BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1208
AUTHOR: Pan
AMENDED: May 9, 2013
HEARING DATE: June 26, 2013
CONSULTANT: Marchand
SUBJECT : Medical homes.
SUMMARY : Establishes the Patient Centered Medical Home Act of
2013, which defines "medical home" and "patient centered medical
home" as a health care delivery model in which a patient
establishes a relationship with a licensed health care provider
in a physician-led practice team to provide comprehensive,
accessible, and continuous primary and preventive care, and to
coordinate the patient's health care needs across the health
care system.
Existing law:
1.Establishes the "Bridge to Reform Demonstration Project,"
under which coverage is expanded to eligible low income adults
through the Low Income Health Program (LIHP).
2.Requires one of the elements of a LIHP participating in the
above demonstration project to be the assignment of eligible
individuals to a medical home. A "medical home," for purposes
of this demonstration project, is defined as a single
provider, facility, or health care team that maintains an
individual's medical information, and coordinates health care
services for enrolled individuals. Requires the medical home
to provide certain specified elements, including the
following:
a. A primary health care contact who facilitates
the enrollee's access to preventive, primary,
specialty, mental health, or chronic illness
treatment, as appropriate;
b. An intake assessment of each new enrollee's
general health status;
c. Referrals to qualified professionals,
community resources, or other agencies;
d. Care coordination for the enrollees across the
service delivery system, as agreed to between the
medical home and the LIHP;
Continued---
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e. Use of clinical guidelines and other
evidence-based medicine when applicable for treatment
of the enrollee's health care issues and timing of
clinical preventive services;
f. Focus on continuous improvement in quality of
care; and,
g. Health information, education, and support to
beneficiaries and, where appropriate, their families,
if and when needed, in a culturally competent manner.
This bill:
1.Establishes the Patient Centered Medical Home Act of 2013, and
requires medical homes to include various specified
requirements unless otherwise provided by statute.
2.Defines "medical home" and "patient centered medical home"
(PCMH) as 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.
3.Specifies 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.
4.Requires a PCMH 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 or the patient's
representative, upon the consent of the patient.
5.Requires individual patients in a PCMH to 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.
6.Requires a provider in a PCMH, working in concert with a
multidisciplinary team of individuals at the practice level,
to take responsibility for the ongoing health care of
patients, including appropriately arranging health care by
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3
other qualified health care professionals and making
appropriate referrals.
7.Requires care in a PCMH to 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.
8.Requires care in a PCMH to 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.
9.Requires the PCMH payment structure to be designed to reward
the provision of the right care in the right setting, and to
discourage the delivery of too much or too little care.
10.Requires the PCMH payment structure to 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.
11.Requires all of the following quality and safety components
to be incorporated into the PCMH:
a. 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 or representative;
b. Evidence-based medicine and clinical decision
support tools to guide decision-making;
c. The licensed health care providers in the practice
accept accountability for continuous quality improvement
through voluntary engagement in performance measurement
and improvement;
d. Active patient participation in decision-making,
with feedback sought to ensure that the patient's
expectations are being met;
e. Information technology is utilized appropriately to
support optimal patient care, performance measurement,
patient education, and enhanced communication; and,
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f. Patients and families or representatives participate
in quality improvement activities at the practice level.
12.Requires patients in a PCMH to be provided with enhanced
access to health care that meets the requirements of a
nationally recognized, independent medical home accreditation
agency.
13.Prohibits anything in this bill from being construed 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 physician, nurse
practitioners, or other health providers;
c. Affect the ability of a nurse to operate under
standardized procedures, as specified;
d. Require adherence to the Low Income Health Program,
as specified, including the program's provider network
and service delivery system, or to activities conducted
as part of a demonstration project developed under the
Health Care Coordination, Improvement, and Long-Term Cost
Containment Waiver; or
e. Prevent or limit participation in activities
authorized by specified provisions of the federal Patient
Protection and Affordable Care Act (ACA), if the
participation is consistent with state law pertaining to
scope of practice.
FISCAL EFFECT : This bill has been keyed non-fiscal.
PRIOR VOTES :
Assembly Health: 17- 2
Assembly Floor: 62- 12
COMMENTS :
1.Author's statement. According to a May 2013 Policy Brief by
the UCLA Center for Health Policy Research, the success of
health care reform implementation in 2014 partly depends on
more efficient delivery of care to the millions of California
residents eligible to gain insurance. The Policy Brief
indicates that there is evidence that the medical home model
improves health outcomes and reduces costs. By adding a PCMH
definition, this bill ensures uniform standards of quality and
access, encourages health care providers to work as a team to
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5
provide patient-centered care and promotes a more efficient
delivery of 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.Affordable Care Act. The ACA contained several provisions to
support and advance the medical home model of care. One of
these was entitled, "Establishing Community Health Teams to
Support the Patient-Centered Medical Home." This is a grant
program to help establish community-based interdisciplinary,
interprofessional teams to support primary care practices, and
requires grants to be used to establish health teams to
provide support services to primary care providers and provide
capitated payments to primary care providers. Under this
program, patient-centered medical home is defined as a model
of care that includes the following: 1) personal physicians;
2) whole person orientation; 3) coordinated and integrated
care; 4) safe and high-quality care through evidence-informed
medicine, appropriate use of health information technology,
and continuous quality improvements; 5) expanded access to
care; and, 6) payment that recognizes added value from
additional components of patient-centered care.
Another provision of the ACA, entitled "State Option to Provide
Health Homes for Enrollees with Chronic Conditions,"
established a waiver program to give states the option of
enrolling Medicaid beneficiaries with chronic conditions into
a health home. "Health home," for purposes of this program, is
defined as "a designated provider (including a provider that
operates in coordination with a team of health care
professionals) or a health team selected by an eligible
individual with chronic conditions to provide health home
services." The term "designated provider" is defined as a
physician, clinical practice or clinical group practice, rural
clinic, community health center, community mental health
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center, home health agency, or any other entity or provider
(including pediatricians, gynecologists, and obstetricians)
that is determined by the State and approved by the Secretary
to be qualified to be a health home for eligible individuals
with chronic conditions." This waiver program would provide a
90 percent federal match for the first two years. States are
permitted to tier payments to reflect a team of health care
professionals operating with a designated provider, as well as
the severity or number of individual's with chronic conditions
or the specific capabilities of the designated provider and
health team. "Health home services" is defined as
comprehensive and timely high-quality services that are
provided by a designated provider or a team of health care
professionals operating with a designated provider and
include: 1) comprehensive care management; 2) care
coordination and health promotion; 3) comprehensive
transitional care, including appropriate follow-up, from
inpatient to other settings; 4) patient and family support; 5)
referral to community and social support services; and 6) use
of health information technology to link services.
3.Background on the medical home model. According to a September
2012 brief prepared by the National Conference of State
Legislatures (NCSL), the medical home model of care offers one
method of transforming the health care delivery system.
Medical homes can reduce costs while improving quality and
efficiency through an innovative approach to delivering
comprehensive patient-centered preventive and primary care.
Also known as the PCMH, this model is designed around patient
needs and aims to improve access to care (e.g. through
extended office hours and increased communication between
providers and patients via email and telephone), increase care
coordination and enhance overall quality, while simultaneously
reducing costs. The medical home relies on a team of
providers-such as physicians, nurses, nutritionists,
pharmacists, and social workers-to meet a patient's health
care needs. Studies have shown that the medical home model's
attention to the whole-person and integration of all aspects
of health care offer potential to improve physical health,
behavioral health, access to community-based social services
and management of chronic conditions.
NCSL notes that although general agreement exists about the
basic tenets of the medical home, the model is still evolving.
Not all medical homes look alike or use the same strategies
to reduce costs, improve quality and coordinate care.
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Accreditation offers formal recognition and a stamp of
approval to those that successfully meet specific standards
and requirements, facilitating payment from both public and
private payers. Medical home accreditation is available from
national accreditation organizations, as well as a few states
that have developed their own standards. Although certain
health care providers already embody many elements of the
PCMH, many are seeking formal recognition, due in part to the
fact that medical practices that participate in medical home
pilot programs often qualify for enhanced reimbursement rates,
or receive other financial incentives for coordinating care.
According to NCSL, as of January 2012, 41 states had policies
promoting the medical home model for certain Medicaid or
Children's Health Insurance Program beneficiaries. States have
created pilot projects, reformed payment structures, invested
in health information technology, restructured Medicaid
provider systems, and included the medical home model in
service delivery.
4.Related legislation. AB 361 (Mitchell) authorizes the
Department of Health Care Services (DHCS) to submit State Plan
Amendments to the federal Centers for Medicare and Medicaid
Services for approval to create a California Health Home
Program to provide health home services to adults and children
in the Medi-Cal program. AB 361 defines a "health home" as a
provider or team of providers that meets federal guidelines
and that offers a whole person approach and offers services in
a range of settings. AB 361 permits DHCS to require a lead
provider to be a physician, a community clinic, a mental
health plan, a community-based nonprofit organization, a
county health system, a substance use disorder treatment
professional or facility, or a hospital. AB 361 is scheduled
to be heard in this committee on July 3.
5.Prior legislation. AB 2266 (Mitchell) of 2012, would have
required DHCS to establish a program to provide specified
health home services, with the intent of reducing avoidable
hospitalization or use of emergency medical services. AB 2266
died on the Senate Inactive File.
SB 393 (Ed Hernandez) would have enacted the PCMH Act of 2012
and established a definition for a medical home based upon
specified standards. SB 393 was vetoed by the Governor. In
his veto message, the Governor stated that he commended the
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author for trying to improve the delivery of health care by
encouraging the greater use of "patient-centered medical
homes," but because the concept is still evolving, he thought
more work was needed before the definition was codified.
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.
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.
6.Support. This bill is co-sponsored by the California Academy
of Family Physicians (CAFP), the California Medical
Association (CMA), and the California Academy of Physician
Assistants (CAPA), and supported by numerous other provider
organizations and other groups. CAFP states that the goal of
the medical home is to provide a patient with a broad spectrum
of coordinated care. More than 40 states have adopted medical
home legislation, but CAFP states that California has been
slow to act. With the number of Americans with one or more
chronic diseases projected to increase from 125 million in
2000 to 157 million in 2020, CAFP asserts that it is more
important than ever to ensure adequate management of these
conditions. CMA states that this bill is a critical piece of
California's effort to move into the future of healthcare
delivery. According to CMA, in the years to come, as federal
health reform is implemented and states work on ways to
deliver higher quality, more efficient care to patients,
better care coordination will be key. CMA states that while
establishing PCMH's is a primary means of streamlining the
system and improving individual health outcomes, not all
"medical homes" are created equal and this bill will help to
provide necessary parameters by defining "medical home" in
state law. CMA states that medical home models have proven
successful only when they operate with the involvement of a
patient's entire care team, and that physicians play a
fundamental role in successful medical homes and help to
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ensure that all of a patient's care needs are effectively
addressed and coordinated. CAPA states that this bill will
encourage health care providers and patients to partner in a
PCMH that promotes access to high-quality, comprehensive and
coordinated care. According to CAPA, developing a standard
definition for PCMH's could help reduce disparities, rein in
costs and improve quality and outcomes in health care.
7.Opposition. The California Right to Life Committee (CRLC)
states in opposition that it is concerned that in the course
of years, usage of the term "medical home" includes school
based clinics. According to CRLC, there are school districts
in California which have school- based clinics and offer
family planning and abortion referrals to minors without
parental consent. With school-based clinics or "wellness
centers" under the domain of "medical homes," students would
be vulnerable to suggestions or requests to accept family
planning and abortion referrals, without parental involvement.
CRLC also states that this bill appears to be a California
measure to mesh with the federal 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.
8.Author's amendment to remove accreditation language. One of
the provisions of this bill requires patients in a PCMH to be
provided with enhanced access to health care that "meets the
requirements of a nationally recognized, independent medical
home accreditation agency." The author intends to offer
amendments in committee to delete the language referencing
accreditation, so that this provision will just require
patients to be provided with enhanced access to health care.
9.Drafting concern. One of the provisions in this bill specifies
that nothing should be construed as "requiring adherence to
the Low Income Health Program" (LIHP), as specified, "or to
activities conducted as part of a demonstration project
developed under the Health Care Coordination, Improvement, and
Long-Term Cost Containment Waiver." The author indicates that
this provision is intended to exempt LIHP's and the specified
demonstration project activities from having to comply with
the requirements of this bill, but that is not the way this
provision is drafted. To reflect the author's intent, this
provision should be amended so that nothing in this bill shall
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be construed to "apply to" the LIHP and specified
demonstration project activities.
SUPPORT AND OPPOSITION :
Support: California Academy of Physician Assistants
(co-sponsor)
California Academy of Family Physicians (co-sponsor)
Alzheimer's Association
American Osteopathic Association
California Black Health Network
California Association of Physician Groups
California Chiropractic Association
California Council of Community Mental Health Agencies
California Coverage and Healthcare Initiatives
California Optometric Association
California Primary Care Association
California Society of Health-System Pharmacists
Children Now
Children's Defense Fund California
Children's Partnership
Children's Specialty Care Coalition
Mental Health America of California
Osteopathic Physicians and Surgeons of California
PICO California
United Ways of California
100% Campaign
Oppose: California Right to Life Committee, Inc.
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