BILL ANALYSIS �
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THIRD READING
Bill No: AB 411
Author: Pan (D)
Amended: 9/11/13 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 8-1, 6/26/13
AYES: Hernandez, Anderson, Beall, De Le�n, DeSaulnier, Monning,
Pavley, Wolk
NOES: Nielsen
SENATE APPROPRIATIONS COMMITTEE : 5-2, 8/30/13
AYES: De Le�n, Hill, Lara, Padilla, Steinberg
NOES: Walters, Gaines
ASSEMBLY FLOOR : 54-19, 5/16/13 - See last page for vote
SUBJECT : Medi-Cal: performance measures
SOURCE : California Pan-Ethnic Health Network
DIGEST : This bill requires, when the Department of Health
Care Services (DHCS) enters into a new contract with an External
Quality Review Organization (EQRO) for the EQRO to perform work
associated with Medi-Cal managed care programs, requires DHCS to
include in the terms of the new contract a requirement that,
upon approval of the contract, the EQRO stratify all
patient-specific Healthcare Effectiveness Data and Information
Set (HEDIS) measures, or their External Accountability Set (EAS)
performance measure equivalent, by certain characteristics,
including geographic area and primary language. Requires DHCS
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to publicly report this analysis on their Internet Web site.
States that its provisions will only be implemented to the
extent that funding is available.
Senate Floor Amendments of 9/11/13 clarify that the EQRO is
required to collect specified data only to the extent that it is
reliable.
Senate Floor Amendments of 9/6/13 (1) delete provisions
requiring Medi-Cal managed care plans, when DHCS contracts with
an EQRO, to link specified data to patient identifiers and
instead require an EQRO to perform work associated with Medi-Cal
managed care programs, (2) clarify that this bill will only be
implemented to the extent that funding is available, and (3)
make other technical changes.
ANALYSIS :
Existing law:
1.Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services.
2.Permits the director of DHCS to contract, on a bid or non-bid
basis, with any qualified individual, organization, or entity
to provide services to, arrange for or case manage the care of
Medi-Cal beneficiaries. Permits, at the director's
discretion, the contract to be exclusive or nonexclusive,
statewide or on a more limited geographic basis, and include
provisions to provide for delivery of services in a manner
consistent with managed care principles, techniques, and
practices directed at ensuring the most cost-effective and
appropriate scope, duration, and level of care.
3.Requires, under federal regulations, states to require through
their contracts with managed care plans, that each plan have
an ongoing quality assessment and performance improvement
program for the services it furnishes to its enrollees.
This bill:
1.Requires, when DHCS enters into a new contract with an EQRO,
to perform work associated with Medi-Cal managed care
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programs, the terms of the new contract to contain a
requirement that, upon approval of the contract, the EQRO
stratify all patient-specific HEDIS measures, or their EAS
performance measure equivalent, by geographic area, primary
language, race, ethnicity, gender, and, to the extent reliable
data is available, by sexual orientation and gender identity,
in order to identify disparities in the quality of care
provided to Medi-Cal managed care enrollees based on those
factors.
2.Requires DHCS to publicly report the analysis on their
Internet Web site.
3.Clarifies these provisions will be implemented only to the
extent that funding is available.
Background
Health care disparities . The Institute of Medicine (IOM), in a
2002 report entitled "Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care," found that a consistent body
of research demonstrates significant variation in the rates of
medical procedures by race, even when insurance status, income,
age, and severity of conditions are comparable. This research
indicates that U.S. racial and ethnic minorities are less likely
to receive even routine medical procedures and experience a
lower quality of health services. The IOM report says a large
body of research underscores the existence of disparities. For
example, minorities are less likely to be given appropriate
cardiac medications or to undergo bypass surgery, and are less
likely to receive kidney dialysis or transplants. By contrast,
they are more likely to receive certain less-desirable
procedures, such as lower limb amputations for diabetes and
other conditions.
Current quality measures . According to the Senate Health
Committee analysis, DHCS reports on a variety of measures, some
of which are unique to a specific population or initiative and
others that apply more generally. Two of the quality measures
referenced in this bill are EAS and HEDIS.
External accountability set . The federal Centers for Medicare
and Medicaid Services (CMS) requires that states, through their
contracts with Medi-Cal managed care plans, measure and report
on performance to assess the quality and appropriateness of care
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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 EAS. DHCS designates EAS
performance measures on an annual basis and requires plans to
report on them. DHCS uses HEDIS measures as the primary tool.
Currently required HEDIS measures include well child visits,
immunizations, comprehensive diabetes care, and annual
monitoring of patients on persistent medications. For 2013,
Medi-Cal managed care plans will be reporting on 14 HEDIS
measures. In addition, DHCS is requiring one customized measure
for determining rates of hospital readmissions within 30 days of
discharge.
HEDIS . HEDIS is a standardized set of performance measures used
to provide health care purchasers, consumers, and others with a
reliable comparison between health plans. HEDIS data are often
used to produce health plan "report cards," analyze quality
improvement activities, and benchmark performance. NCQA
classifies the broad range of HEDIS measures across eight
domains of care: effectiveness of care; access/availability of
care; satisfaction with the experience of care; use of services;
cost of care; health plan descriptive information; health plan
stability; and, informed health care choices. DHCS and plans
use plan-specific data, aggregate data, and comparisons to state
and national benchmarks to identify opportunities for
improvement, analyze performance, and assess whether previously
implemented interventions were effective.
Managed Risk Medical Insurance Board (MRMIB) monitoring of
plans . MRMIB administers the Healthy Families Program (HFP),
and requires its HFP-health and dental plans to ensure that
access to quality health care was shared by all of its members.
Analysis of HEDIS data was performed for measures that use
administrative data where all eligible members are counted.
Data groupings used by MRMIB for its HEDIS report are health
plan, region, income level, language spoken in the home,
ethnicity, and age. For example, MRMIB reported in the 2011
Healthy Families Program Healthcare Effectiveness Data and
Information Set Report that 88% of white children saw a primary
care physician 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
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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 a 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 contracting plans in the same way and does not
require the plans to report the data in a way that would allow
similar analysis.
Prior Legislation
AB 1494 (Assembly Budget Committee, Chapter 28, Statutes of
2012) provides for the transition of children from HFP to
Medi-Cal starting no earlier than January 1, 2013.
AB 1467 (Assembly Budget Committee, Chapter 23, Statutes of
2012) authorized the expansion of Medi-Cal managed care to 28
mostly rural counties.
AB 2002 (Cedillo, 2012) would have defined "safety net provider"
for the purpose of determining which Medi-Cal managed care a
beneficiary will be assigned to if they do not choose a plan.
AB 2002 was held in the Assembly Appropriations Committee.
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 managed care plans of over 600,000 low-income seniors
and persons with disabilities who are eligible for Medi-Cal only
(not Medicare) in 16 counties.
SB 1008 (Senate Budget and Fiscal Review Committee, Chapter 33,
Statutes of 2012) and SB 1036 (Senate Budget and Fiscal Review
Committee, Chapter 45, Statutes of 2012) enacted the Coordinated
Care Initiative.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
Likely costs in the hundreds of thousands per year for data
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analysis and reporting by DHCS or an external contractor,
based on similar data analysis costs incurred by MRMIB for HFP
(50% General Fund, 50% federal funds).
Minor potential costs to Medi-Cal managed care plans to
collect and report data to DHCS or an external contractor. To
the extent that additional costs for the Medi-Cal managed care
plans are built into future managed care rates, state Medi-Cal
costs could increase slightly.
SUPPORT : (Verified 9/9/13)
California Pan-Ethnic Health Network (source)
100% Campaign
AARP
Access to Healthcare Momentum Team
American Cancer Society Cancer Action Network
American Federation of State, County and Municipal Employees,
AFL-CIO
American GI Forum of California
AnewAmerica Community Corporation
Asian & Pacific Islander American Health Forum
Asian American Business Women Association
Asian Journal Publications
Asian Law Alliance
Asian Pacific Islander Caucus for Public Health
Azul Management Systems Institute
Binational Center for the Development of Oaxaca Indigenous
Communities
Black Economic Council
Bridge Clinical Research
California Association of Physician Groups
California Black Health Network
California Center for Public Health Advocacy
California Center for Research on Women and Families
California Council of Community Mental Health Agencies
California Immigrant Policy Center
California National Organization for Women
California Primary Care Association
California Rural Legal Assistance Foundation
California School Employees Association
California School Health Centers Association
Cal-Islanders Humanitarian Association
Chicana/Latina Foundation
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Children Now
Children's Defense Fund California
Children's Partnership
Community Clinic Association of Los Angeles County
El Concilio of San Mateo County
FAME Assistance Corporation
Full Gospel Business Men's Fellowship International
Greenlining Institute
Guam Communications Network
Having Our Say
Health Access California
Health Officers Association of California
KidWorks Community Development Corporation
Korean Health, Education, Information and Research Center
Manila-US Times
March of Dimes, California Chapter
Mental Health America of California
National Association of Social Workers, California Chapter
National Health Law Program
PICO California
Public Health Institute
Street Level Health Project
The Children's Partnership
Transgender Law Center
United Ways of California
West Angeles Community Development Corporation
Western Center on Law and Poverty
Worksite Wellness LA
ARGUMENTS IN SUPPORT : The California Pan-Ethnic Health
Network (CPEHN), sponsor of this bill, writes that even though
73% of Medi-Cal enrollees are from communities of color, no
requirement exists for Medi-Cal managed care plans 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
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hospital admission for congestive heart failure. CPEHN points
to a UCSF study that found 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
Medi-Cal managed care plans to begin to seriously and
systematically identify and address the disparities of its
diverse enrollee population. CPEHN concludes that this bill
will help inform DHCS and Medi-Cal managed care plans of health
disparities among enrollees and develop strategies to address
them.
ASSEMBLY FLOOR : 54-19, 5/16/13
AYES: Alejo, Ammiano, Atkins, Bloom, Blumenfield, Bocanegra,
Bonilla, Bonta, Bradford, Brown, Buchanan, Ian Calderon,
Campos, Chau, Ch�vez, Chesbro, Cooley, Daly, Dickinson,
Eggman, Fong, Fox, Frazier, Garcia, Gatto, Gomez, Gordon,
Gray, Hall, Roger Hern�ndez, Jones-Sawyer, Levine, Lowenthal,
Medina, Mitchell, Mullin, Muratsuchi, Nazarian, Nestande, Pan,
Perea, V. Manuel P�rez, Quirk, Quirk-Silva, Rendon, Salas,
Skinner, Ting, Torres, Weber, Wieckowski, Williams, Yamada,
John A. P�rez
NOES: Achadjian, Bigelow, Conway, Dahle, Donnelly, Beth Gaines,
Gorell, Hagman, Harkey, Jones, Linder, Logue, Maienschein,
Mansoor, Olsen, Patterson, Wagner, Waldron, Wilk
NO VOTE RECORDED: Allen, Grove, Holden, Melendez, Morrell,
Stone, Vacancy
JL:ej 9/11/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
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