BILL ANALYSIS Ó
SB 764
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Date of Hearing: June 26, 2012
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Jim Beall Jr., Chair
SB 764 (Steinberg) - As Amended: June 20, 2012
SENATE VOTE : 24-13
SUBJECT : Developmental services: telehealth systems program
SUMMARY : Establishes a pilot program for the provision of
treatment and intervention services through the use of
telehealth. Specifically, this bill :
1)States legislative intent to do all of the following:
a) Improve access to treatment and intervention services
for individuals with autism spectrum disorders (ASDs) and
their families in underserved populations;
b) Provide more cost-effective treatments and intervention
services for individuals with ASDs and their families;
c) Maximize the effectiveness of the interpersonal and
face-to-face interactions that are utilized for the
treatment of individuals with ASDs; and,
d) Continue maintenance and support of the existing service
workforce for individuals with ASDs.
2)Requires the Department of Developmental Services (DDS) to do
the following as a demonstration pilot project intended to
promote the use of telehealth to provide services for
individuals with ASDs:
a) Authorize providers vendorized by a regional center to
provide intervention or therapeutic services to provide
such services through telehealth as part of a consumer's
individual program plan (IPP) upon approval of a regional
center and voluntary approval of the consumer or, when
appropriate, his or her parents, legal guardian,
conservator or authorized representative.
b) Authorize regional centers to purchase intervention or
therapeutic services provided through the use of telehealth
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as part of a consumer's IPP if the following conditions are
met:
i) The consumer or, when appropriate, his or her
parents, legal guardian, conservator or authorized
representative voluntarily approves this use of
telehealth;
ii) The provider demonstrates that the proposed use of
telehealth meets the needs of the consumer as defined in
the consumer's IPP;
iii) The provider establishes that the telehealth
services are, at a minimum, in compliance with the
following:
(1) All requirements related to consumer privacy
and confidentiality;
(2) The requirements of the Lanterman
Developmental Disabilities Services Act (Lanterman
Act);
(3) State and federal requirements with regard to
the purchase of regional center services; and,
(4) All federal funding participation guidelines
and requirements.
c) Require regional centers to consider the use of
telehealth in the implementation of parent training on
behavior intervention techniques in lieu of some or all of
the in-home parent training component of behavioral
intervention services for autism.
3)Requires DDS to implement vendorization codes or subcodes for
all telehealth services and programs that apply under the
pilot project.
4)Provides that the provider is responsible for all expenses and
costs related to the equipment, transmission, storage,
infrastructure, and other expenses related to telehealth.
5)Defines "telehealth" as that term is defined in the Business
and Professions Code.
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6)Authorizes consumers to receive intervention or therapeutic
services through telehealth on a provisional basis for a
period not to exceed 12 months, during which time the consumer
has an automatic right to return to his or her preexisting
services, as defined in the consumer's IPP, that were in place
prior to the implementation of the telehealth service.
7)Requires that DDS, by December 1, 2017, based on information
provided by regional centers, provide information to the
Legislature on the effectiveness and appropriateness of
telehealth to provide services to people with developmental
disabilities through the IPP process.
8)Provides that this bill does not prevent or preclude the use
of telehealth by regional centers for services to consumers
with developmental disabilities other than ASD.
9)Specifies a sunset date for the pilot demonstration program of
January 1, 2018.
EXISTING LAW
1)Establishes the Lanterman Developmental Disabilities Services
Act (Lanterman Act), under which DDS contracts with 21 private
non-profit regional centers to provide case management
services and arrange for, or purchase, services that meet the
needs of individuals with developmental disabilities. Welfare
& Institutions (W&I) Code Section 4500 et seq.
2)Provides that an array of services and supports should be
established that is sufficiently complete to meet the needs
and choices of each person with developmental disabilities,
regardless of age or degree of disability, to support their
integration into the mainstream life of the community, and
that, to the maximum extent feasible, services and supports
should be available throughout the state.
3)Provides that the determination of which services and supports
are necessary for each consumer shall be made through the IPP
process and shall include consideration of a range of service
options proposed by the IPP participants, the effectiveness of
each option in meeting the goals stated in the IPP, and the
cost-effectiveness of each option. W&I Code Section 4512(b).
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4)States the intent of the Legislature to ensure that the
provision of services to consumers and their families be
effective in meeting the goals stated in the IPP, reflect the
preferences and choices of the consumer, and reflect the
cost-effective use of public resources. W&I Code Section
4646(a).
5)Provides that, if a consumer or, where appropriate, the
consumer's parents, legal guardian, authorized representative,
or conservator requests an IPP review, the IPP shall be
reviewed within 30 days after the request is submitted. W&I
Code Section 4646.5(b).
6)States the intent of the Legislature that regional centers
find innovative and economical methods of achieving IPP
objectives and that DDS encourage and assist regional centers
to use innovative programs, techniques, and staffing patterns
to carry out their responsibilities. W&I Code Section 4651.
7)Provides that, when necessary to expand the availability of
services of good quality, regional centers may use creative
and innovative service delivery models. W&I Code Section
4648(e)(3).
8)Authorizes regional centers to utilize innovative
service-delivery mechanisms to ensure that services and
supports designed to assist families to care for their
children at home are provided in the most cost-effective and
beneficial manner. W&I Code Section 4685(c)(3).
9)Requires regional centers to consider the use of group
training for parents on behavioral intervention techniques in
lieu of some or all of the in-home training component of the
behavioral intervention services. 4685(c)(3)(B)(i).
10)Defines "telehealth" to mean "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 provider is at
a distant site. Telehealth facilitates patient
self-management and caregiver support for patients and
includes synchronous interactions and asynchronous store and
forward transfers." Business & Professions Code Section
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2290.5(a)(6).
FISCAL EFFECT : Unknown
COMMENTS :
Need for this bill : According to the author, this bill is intended
to promote and encourage the use of Tele-Health and Tele-Medicine
applications for the diagnosis and treatment of ASD by DDS and
regional centers; to improve access for the appropriate evaluation
and treatment of ASD by regional centers to underserved communities;
and, to provide services for the appropriate evaluation and
treatment of ASD by regional centers in the most competent and
cost-effective manner possible.
The author notes that there has been a twelve fold increase in the
diagnosis of ASD during the past decade. ASDs are increasing at an
average annual rate of 17 percent, and two-thirds of all new
consumers who are entering the regional center system are now
diagnosed with ASD. The cost to DDS and the regional centers for
the evaluation, diagnosis, assessment, and treatment of ASD, the
author says, is significantly higher than the costs for services and
programs provided for other developmental disorders. According to
the author, because there are currently over 51,000 ASD consumers
who are receiving services from DDS and regional centers, the number
of programs and service providers available for these consumers are
diminishing, especially in geographically remote communities and in
underserved populations. The author points out that there are
currently innovative approaches and applications that are being used
extensively in the area of Tele-Health and Tele-Medicine. Autism
experts and healthcare professionals, the author says, have
recommended that these applications and systems be used for the
evaluation and treatment of ASD.
Should this bill focus on ASD? : According to the statement of
legislative intent, this bill is intended to improve access to more
cost-effective treatments and intervention services for individuals
with ASDs and their families in underserved populations. To promote
the use of telehealth to provide services for individuals with ASD,
this bill requires DDS to establish a five-year demonstration pilot
project to authorize the use of telehealth under specified
conditions.
On April 12, 2012, the Senate Select Committee on Autism & Related
Disorders held an informational hearing, Ensuring Fair & Equal
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Access to Regional Center Services for Autism Spectrum Disorders.
Testimony addressed disparities, including racial and ethnic
disparities, in access to regional center services, often based on
where in the state the consumer lives. Access issues exist
particularly within low-income communities or rural areas where
services may not exist, or where other barriers, such as inadequate
transportation, are common. Significantly, however, and relevant to
this bill, it was clear from testimony at the Select Committee
hearing that these disparities and access issues do not exist only
for regional center consumers with ASD.
The California Association of Marriage and Family Therapists (CAMFT)
points out, in support of this bill, that telehealth "serves the
purpose of removing barriers in California to the access to health
care to underserved, remote, and difficult to reach populations."
CAMFT also notes that telehealth "reduces costs, increases access,
and improves quality of care, especially in hard to reach
populations." But, as CAMFT also notes, children with ASD are
"Ý o]ne specific group who will greatly benefit from telehealth."
(Emphasis added.)
Promoting the use of telehealth to provide better access to services
and to provide treatment and services in the most competent and
cost-effective manner possible are appropriate goals-not only for
people with ASD but for all people served by regional centers. It
may be the case that some services frequently, though not
exclusively, used for individuals with ASD are especially amenable
to delivery through telehealth (e.g., training for parents on
behavior intervention techniques). It would be inconsistent with
the intent of the Lanterman Act, however, if consumers and family
members were denied or had lesser access to telehealth services
based not on individual need and choice but on diagnosis.
Is a pilot project necessary? : Nothing prevents the use of
telehealth for regional center consumers under current law. As
described in the Existing Law section, above, the Lanterman Act
includes numerous references to the use of innovative and economical
service mechanisms and methods of achieving IPP objectives. Because
it can increase access to needed services by means of an innovative
and cost-effective service mechanism, telehealth is certainly
consistent with the intent of the Lanterman Act and not precluded by
the current statute when identified as the preferred means of
achieving a consumer's IPP objectives.
Establishment of a pilot program for telehealth might, in fact, have
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adverse unintended consequences to the extent it implies that
telehealth is not an option under existing law or would no longer be
available once the pilot program sunsets. Moreover, a pilot
offering a service to a specific group carries the implication that
the service is not equally available to those outside the group.
This bill is confusing on this point. On the one hand, this bill
provides that the pilot is intended to promote the use of telehealth
to provide services for individuals with ASD but, on the other hand,
it says that nothing in the bill precludes the use of telehealth by
consumers who do not have ASD. It is not clear, therefore, what
would change or be accomplished by establishing an ASD pilot program
for telehealth.
What would the pilot consist of? : This bill would establish a
"demonstration pilot project" but does not indicate what the pilot
would consist of or who would participate. As noted, there is
nothing in the Lanterman Act that precludes the use of telehealth to
provide services to regional center consumers if it is specified in
the consumer's IPP. This bill, itself, states that it does not
preclude or prevent the use of telehealth for individuals with
developmental disabilities other than ASD. What, therefore, is the
scope of the pilot? Who would the participants be? How would
participants be identified? If anyone can utilize telehealth, what
distinguishes consumers in the "pilot" from other consumers
utilizing telehealth?
Some requirements of this bill are unnecessary : Some provisions of
this bill are appropriate but are not dependent on establishment of
a pilot program-e.g., requiring DDS to establish vendorization codes
or subcodes for telehealth services and programs, and emphasizing
that telehealth providers must adhere to all requirements related to
consumer privacy and confidentiality. Other provisions, on the
other hand, already apply to any provider and are therefore
unnecessary here-e.g., requiring telehealth providers to adhere to
the requirements of the Lanterman Act or state and federal
purchase-of-service requirements.
The provision concerning providing telehealth to a consumer on a
one-year "provisional basis" with an "automatic right to return to
his or her preexisting services" is an unwarranted departure from
the IPP process and likely impractical. The only other reference in
the Lanterman Act to provisional services with a one-year automatic
right of return is in relation to people placed from developmental
centers into the community. While such a mechanism makes sense in
that context, it is less appropriate here. Many consumers receiving
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a service through telehealth will not have had the service in
question provided previously; so, unlike return to a developmental
center of former residents, there would be no prior IPP service to
return to. In addition, unlike a developmental center, the prior
service specified in the IPP may not be available to return to. A
parent training class, for example, may not have openings or may no
longer be offered. The mechanism for determining or modifying the
services and supports provided under the Lanterman Act is the IPP
process. An IPP meeting can always be requested to modify services
and supports specified in the IPP that are no longer appropriate or
no longer the preferred option. W&I Code Section 4646.5(b). There
is no obvious reason to treat telehealth services any differently.
Moreover, because, as discussed above, it would be impossible to
distinguish those participating in the pilot from others receiving
services through telehealth, it would be unclear to whom this
"automatic right of return" would apply.
Opposition : Developmental Disabilities Area Board 10 opposes this
bill, in part, because of the provision on a one-year provisional
placement and automatic right to return to previous services
specified in the IPP. Area Board 10 also opposes because there is
no provision for evaluating the results of the pilot. Area Board 10
may have misinterpreted the one-year provisional period, and the
amended version does include evaluation language. Nonetheless,
these issues are addressed by the proposed alternative language
below.
Proposed alternative : The above discussion of fundamental and
unintended problems with this bill is not meant to suggest that
telehealth may not prove to be a valuable service delivery model for
increasing access to needed services. Nor is it intended to suggest
that the use of telehealth should not be promoted and evaluated.
For the reasons stated above, however, the pilot proposed by this
bill is problematic and unclear. An alternative approach-that
avoids the problems with the current language-would entail having
the evaluation component of the bill comprise the pilot. Under this
alternative, DDS would designate regional centers to evaluate the
cost-effectiveness and efficacy of telehealth over the pilot period.
An evaluation pilot would not preclude or hinder access to
telehealth by any regional center consumer for whom it is an
appropriate and preferred alternative; it would simply involve
identifying a sample of telehealth users for purposes of conducting
an evaluation. The following proposed amendments further the
overall intent of this bill and maintain its significant features
but avoid or address the issues and concerns discussed above.
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PROPOSED AMENDMENTS :
1)Amend SECTION 1 (intent language) to replace "individuals with
ASD" with "individuals with ASD or other developmental
disabilities."
2)Delete SEC. 2 and replace with the following:
4686.21(a) To improve access to intervention and
therapeutic services to consumers and family members,
including those from underserved communities, and for
purposes of facilitating better and cost-effective
services, individual program planning teams shall,
whenever applicable, consider the use of telehealth as
defined in paragraph (6) of subdivision (a) of Section
2290.5 of the Business and Professions Code.
(1) Telehealth shall be considered for parent
trainings, including but not limited to trainings
specified in clause (i) of subparagraph (B) of
paragraph (3) of subdivision (c) of Section 4685.
(2) The department shall implement appropriate
vendorization codes or subcodes for telehealth
services and programs.
(3) Providers of telehealth services shall be
required to maintain the privacy and security of all
confidential consumer information.
(b) The department shall establish a five-year pilot
program for evaluating the efficacy and cost-effectiveness
of telehealth services. Each regional center selected for
the pilot shall provide to the department information, as
requested by the department, on frequency, applications,
cost-effectiveness, consumer and family member
satisfaction, and other information deemed necessary by the
department to evaluate the effectiveness and
appropriateness of telehealth in providing services to
regional center consumers. By December 31, 2017, based on
the information provided to the department by the
participating regional centers, the department shall report
to the appropriate fiscal and policy committees of the
Legislature on the cost-effectiveness and efficacy of
providing services to consumers using telehealth.
Technical amendments to current version : The current version of
this bill would require technical amendments to correct the
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numbering of paragraphs.
REGISTERED SUPPORT / OPPOSITION :
Support
Aspiranet
Association of Regional Center Agencies (ARCA)
Autism and Behavior Training Associates
Autism Treatment Providers' Insurance Authorization Network,
(ATPIAN)
Behavioral Intervention Association (BIA)]]
California Association for Health Services at Home (CAHSAH)
California Association of Marriage and Family Therapists
Capitol Autism Services
Center for Autism and Related Disorders
Center for Reducing Health Disparities (UCD)
Central Valley Regional Center, Inc.
DIR/Floortime Coalition of California
Disability Rights California
North Bay Regional Center
Professor, Sergio Aguilar-Gaxiola, M.D., Ph.D. (UCD)
Special Needs Network (SNN)
Spectrum Center
TARJAN Center
TechNet
The Children's Partnership
The Help Group
Opposition
Developmental Disabilities Area Board 10
Analysis Prepared by : Eric Gelber / HUM. S. / (916) 319-2089