
                 Include the asynchronous application of 
               technologies in the definition of telehealth and 
               remove the 2013 sunset date for Medi-Cal reimbursement 
               of teledermatology, teleophthalmology, and 
               teleoptometry services;
                 Remove restrictions in the current telemedicine 
               definition that prohibit telehealth-delivered services 
               provided via email and telephone;
                 Eliminate the current Medi-Cal requirement to 
               document a barrier to an in-person visit for coverage 
               of services provided using telehealth;
                 Require private health care payers and Medi-Cal to 
               cover encounters between licensed health practitioners 
               and enrollees irrespective of the setting of the 
               enrollee and providers; and
                 Remove the requirement necessitating an additional 
               informed consent waiver be obtained prior to any 
               telehealth services being rendered.

          The CCHP indicates that telehealth is a mode of providing 
          services, not a treatment or procedure, but is treated in 
          California law in the same manner as highly invasive 
          procedures.  The report states that by eliminating the 
          duplicative required written informed consent, more 
          patients can make more expedient choices regarding their 
          care.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes   
          Local:  Yes

          According to the Senate Appropriations Committee:

                          Fiscal Impact (in thousands)

           Major Provisions                2011-12     2012-13    
           2013-14   Fund
           DMHC                $53       $105      $105 Special*

          Potential increased                               unknown, 
          potentially significant                           
          General/**

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          number of Medi-Cal visits                              
          Federal/
                                                            Local

          * Managed Care Fund
          **50 percent federal funds, 50 percent non-federal funds 
            (usually General Fund, but would be local funds if 
            provided by designated public hospitals or paid for the 
            Low-Income Health Care Program)

           SUPPORT  :   (Verified  8/25/11)

          AgeTech California
          Association of California Healthcare Districts
          BayBio
          California Association of Physician Groups
          California Center for Rural Policy at Humboldt State 
          University
          California Healthcare Institute
          California Hospital Association
          California Medical Association
          California State Rural Health Association
          Continua Health Alliance
          Del Norte Clinics, Inc.
          Kaiser Permanente
          Kings View Corporation
          Latino Coalition for a Healthy California
          Medical Board of California
          National Multiple Sclerosis Society - California Action 
          Network
          Occupational Therapy Association of California
          Peach Tree Healthcare
          Regional Council of Rural Counties
          Rural Health Sciences Institute
          The Children's Partnership
          University of California


           ARGUMENTS IN SUPPORT  :    The California State Rural Health 
          Association (CSRHA) states that telehealth and other health 
          information technologies (HIT) are critical tools for 
          California's rural health care safety net, and have the 
          potential to increase health care access, quality, and the 
          cost-effectiveness of care in rural communities, especially 

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          for specialty care.  Telehealth and other HIT can ensure 
          that rural patients receive timely care that otherwise 
          would be unavailable to them.  CSRHA believes that the lack 
          of adequate care increases the costs of health care in 
          rural communities.  Further, telehealth allows rural 
          communities to care for patients in their home community 
          rather than requiring them to travel to distant cities, and 
          allows more health care dollars to be spent in the rural 
          community where the patient's home is located.  CSRHA also 
          asserts that telehealth and other advanced HIT applications 
          can alleviate chronic shortages of specialty care providers 
          and increase the ability of rural communities to attract 
          and retain health care providers.  

          The Children's Partnership (TCP) supports this bill because 
          low-income children living in medically underserved areas, 
          both rural and parts of urban areas, face geographic and 
          economic barriers to accessing health care.  TCP states 
          that telehealth helps to overcome these barriers, such as 
          provider shortages, transportation costs, and lost time 
          from work and school, by using technology to bring the care 
          to where the children are located.  

          According to the University of California (UC), which 
          supports this bill, there are three major initiatives 
          underway to expand the use of telehealth technologies and 
          expertise throughout the state.  The first is the 
          California Telehealth Network (CTN), a recent statewide 
          broadband initiative to provide managed broadband access to 
          hundreds of primarily rural health care facilities 
          throughout California.  The CTN expects to link more than 
          800 qualified sites, including the five UC academic health 
          systems, Stanford University, University of Southern 
          California, and Loma Linda University in a peer-to-peer 
          network which will be one of the largest in the nation.  A 
          second initiative nables the expansion of existing 
          telemedicine programs at UC medical school campuses to 
          provide facilities and state-of-the-art equipment to expand 
          use of telemedicine across the state.  Lastly, the 
          Specialty Care Safety Net Initiative is a collaborative 
          effort between UC medical school specialty departments and 
          safety net clinics in California.  The initiative seeks to 
          identify barriers to adoption and sustainability of 
          telehealth programs in high-need specialties such as 

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          dermatology, endocrinology, hepatology, neurology, 
          orthopedics and psychiatry.


           ASSEMBLY FLOOR  :  76-0, 06/01/11
          AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Beall, Bill 
            Berryhill, Block, Blumenfield, Bonilla, Bradford, 
            Brownley, Buchanan, Butler, Charles Calderon, Campos, 
            Carter, Cedillo, Chesbro, Conway, Cook, Davis, Dickinson, 
            Donnelly, Eng, Feuer, Fletcher, Fong, Fuentes, Furutani, 
            Beth Gaines, Galgiani, Gatto, Gordon, Grove, Hagman, 
            Halderman, Hall, Harkey, Hayashi, Roger Hernández, Hill, 
            Huber, Hueso, Huffman, Jones, Knight, Lara, Logue, Bonnie 
            Lowenthal, Ma, Mansoor, Mendoza, Miller, Mitchell, 
            Monning, Morrell, Nestande, Nielsen, Norby, Olsen, Pan, 
            Perea, Portantino, Silva, Skinner, Smyth, Solorio, 
            Swanson, Torres, Valadao, Wagner, Wieckowski, Williams, 
            Yamada, John A. Pérez
          NO VOTE RECORDED: Garrick, Gorell, Jeffries, V. Manuel 
            Pérez


          CTW:nl  8/26/11   Senate Floor Analyses 

                         SUPPORT/OPPOSITION:  SEE ABOVE

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