BILL ANALYSIS Ó
AB 1208
Page 1
Date of Hearing: April 16, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1208 (Pan) - As Amended: April 1, 2013
SUBJECT : Medical homes.
SUMMARY : Establishes the Patient Centered Medical Home (PCMH)
Act of 2013 which defines medical homes and specifies its
characteristics. Specifically, this bill :
1) Defines medical home and PCMH to mean a health care
delivery model in which a patient establishes an ongoing
relationship with a personal primary care physician or
other licensed health care provider acting within the scope
of his or her practice.
2) Provides that the personal provider works in a
physician-led practice team to provide comprehensive,
accessible, and continuous evidence-based primary and
preventative care, and to coordinate the patient's health
care needs across the health care system in order to
improve quality and health outcomes in a cost-effective
manner.
3) Requires a health care delivery model specified above to
stress a team approach to providing comprehensive health
care that fosters a partnership among the patient, the
licensed health care provider acting within his or her
scope of practice, other health care professionals, and, if
appropriate, the patient's family.
4) Requires a PCMH to include all of the following
characteristics:
a) Individual patients shall have an ongoing relationship
with a physician or other licensed health care provider
acting within his or her scope of practice, who is trained
to provide first contact and continuous and comprehensive
care, or, if appropriate, provide referrals to health care
professionals that provide continuous and comprehensive
care;
b) A provider-led team of individuals at the practice level
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shall take collective responsibility for the ongoing health
care of patients, including appropriately arranging health
care by other qualified health care professionals and
making appropriate referrals.
c) Care shall be coordinated and integrated across all
elements of the complex health care system, including
mental health and substance use disorder care, and the
patient's community. Care shall be facilitated by health
information technology, such as electronic medical records,
electronic patient portals, health information exchanges,
and other means to ensure that patients receive the
indicated care when and where they need and want this care
in a culturally and linguistically appropriate manner.
d) The medical home payment structure shall be designed to
reward the provision of the right care in the right
setting, and discourage the delivery of too much or too
little care. The payment structure shall encourage
appropriate management of complex medical cases, increased
access to care, the measurement of patient outcomes,
continuous improvement of care quality, and comprehensive
integration and coordination across all stages and settings
of a patient's care.
e) Patients shall be provided with enhanced access to
health care that meets the requirements of a nationally
recognized, independent, medical home accreditation agency
f) All of the following quality and safety components shall
be incorporated into the PCMH:
i) Advocacy for patients to support the attainment of
optimal, patient-centered outcomes that are defined by a
care planning process driven by a compassionate, robust
partnership between providers, the patient, and the
patient's family;
ii)Evidence-based medicine and clinical decision support
tools guide decisionmaking;
iii)The licensed health care providers in the practice
accept accountability for continuous quality improvement
through voluntary engagement in performance measurement
and improvement;
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iv)Active patient participation in decision making.
Feedback is sought to ensure that the patient's
expectations are being met;
v) Information technology is utilized appropriately to
support optimal patient care, performance measurement,
patient education, and enhanced communication; and,
vi)Patients and families participate in quality improvement
activities at the practice level.
5) Prohibits construing this bill to do any of the
following:
a) Permit a PCMH to engage in or otherwise aid and abet in
the unlicensed practice of medicine, either directly or
indirectly;
b) Change the scope of practice of physicians and surgeons,
nurse practitioners, or other health care providers;
c) Affect the ability of a nurse to operate under standard
procedures, as specified;
d) Apply to a Low Income Health Program (LIHP) development,
as specified, including the program's provider network and
service delivery system, or to activities conducted as part
of a demonstration project, as specified; or,
e) Prevent or limit participation in authorized federal
activities, as specified, if the participation is
consistent with state law pertaining to scope of practice.
EXISTING LAW :
1)Defines PCMH under the federal Affordable Care Act (ACA) and
authorizes tests of innovative Medicaid (Medi-Cal in
California) and Medicare service delivery models in federal
fiscal years 2010 to 2019, to reduce program expenditures
while preserving or enhancing patient quality of care.
Provides that innovative models include PCMHs for high-need
patients and medical homes that address women's unique health
care needs.
2)Makes grants under the ACA available to states to establish
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community-based interdisciplinary teams to support medical
homes and help primary care providers implement them in
federal fiscal years 2011 and 2012.
3)Authorizes the waiving of specified Medicaid requirements for
demonstration projects, for care delivered through primary
care case-management systems, or for the provision of home- or
community-based services.
4)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income persons receive health care benefits.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, by adding a
PCMH definition this bill ensures uniform standards of quality
and access, and encourage health care providers to work as a
team to provide patient-centered care. Additionally, adding a
PCMH definition sends an important signal to health care
providers and patients that California supports: a) care that
is patient-centered, cost-efficient, continuous, focused on
prevention, and based on sound, evidence-based medicine rather
than episodic, illness-oriented "siloed" care; and, b) a
health care team (doctors, nurses, physician assistants,
medical assistants, mental health providers, community health
workers, social workers, etc.) working in partnership with one
another, their patients and their patients' families to
coordinate care, navigate the complex and often confusing
health care system and ensure that patients receive the right
care at the right time.
2)BACKGROUND .
a) PCMH Models . According to the National Conference of
State Legislatures (NCSL), PCMH is a way to provide
comprehensive care that is designated and centered around
the patient's needs. In the PCMH model, a health care team
(i.e. doctors, nurses, physician assistants, medical
assistants, mental health providers, community health
workers, and social workers) works in partnership with one
another, their patients, and their patients' families to
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coordinate care and navigate the complex and often
confusing health care system to ensure that patients
receive the right care at the right time. The model aims
to improve coordination of care, increase the value of
health care received, expand administrative and quality
innovations, promote active patient and family involvement,
and help control the rising costs of health care for both
individuals and payers, such as Medicaid and private
insurers.
According to the federal Agency for Healthcare Research and
Quality, PCMH is an organization of primary health care
that encompasses the following five core functions:
i) Comprehensive Care: The PCMH is accountable for
meeting the large majority of each patient's physical and
mental health care needs, including prevention and
wellness, acute care, and chronic care. Providing
comprehensive care requires a team of care providers.
This team might include physicians, advanced practice
nurses, physician assistants, nurses, pharmacists,
nutritionists, social workers, educators, and care
coordinators. Although some medical home practices may
bring together large and diverse teams of care providers
to meet the needs of their patients, many others,
including smaller practices, build virtual teams linking
themselves and their patients to providers and services
in their communities.
ii) Patient-Centered: The PCMH provides primary health
care that is relationship-based with an orientation
toward the whole person. Partnering with patients and
their families requires understanding and respecting each
patient's unique needs, culture, values, and preferences.
The medical home practice actively supports patients in
learning to manage and organize their own care at the
level the patient chooses. Recognizing that patients and
families are core members of the care team, medical home
practices ensure that they are fully informed partners in
establishing care plans.
iii) Coordinated Care: The PCMH coordinates care across
all elements of the broader health care system, including
specialty care, hospitals, home health care, and
community services and supports. Such coordination is
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particularly critical during transitions between sites of
care, such as when patients are being discharged from the
hospital. Medical home practices also excel at building
clear and open communication among patients and families,
the medical home, and members of the broader care team.
iv) Accessible Services: The PCMH delivers accessible
services with shorter waiting times for urgent needs,
enhanced in-person hours, around-the-clock telephone or
electronic access to a member of the care team, and
alternative methods of communication, such as email and
telephone care. The medical home practice is responsive
to patients' preferences regarding access.
v) Quality and Safety: The PCMH demonstrates a
commitment to quality and quality improvement by ongoing
engagement in activities, such as using evidence-based
medicine and clinical decision-support tools, to guide
shared decision-making with patients and families,
engaging in performance measurement and improvement,
measuring and responding to patient experiences and
patient satisfaction, and practicing population health
management. Sharing robust quality and safety data and
improvement activities publicly is also an important
marker of a system-level commitment to quality.
According to NCSL, as of January 2012, 41 states had policies
to promote the medical home model for some beneficiaries of
Medicaid or the Children's Health Insurance Program. PCMH
continues to evolve and not all medical homes look alike or
use the same strategies to reduce costs, improve quality, and
coordinate care. While the model was originally developed for
pediatrics and has since been refined to serve chronically ill
patients, it has also been applied in programs serving both
the public and private sectors.
b) PCMH & the ACA . The ACA presents several opportunities
to advance the medical home concept and improve the
continuum of care for people with chronic conditions and
functional impairment, thereby creating and strengthening
linkages between medical care and supportive services. The
ACA defines a medical home as a "model of care that
includes personal physicians; whole person orientation;
coordinated and integrated care; safe and high-quality care
through evidence informed medicine; appropriate use of
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health information technology; continuous quality
improvements; expanded access to care; and, payment that
recognizes added value from additional components of
patient-centered care." Key provisions in the ACA that
recognize alternate models of organizing care, such as the
PCMH, include the following:
i) Gives states the option of enrolling Medicaid
beneficiaries with chronic conditions into a health home.
Health homes would be composed of a team of health
professionals and provide a comprehensive set of medical
services, including care coordination. Provides states
with 90% federal money for two years to deliver these
wraparound services.
ii) Creates a more rapid environment to develop, test,
and expand innovative payment and delivery models that
improve quality while controlling costs through the
establishment of the Center for Medicare and Medicaid
Innovation (CMI). When considering which demonstration
projects to support, the ACA directs the CMI to give
greater weight to those projects that address the key
elements of person-centered care coordination, such as
individualized assessment, direct engagement with
patients and their caregivers, and interdisciplinary team
care.
iii) Provides grants to develop and operate training
programs; provide financial assistance to trainees and
faculty; enhance faculty development in primary care and
physician assistant programs; and, establish, maintain,
and improve academic units in primary care. Priority is
given to programs that educate students in team-based
approaches to care, including the PCMH model.
c) Hearing on PCMH . On January 29, 2013, this Committee
conducted an informational hearing on PCMH entitled
"Improving Outcomes through the Patient Centered Medical
Home." The purpose of the hearing was to examine the core
concepts of the PCMH model and evaluate how it can be
appropriately utilized as a key tool in successful chronic
disease management.
3)SUPPORT . The California Academy of Family Physicians states
that California has been slow in adopting the PCMH model and
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this bill addresses out of control health care costs and
diminishing state revenue, high cost and low quality of
compartmentalized patient care.
Children Now, United Ways of California and the Children's
Defense Fund state that this bill would ensure that medical
homes in California incorporate the features that have made
this a successful model nationally, and would encourage health
care providers to move toward a future characterized by
patient-centered, prevention-focused, evidence-based, and
cost-efficient health care.
The California Council of Community Mental Health Agencies and
the Mental Health America of California indicate this bill
improves the integration of mental health and physical health
care to provide comprehensive care coordination services to
chronic medical conditions especially those with chronic
mental health problems.
4)SUPPORT IF AMENDED . The California Association of Physician
Groups (CAPG) states that any process that involves a
patient's family in the PCMH process should include the
patient's consent. CAPG also points out that requiring PCMH
to meet the requirements of a nationally recognized
accreditation agency is expensive and proposes that the
recognition of the PCMH model should be California-based.
5)OPPOSITION . The California Right to Life Committee indicates
that this bill appears to mesh with the ACA and to have the
medical profession participate in a centralized government
record keeping on every individual's health, nutrition, and
exercise, using community care standards instead of what may
be best for the individual.
6)RELATED LEGISLATION . AB 361 (Mitchell) authorizes DHCS to
submit State Plan Amendments to the federal Centers for
Medicare and Medicaid Services for approval to provide health
home services to adults and children. AB 361 is pending in
Assembly Appropriations Committee.
7)PREVIOUS LEGISLATION .
a) AB 2266 (Mitchell) would have required DHCS to establish
a program to provide health home services designed to
reduce a participating individual's avoidable use of
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hospitals when more effective care can be provided in less
costly settings. Defined the population of individuals
eligible to receive health home services, the required
services, and the criteria for health care providers
selected through a request for proposal process. Required
DHCS to prepare or contract for an evaluation of the
program, to complete the evaluation, and to submit a report
to the appropriate policy and fiscal committees of the
Legislature.
b) SB 393 (Ed Hernandez) would have enacted the PCMH Act
of 2011 and established a definition for a medical home
based upon specified standards. SB 393 was vetoed by
Governor Brown who stated in his veto message that he
commends the author for trying to improve the delivery of
health care by encouraging the greater use of
"patient-centered medical homes." While this concept is
not new, it is still evolving. For this reason, he thought
more work was needed before we codify the definition
contained in this bill.
c) AB 1542 (Jones) of 2010 would have defined a PCMH to
mean, in part, a health care delivery model in which a
patient establishes an ongoing relationship with a
physician or other licensed health care provider, working
in a physician-directed practice team to provide
comprehensive, accessible, and continuous evidence-based
primary care and coordinate the patient's health care needs
across the health care system. AB 1542 died on the
Assembly Floor.
d) SB 1738 (Steinberg) of 2008 would have required DHCS to
establish a three-year pilot program to provide intensive
multidisciplinary services to 2,500 Medi-Cal beneficiaries
identified as frequent users of health care. SB 1738 was
vetoed by Governor Schwarzenegger who stated in his veto
message that he could not support the bill because of the
state's ongoing fiscal challenges and asked the author and
stakeholders to work with his Administration to identify
strategies to ensure these beneficiaries receive the right
care, at the right time, in the right setting.
8)TECHNICAL AMENDMENTS .
a) The author would like to clarify that any of the
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provisions of the bill relating to a patient's family also
applies to a patient's representative, and any inclusion of
a patient's family or representative should be upon the
consent of the patient.
b) On page 2, line 16, clarify that the health care
delivery model referred to is a medical home.
c) On page 4, line 12, clarify that this bill does not
require adherence by a LIHP.
REGISTERED SUPPORT / OPPOSITION :
Support
California Academy of Family Physicians (co-sponsor)
California Academy of Physician Assistants (co-sponsor)
California Medical Association (co-sponsor)
100% Campaign
American Academy of Pediatrics
American College of Physicians
California Black Health Network
California Council of Community Mental Health Agencies
California Coverage and Health Initiatives
California Primary Care Association
Children's Defense Fund
Children Now
Children's Partnership
Mental Health America of California
Pacific Clinics
PICO California
United Ways of California
Opposition
California Right to Life Committee
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097