BILL ANALYSIS �
AB 361
Page 1
ASSEMBLY THIRD READING
AB 361 (Mitchell)
As Amended April 4, 2013
Majority vote
HEALTH 15-3 APPROPRIATIONS 12-1
-----------------------------------------------------------------
|Ayes:|Pan, Ammiano, Atkins, |Ayes:|Gatto, Bocanegra, |
| |Bonilla, Bonta, Chesbro, | |Bradford, |
| |Gomez, | |Ian Calderon, Campos, |
| |Roger Hern�ndez, Gordon, | |Eggman, Gomez, Hall, |
| |Maienschein, Mitchell, | |Ammiano, Pan, Quirk, |
| |Nazarian, Nestande, V. | |Weber |
| |Manuel P�rez, Wieckowski | | |
| | | | |
|-----+--------------------------+-----+--------------------------|
|Nays:|Mansoor, Wagner, Wilk |Nays:|Donnelly |
| | | | |
-----------------------------------------------------------------
SUMMARY : Authorizes the Department of Health Care Services
(DHCS) to submit State Plan Amendments (SPAs) to the federal
Centers for Medicare and Medicaid Services (CMS) for approval to
provide health home services to adults and children and create a
California Health Home Program (HHP). Specifically, this bill :
1)Defines the population of individuals eligible to receive
health home services, the required services, and the criteria
for health care providers and authorizes DHCS to design one or
more SPAs to provide home health services to children and
adults and, subject to enhanced federal matching funds,
requires specific services including comprehensive and
individualized care management, care coordination,
transitional care, individual and family support, and referral
to community and social services supports.
2)Requires DHCS to determine if a SPA that targets adults, as
specified, is feasible; and if DHCS submits a SPA targeting
any adults, requires a SPA targeting adults who meet specified
criteria to also be submitted.
3)Defines targeted adults as adults who meet the following
criteria:
AB 361
Page 2
a) Have current diagnoses of chronic, co-occurring physical
health, mental health, or substance use disorders prevalent
among frequent hospital users; and,
b) A severity level determined by DHCS, using one or more
of the following indicators:
i) Frequent inpatient hospital admissions, including
hospitalization for medical, psychiatric, or substance
use related conditions;
ii) Excessive use of crisis or emergency services; and,
iii) Chronic homelessness.
4)Implements this bill only if federal financial participation
(FFP) is available and imposes limitations on use of
additional General Funds (GFs) during the first eight
quarters. Provides that the 10% state share shall not be
provided from state sources and may be provided by funds from
local governments, private foundations or other sources
permitted by federal law. Permits DHCS to revise or terminate
the health home program any time after the first eight
quarters of implementation if it finds that the program fails
to result in improved health outcomes or results in
substantial GF expense without commensurate decreases in
Medi-Cal costs among program participants.
5)Requires DHCS to ensure that an evaluation is completed within
two years after implementation.
6)Authorizes DHCS to conduct the activities necessary to design,
submit, and implement the program to provide health home
services to adults and children with chronic conditions
pursuant to the federal Patient Protection and Affordable Care
Act (ACA).
7)Requires health homes to meet federal criteria, to offer a
whole person approach, including coordinating with other
services that affect a person's health, and to offer services
in a range of settings. Specifies the services that are to be
provided under the program.
AB 361
Page 3
8)Requires DHCS to administer the program in a manner that
maximizes FFP and conditions implementation on the
availability of FFP and approval of the SPA.
9)Permits DHCS to use new funding in the form of enhanced FFP
for health home services that are currently funded for any
additional costs for new health home services.
10)Permits DHCS to enter into exclusive or nonexclusive
contracts, as specified, or amend existing contracts; and,
implement by means of specified letters, bulletins, or other
instructions without taking regulatory action until
regulations are adopted and requires emergency regulations
within two years.
11)Requires if DHCS determines a HHP is not operationally
viable, report the basis for the determination and a plan to
address the needs of the chronically homeless and frequent
hospital users to the Legislature.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, tens of millions of dollars, for design,
implementation, and evaluation, with 90% federal funds, 10%
state matching rate. The state share is to come from non-state
sources, except as specified based on DHCS projections of
expenditures.
COMMENTS : According to the author, this bill will allow the
state to access federal funding for "Health Home Services" for
Medi-Cal beneficiaries, while ensuring the state targets
beneficiaries with chronic medical, mental health, or substance
abuse conditions who are chronically homeless or frequent
hospital users. This bill takes advantage of the "Health Home"
option offering states 90% federal money for two years for
services such as intensive case management and care coordination
and provides options for ongoing funding should these health
homes demonstrate decreased costs. The author points out that
the Health Home option is an ideal vehicle for providing
appropriate health-related services and social service supports
to overlapping populations of people who are chronically
homeless and to people who are frequent hospital users. The
author states that many among this group experience a
combination of chronic medical, mental health, and substance
abuse conditions, as well as social issues that negatively
AB 361
Page 4
impact their ability to access care. The sponsor, Corporation
for Supportive Housing (CSH), states that California spends
significant Medi-Cal resources on a small group of
beneficiaries. According to data CSH reviewed, about 1,000
Medi-Cal beneficiaries who frequently used hospitals for reasons
that could be avoided with better access to care (frequent
users) incurred over $100,000 in Medi-Cal costs in 2007 alone.
CSH states that in administering the Frequent Users of Health
Services Initiative (Initiative), a foundation-funded five-year
program, supporting six projects offering community-based
multidisciplinary services to frequent users, evidence showed
medical home services alone are ineffective in addressing the
needs of this population. CSH cites a Lewin Group evaluation of
the Initiative showing that frequent users experience
psychosocial complexities, like chronic disease, mental
disability, substance addiction, social isolation, and
homelessness. According to the sponsor, intensive face-to-face
services that coordinate and help frequent users manage their
care not only improved health outcomes among these individuals,
but significantly decreased hospital costs. Medi-Cal
beneficiaries participating in the Initiative programs
experienced a 60% decrease in emergency room visits and a 69%
decrease in inpatient days. Data from similar programs across
the country, several using randomized, control-group studies,
show these services save between $7,500 and $29,000 per year,
per beneficiary in Medicaid costs. These evaluations and
studies also demonstrated significantly improved health
outcomes, decreased nursing home stays, and longer life spans
among participants.
The author further states that chronically homeless people and
frequent users who are homeless have such poor health outcomes
that they die, on average, 30 years younger than life expectancy
in this country. For these reasons, medical home services alone
cannot sufficiently address the myriad of barriers these
populations face in accessing appropriate care. The author
points out that with the addition of comprehensive case
management, hospital discharge planning, and connection to
social services, including housing, enhanced medical home
programs have proved to reduce high-cost care among the most
vulnerable Californians. Social services interventions, like
connecting participants to housing, are a critical step to
reducing the costs and improving the care of homeless frequent
users. According to the author, programs offering health home
AB 361
Page 5
services to frequent users integrate primary and behavioral
health care, foster a "whole person" approach, and reduce health
disparities.
The ACA allows states to elect the health home option in their
Medicaid program and receive a 90% federal matching rate for two
years for these services. Federal law defines the individuals
eligible for health home services as individuals meeting one of
the following: 1) having at least two chronic conditions; 2)
having one chronic condition and are at risk of having a second
chronic condition; or, 3) having one serious and persistent
mental health condition. The Federal guidance defines "health
home services" as services provided by a designated provider, a
team of health care professionals operating with such a
provider, or a health team that provides: comprehensive care
management; care coordination and health promotion;
comprehensive transitional care, including appropriate
follow-up, from inpatient to other settings; patient and family
support (including authorized representatives); referral to
community and social support services, if relevant; and, use of
health information technology to link services, as feasible and
appropriate.
According to the CMS guidance, the whole-person philosophy is
fundamental to a health home model of service delivery. CMS
expects health homes to build on the expertise and experience of
medical home models and, when appropriate, to deliver health
home services. The state will be expected to develop a health
home model of service delivery that has designated providers
operating under a "whole-person" approach to care within a
culture of continuous quality improvement. According to CMS, a
whole-person approach to care looks at all the needs of the
person and does not compartmentalize aspects of the person, his
or her health, or his or her well-being. The guidance states
that CMS expects providers of health home services to use a
person-centered planning approach in identifying needed services
and supports and providing care and linkages to care that
address all of the clinical and non-clinical needs of an
individual.
Supporters, representing providers, clinics, affordable housing
groups, and consumer advocates, state that this bill will reduce
Medi-Cal costs, decrease avoidable emergency department visits
and inpatient stays, and improve health outcomes for extremely
AB 361
Page 6
vulnerable Californians, without any initial state investment.
Supporters point out that this bill will give California the
opportunity to draw down 90% FFP to target vulnerable and
difficult to reach populations. The sponsors also state that
foundation funding is available for the State's 10% share.
Supporters also state that people, who frequently use hospital
services for what seem like avoidable reasons, face numerous
challenges accessing care. They are often homeless, live in
provider shortage areas, and almost all of them have multiple
chronic medical and co-morbid behavioral health conditions.
According the supporters, robust research demonstrates programs
providing outreach to these populations, offering intensive case
management, and connecting individuals to appropriate care and
social services - "health homes" - are the only models proven to
improve health outcomes, decrease hospital and nursing home
stays, and reduce emergency room visits. These supporters
conclude this results not only in cost savings, but also yields
a cohort of better-informed consumers who are increasingly
focused on preventive rather than reactive care.
The California Right to Life Committee writes in opposition that
its concerns relate to the requirement of health related bills
to implement the ACA and that while there are issues that may
not be directly in this bill language, could be the resulting
consequence of its passage. Specifically, California Right to
Life Committee states that one of the legislative findings "to
access better care and better health, while decreasing costs"
could encourage the use of Physician's Orders for Life
Sustaining Treatment for the very ill and homeless veterans, a
document promoted by Compassion and Choice.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097
FN: 0000807