BILL ANALYSIS Ó
AB 411
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Date of Hearing: April 2, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 411 (Pan) - As Introduced: February 15, 2013
SUBJECT : Medi-Cal: performance measures.
SUMMARY : Provides that the Department of Health Care Services
(DHCS) require all Medi-Cal managed care plans (MCPs) to analyze
Healthcare Effectiveness Data and Information Set (HEDIS)
measures, or their External Accountability Set (EAS) performance
measure equivalent, by race, ethnicity, and primary language to
identify disparities in medical treatment and to implement
strategies to reduce disparities. Requires MCPs to link
individual level data to patient identifiers in order to allow
for an analysis of disparities in medical treatment by race,
ethnicity, and primary language and provide the information
annually to DHCS. Requires DHCS to make the data available for
research in a method that complies with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
EXISTING LAW :
1)Establishes the Medi-Cal program, to provide various health
and long-term services to low-income women and children,
elderly, and people with disabilities.
2)Authorizes DHCS to enter into contracts with MCPs to provide
services to Medi-Cal enrollees.
3)Requires most persons eligible for Medi-Cal to enroll in a MCP
and establishes a process for informing enrollees regarding
plan selection.
4)Authorizes DHCS to expand Medi-Cal managed care (MCMC) to the
28 mostly rural counties that are currently in the Medi-Cal
fee-for-service program.
5)Establishes under federal law, through HIPAA various
safeguards for the privacy of medical information.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
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COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, as of February
2013, approximately 5.2 million Californians are enrolled in
Medi-Cal MCPs in 30 counties, the majority of whom are from
communities of color. Additionally, 43% of Medi-Cal enrollees
speak a language other than English. DHCS is in the process
of transitioning over 850,000 children from the Healthy
Families Program (HFP) to Medi-Cal and most of them will be
enrolled in Medi-Cal MCPs. Of these children 47% are Latino
and 9% Asian American or Pacific Islander. Forty-six percent
of these children's households speak a language other than
English. The author points out that when HFP was administered
by the Managed Risk Medical Insurance Board (MRMIB), plans as
in Medi-Cal, were required to report HEDIS data. However,
MRMIB did more than report the results of the HEDIS measures.
For instance MRMIB monitored its plans to ensure that access
to quality health care was shared by all members. In order to
accomplish this, MRMIB performed demographic statistical
analysis of HEDIS data where all eligible members were
counted. MRMIB then considered groupings of this data by
health plan, region, income level, language spoken in the
home, ethnicity, and age. The author explains that this
allowed MRMIB to conduct qualitative and comparative analysis,
to identify disparities and to develop strategies for
improvement or to reduce disparities.
According to the author, the purpose of this bill is to ensure
that the qualitative aspects of the way MRMIB measured and
reported plan data is not lost in the transition to Medi-Cal.
The author points out that currently, Medi-Cal MCPs analyze
and report HEDIS measures on important dimensions of care and
service. Additionally, demographic data, including race,
ethnicity, and primary language, is collected at the time of
enrollment for the Medi-Cal program. However, it is not
collected or reported in a manner that allows for the same
type of demographic analysis that was conducted at MRMIB. In
addition, it is the author's intent to apply these practices
to the other managed care populations in Medi-Cal. By
analyzing utilization, quality, and outcome data by race,
ethnicity, and primary language, Medi-Cal MCPs and DHCS will
better understand the specific needs of these enrollees, allow
plans to better develop culturally and linguistically
appropriate interventions, enable plans and the State to
allocate resources to more effectively, and ultimately reduce
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historic health disparities that communities of color face.
2)BACKGROUND . DHCS has embarked on an ambitious expansion of
the MCMC program. These program changes include all age
groups and all geographic regions. In 2011 DHCS transferred
Medi-Cal only seniors and people with disabilities (SPDs) from
voluntary to mandatory enrollment in MCMC as part of the
Section 1115(b) Medicaid Demonstration Waiver from the Centers
for Medicare and Medicaid Services (CMS) entitled "A Bridge to
Reform Waiver." Enrollment was phased in over a one-year
period, beginning on June 1, 2011 in the 16 two-plan and
Geographic Managed Care (GMC) counties.
DHCS is also participating in a demonstration project authorized
by the 2010 federal Affordable Care Act (ACA) to improve
coordination of services for persons who are dually eligible
for state Medicaid programs (Medi-Cal in California) and
Medicare. Approximately 456,000 potential enrollees will be
eligible for enrollment in MCPs in this Coordinated Care
Initiative (CCI) in a three-year, eight county demonstration
project. (The eight counties are Alameda, Los Angeles,
Orange, Riverside, San Bernardino, San Diego, San Mateo, and
Santa Clara). On March 27, 2013 DHCS signed a Memorandum of
Understanding. Phased in enrollment is currently scheduled to
begin no earlier than October 1, 2013.
DHCS is currently in the process of transitioning about 863,000
children, up to age 19, in families with incomes above the
thresholds needed to qualify for Medi-Cal but below 250% of
the federal poverty level into the Medi-Cal program from the
HFP. Until January 1, 2013, the HFP was administered by MRMIB
and provided coverage by contracting with plans that provide
health, dental, and vision benefits to HFP enrollees.
AB 1467 (Committee on Budget), Chapter 23, Statutes of 2012,
authorized the expansion of MCMC to 28 mostly rural counties
which could add approximately 365,000 additional enrollees to
MCMC program. In February 2013, DHCS announced that Anthem
Blue Cross and California Health and Wellness Plan, received
Notices of Intent to Award for the expansion to the counties
of Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn,
Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter,
Tehama, Tuolumne, and Yuba. DHCS is also planning an
exclusive MCMC contract with Partnership HealthPlan of
California for expansion in Del Norte, Humboldt, Lassen,
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Modoc, Shasta, Siskiyou, and Trinity counties. In addition,
Lake and San Benito counties will become County Operated
Health System (COHS) managed care counties served by
Partnership HealthPlan of California and Central California
Alliance for Health, respectively. DHCS is currently working
with Imperial County on its managed care plan selection
process.
There are three models of Medi-Cal MCPs. The oldest model is
the COHS. COHS plans serve about one million enrollees
through six health plans in 14 counties: Marin, Mendocino,
Merced, Monterey, Napa, Orange, San Mateo, San Luis Obispo,
Santa Barbara, Santa Cruz, Solano, Sonoma, Ventura, and Yolo.
In the COHS model, DHCS contracts with a health plan created
by the County Board of Supervisors and all Medi-Cal enrollees
are in the same health plan. The second model is the Two-Plan
model in which there is a "Local Initiative" and a "commercial
plan" (CP). DHCS contracts with both plans. The Two-Plan
model serves about 3.6 million beneficiaries in Alameda,
Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera,
Riverside, San Bernardino, San Francisco, San Joaquin, Santa
Clara, Stanislaus, and Tulare. Two-counties employ the GMC
model: Sacramento and San Diego. DHCS contracts with several
commercial plans in those counties and there are about 600,000
enrollees.
3)EAS . CMS requires that states, through their contracts with
MCPs, measure and report on performance to assess the quality
and appropriateness of care and services provided to members.
In response, DHCS implemented a monitoring system that is
intended to provide an objective, comparative review of health
plan quality-of-care outcomes and performance measures called
the EAS. DHCS designates EAS performance measures on an
annual basis and requires plans to report on them. DHCS uses
the HEDIS as the primary tool.
HEDIS is a national, standardized set of measures developed by
the National Committee for Quality Assurance. DHCS selects
which HEDIS measures to use after consultation with the plans
and with input from an External Quality Review Organization
(EQRO). All current measures are applicable across
populations. For example, well child visits, immunizations,
comprehensive diabetes care and annual monitoring of patients
on persistent medications are just a few of the currently
required HEDIS measures that are applied equally to all
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Medi-Cal MCP enrollees. In 2011 the EAS consisted of 11
performance measures. The EAS for 2012 consisted of 13 HEDIS
and 1 DHCS developed measures. For 2013, MCPs will be
reporting on 14 HEDIS measures. DHCS in collaboration with
MCPs and the EQRO, developed a methodology by which to
stratify several measures (comprehensive diabetes care,
children and adolescent access to Primary Care Providers,
annual monitoring for persistent medications, ambulatory care
utilization, and all cause readmissions) into SPD and non-SPD
groups.
MRMIB also collected HEDIS data from the 25 HFP health plans.
For 2009, 2010 and 2011 MRMIB collected data on 17 HEDIS
measures specific to children and adolescents. HEDIS results
were provided to subscribers in enrollment materials,
including the program handbook, so that families could use the
information to compare health plan performance in areas
important to them. HEDIS results were also used by MRMIB to
monitor plan performance and to inform decision-making
regarding quality improvement activities and health plan
participation in HFP.
4)USE OF DEMOGRAPHIC ANALYSIS . MRMIB monitored its HFP health
and dental plans to ensure that access to quality healthcare
was shared by all of its members. Demographic statistical
analysis of HEDIS data was performed for measures that use
administrative data, that is, measures where all eligible
members are counted. Groupings considered by MRMIB for its
HEDIS report are health plan, region, income level, language
spoken in the home, ethnicity, and age. This bill would
require all MCPs contracting with DHCS to provide information
that would allow the same analysis as was done by MRMIB for
HFP. For example MRMIB reported in the 2011 HFP HEDIS Report
that 88% of white children saw a PCP at least once; for
Black/African American children the rate was 85%; and, for
Asian/Pacific Islander children it was 86%. The HEDIS measure
for appropriate medications for asthma, there was a range of
95% for Vietnamese speaking to 88% for English speaking.
MRMIB was able to accomplish this analysis by requiring the
plans to provide patient identifiers with the individual HEDIS
measure. MRMIB matched the information, through an EQRO
contractor, with demographic information reported by the
enrollee. This allows demographic analysis, comparison, and
reporting without breaching patient confidentiality.
Medi-Cal does not analyze and report the HEDIS data from its
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contracting plans in the same way and does not require the
plans to report the data in a way that would allow similar
analysis. Nonetheless, some plans are conducting similar
analysis on their own. For instance, the Anthem Blue Cross
Partnership Plan Performance Evaluation Report, September 2011
reported on Anthem's continued efforts to improve performance
on the Breast Cancer Screening measure. The Report lists the
intervention efforts implemented by the plan and states that
Anthem conducted additional analysis and found statistically
significant differences based on members' spoken languages and
race. As the strategies included newsletter articles and
other written materials, this is particularly useful
information in designing the strategy for improvement. Anthem
also reported statistically significant differences based on
language and ethnicity in the rates of childhood immunizations
in Sacramento County. With regard to prenatal and postpartum
care, the Report states that Anthem continues to struggle with
prenatal and postpartum care performance measure rates and
that additional analysis noted differences in language and
ethnicity in some of the counties which should be considered
when exploring additional approaches to interventions. The
L.A. Care Health Plan Performance Evaluation Report, December
2011 reported on follow-up from the prior year's EQRO
recommendation which was to analyze performance measure data
and explore opportunities to increase rates for measures where
performance had remained stable. LA Care's plan included
analyzing HEDIS results by several variables including plan
partner, region, language, gender, ethnicity, and age cohort.
On the other hand the lack of this break down can interfere with
a plan's efforts to improve. For instance, the Inland Empire
Health Plan (IEHP) Performance Evaluation Report, October
2011, found that member satisfaction related to access to care
was low across adult and child global and composite ratings,
with the exception of customer service. The Report states
that health plan performance in customer service impacts
access to care. However, in the absence of a breakdown by
race, ethnicity, and language spoken, it is impossible to tell
whether there are disparities within this plan or to identify
improvement strategies to target a specific population. In
addition, the Report found a statistically significant
decrease in the Comprehensive Diabetes Care measure. IEHP
identified Diabetes as the second most common chronic
condition in its Medi-Cal population. Given that rates of
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diabetes are twice as high among Native Americans and African
Americans as among whites, IEHP could be more effective in
assessing strategies to improve this measure if there was a
comparative analysis by race and ethnicity.
CPs in other states have conducted similar analysis and used the
data to improve the quality of care and health outcome of
their members. For example, Aetna sought to decrease breast
cancer death rates among African American and Hispanic women
by increasing the number of yearly mammograms. Aetna analyzed
race, ethnicity, and language data collected at enrollment and
claims data to identify 34,000 African American and Latina
members who had not had a necessary mammogram. The rate of
mammograms following outreach to these women increased from
12% to 27%.
5)Let's Get Healthy California Task Force (Task Force ). On May
3, 2012, Governor Jerry Brown issued Executive Order B-19-12
establishing the Task Force to "develop a 10-year plan for
improving the health of Californians, controlling health care
costs, promoting personal responsibility for individual
health, and advancing health equity." The Executive Order
directed the Task Force to issue a report by mid-December,
2012, with recommendations for how the state can make progress
toward becoming the healthiest state in the nation over the
next decade.
According to the Task Force Report, issued December 2012, the
Task Force developed an overarching Framework. The Framework
identified six goals, organized under two strategic
directions: Health Across the Lifespan and Pathways to Health.
The Report states that the Framework makes clear that health
equity should be fully integrated across the entire effort.
The Report also states that health outcomes vary dramatically
by demographics, geography and a host of socioeconomic
conditions. According to the Report, California is the most
populous and diverse state in the country. Significant health
disparities, or differences in health outcomes, exist by
race/ethnicity, income, educational attainment, geography,
sexual orientation and gender identity, and occupation. These
disparities relate to differences in social, economic, and
environmental conditions, as well as to issues within the
health care system itself. For California to be the
healthiest state in the nation, health disparities must be
reduced and, ultimately eliminated. The underlying principle
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guiding the establishment of 10 year targets is that these
gaps can be closed. Many of the recommendations relate to the
collection of additional data and refer to metrics similar to
those used in HEDIS data. For instance, the Report identifies
childhood asthma as pressing issue and the most prevalent
chronic condition for children. According to the Report
asthma can result in higher school absenteeism and lead to
lower levels of physical activity, in addition to the other
effects of the condition. The Report states there are
significant disparities in asthma prevalence and in the
utilization of health services resulting from asthma. For
example, African American children utilize the emergency
department more than eight times as frequently as Asian
American children for asthma.
The Report concludes that the underlying principle that guided
the establishment of the 10-year targets is that California
can only become the healthiest state in the nation if we close
the race and ethnicity gaps by raising everyone's health to
the highest outcomes that we know can be achieved. It is
seems that the requirements of collecting and analyzing
Medi-Cal HEDIS data by race, ethnicity and language spoken
would be an essential piece of the effort to achieve this goal
and with as applied to the Medi-Cal program would be difficult
to accomplished without this bill.
6)SUPPORT . The California-Pan Ethnic Health Network (CPEHN),
sponsor of this bill writes in support that even though the
majority of Medi-Cal enrollees (73%) are from communities of
color, there are no requirements to analyze quality data by
race, ethnicity, and primary language. CPEHN points out
racial and ethnic health disparities are prevalent and
pervasive. For example in California, African Americans and
Native Americans have at least twice the rate of diabetes as
whites, and Latinos and African Americans have over twice the
rate of preventable hospital admissions for diabetes with
long-term complications as whites. According to CPEHN, data
also show that African Americans have almost four times the
rate of preventable hospital admissions among children with
asthma compared to whites, and three times the rate of
preventable hospital admission for congestive heart failure.
Specifically with regard to Medi-Cal, CPEHN points to a study
conducted by Dr. Andrew Bindman, Professor of Medicine,
University of California, San Francisco. In his study, Health
Plan Auto-Assignment Incentives in Medi-Cal and Health Care
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Disparities for Children, Dr. Andy Bindman found that there
were average deviances from a health plan's overall
performance among racial and ethnic subpopulations on each of
the HEDIS measures they analyzed. CPEHN argues the experience
of such stark racial and ethnic health disparities among
communities of color necessitates MCMC to begin to seriously
and systematically identify and address the disparities of its
diverse enrollee population. The data and process exist for
Medi-Cal MCPs to conduct such an analysis and the information
could be instrumental in helping to improve the quality of
care and health outcome for millions of Californians. Other
supporters such as the Western Center on Law and Poverty, the
California Center for Public Health Advocacy, and the
California School Health Centers Association, Worksite
Wellness LA write in support that beginning in 2014, 1.4
million adults are expected to enroll in Medi-Cal as a result
of the expansion through the ACA of that 67% will be from
communities of color and 35% speak English less than very
well. These supporters and others, such as Asian Journal
Publications, AnewAmerica Community Corporation, Manila-U.S.
Times, Chicana/Latina Foundation state that to address
on-going and persistent health disparities experienced by
communities of color, Medi-Cal MCPs must begin to analyze and
report in quality data measures by race, ethnicity, and
language. This data will help them to develop culturally and
linguistically appropriate interventions, enable them to
allocate resources more effectively, and ultimately reduce
historic health disparities.
The March of Dimes (MOD), California Chapter, points out that
nearly 50% of births in California are paid for by Medi-Cal.
Pointing to statistics on significant health disparities
related to prenatal care, premature birth and infant
mortality, MOD states in support of this bill that it has the
potential to close the gap on these disparities. For example,
MOD reports that the infant mortality rate for all births is
5.1 infant deaths for 1,000 live births, but the rate for
Black infants is more than double at 10.7 infant deaths per
1,000 live births. The preterm birth rate for white infants
is 9.3%, but is higher for infants of other races including
Blacks (14.4%), Native Americans (11.4%), Hispanics (10.3%),
and Asians (9.6%). MOD concludes that in addition to the
overall health benefits for infants, improvements could also
generate significant cost savings as the average first-year
medical costs for a preterm infant are nearly 10 times the
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costs for a term infant.
7)OPPOSITION . The Local Health Plans of California and the
California Association of Health Plans writes in opposition
that this bill will create new costs and administrative
burdens by requiring Medi-Cal MCPs to use inherently limited
data to address health disparities. The opposition writes
that while they appreciate the intent of this measure, they do
not believe this bill will achieve the intended results. This
opposition further states that in theory, this bill could
result in valuable information. However, they argue in
practice, the reliance on limited cultural and linguistic data
is problematic. This is due to the voluntary nature of the
data. According to the opposition, new Medi-Cal enrollees
often do not self-disclose this information. Therefore,
insufficient data would not yield statistically significant
results, nor is this data enough to implement meaningful
strategies to identify or reduce disparities. In order to
sort and analyze the data required under this bill, they argue
MCPs will incur new programming and reporting expenses. This
expense comes at a time when all of California's health plans
are focused on the crucial task of implementing the ACA.
8)RELATED LEGISLATION .
a) AB 209 (Pan) enacts the Medi-Cal Managed Care Quality
and Transparency Act of 2013 and requires the DHCS to
develop and implement a plan to monitor, evaluate, and
improve the quality and accessibility of health care and
dental services provided through MCMC. AB 209 is pending
in the Assembly Health Committee.
b) SB 508 (Ed Hernandez) requires the Office of Statewide
Health Planning and Development (OSHPD), with support from
the California Health and Human Services Agency (CHSSA),
based on the inpatient hospital discharge data set, to
develop a health disparity report to assess the levels of
measurable health disparities in the state among
minorities. SB 508 is pending in the Senate Health
Committee.
9)PREVIOUS LEGISLATION .
a) AB 1494 (Committee on Budget), Chapter 28, Statutes of
2012, provides for the transition of children from HFP to
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Medi-Cal starting no earlier than January 1, 2013.
b) AB 1467 (Committee on Budget), Chapter 23, Statutes of
2012, authorizes the expansion of MCMC to 28 mostly rural
counties.
c) AB 2002 (Cedillo) of 2012 would have defined "safety net
provider" for the purpose of determining which MCMC plan a
beneficiary will be assigned to if they do not choose a
plan. AB 2002 was held in Assembly Appropriations at the
author's request.
d) SB 1008 (Committee on Budget and Fiscal Review), Chapter
33, Statutes of 2012, and SB 1036 (Committee on Budget and
Fiscal Review), Chapter 45, Statutes of 2012, enacts the
CCI.
e) SB 208 (Steinberg), Chapter 714, Statutes of 2010,
contained the provisions implementing Section 1115(b)
Medicaid Demonstration Waiver from CMS entitled "A Bridge
to Reform Waiver." Among the provisions, this waiver
authorized mandatory enrollment into Medi-Cal MCPs of over
600,000 low-income SPDs who are eligible for Medi-Cal only
(not Medicare) in 16 counties.
f) ACR 29 (Jones), Resolution Chapter 9, Statues of 2009,
requests CHHSA to provide leadership to ensure that, within
existing resources and programs, departments within the
agency implement programs, activities, and strategies that
place a priority focus on preventing, reducing, and
eliminating health disparities among racial and ethnic
population subgroups.
g) AB 330 (Hayashi) of 2007 would have required OSHPD, in
conjunction with CHHSA, to develop a health disparity
report by January 1, 2009, based on patient hospital
discharge data. This bill was held on suspense in the
Assembly Appropriations Committee.
h) AB 1142 (Dymally), Chapter 403, Statutes of 2005,
establishes the Statewide African American Initiative to
address the disproportionate impact of HIV/AIDS on the
health of African Americans by coordinating prevention and
service networks around the state and increasing the
capacity of core service providers.
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i) ACR 112 (Chan), Resolution Chapter 103, Statutes of
2006, encourages public health and medical officials to
target vaccination efforts toward Asian Pacific Islander
(API) children to decrease the incidence rate of this
disease in California's API communities.
j) ACR 114 (Coto), Chapter 151, Statutes of 2006,
establishes the Legislative Task Force on Diabetes and
Obesity, consisting of 20 members, as specified, to study
the factors contributing to the high rates of diabetes and
obesity in Latinos, African Americans, Asian Pacific
Islanders, and Native Americans in this country, and
requires the Legislative Task Force on Diabetes and Obesity
to prepare a report containing recommendations, no later
than December 31, 2007, regarding ways to reduce the
incidence of those debilitating conditions.
aa) AB 2047 (Machado) of 2002 would have created the Chronic
Disease Prevention Council (Council) within the Department
of Health Services (DHS) (now DPH) to coordinate and
prioritize disease prevention programs. AB 2047 was vetoed
by Governor Gray Davis, who stated that committees similar
to the Council already existed within DHS. The message
directed DHS to utilize an existing advisory committee or
council to fulfill the objectives of the bill.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees
AnewAmerica Community Corporation
Asian Pacific Islander Caucus for Public Health
Asian & Pacific Islander American Health Forum
Asian Journal Publications
Asian Law Alliance
Azul Management Systems Institute
Black Economic Council
California Black Health Network
California Coverage & Health Initiatives
California Center for Public Health Advocacy
California Immigrant Policy Center
California Rural Legal Assistance Foundation
California School Health Centers Association
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Chicana/Latina Foundation
Children's Defense Fund California
Children Now
The Children's Partnership
Full Gospel Business Men's Fellowship International
Greenlining Institute
Health Access California
Manila-US Times
March of Dimes, California Chapter
PICO California
United Ways of California
Western Center on Law and Poverty
Worksite Wellness LA
One individual
Opposition
Local Health Plans of California
California Association of Health Plans
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097