BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 1208|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 1208
Author: Pan (D)
Amended: 7/2/13 in Assembly
Vote: 21
SENATE HEALTH COMMITTEE : 8-1, 6/26/13
AYES: Hernandez, Anderson, Beall, De León, DeSaulnier, Monning,
Pavley, Wolk
NOES: Nielsen
ASSEMBLY FLOOR : 62-12, 5/13/13 - See last page for vote
SUBJECT : Medical homes
SOURCE : California Academy of Family Physicians
California Academy of Physician Assistants
California Medical Association
DIGEST : This bill establishes the Patient Centered Medical
Home Act of 2013, which defines medical home and patient
centered medical home (PCMH) 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.
ANALYSIS :
Existing law:
CONTINUED
AB 1208
Page
2
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;
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:
CONTINUED
AB 1208
Page
3
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" 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/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/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/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
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.
CONTINUED
AB 1208
Page
4
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,
F. Patients and families or representatives participate
CONTINUED
AB 1208
Page
5
in quality improvement activities at the practice
level.
G. Patients in a PCMH are provided with enhanced access
to health care.
12.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. Applying to the LIHP, 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.
Background
ACA . 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)
CONTINUED
AB 1208
Page
6
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.
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.
Prior Legislation
AB 2266 (Mitchell of 2012) would have required the Department of
Health Care Services (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 Governor Brown. In
his veto message, Governor Brown stated that he commended the
author for trying to improve the delivery of health care by
encouraging the greater use of "PCMH," 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
CONTINUED
AB 1208
Page
7
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.
FISCAL EFFECT : Appropriation: No Fiscal Com.: No Local:
No
SUPPORT : (Verified 7/2/13)
California Academy of Family Physicians (co-source)
California Academy of Physician Assistants (co-source)
California Medical Association (co-source)
100% Campaign
Alzheimer's Association
American Osteopathic Association
California Association of Physician Groups
California Black Health Network
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
OPPOSITION : (Verified 7/2/13)
CONTINUED
AB 1208
Page
8
California Right to Life Committee, Inc.
ARGUMENTS IN 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. 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
ensure that all of a patient's care needs are effectively
addressed and coordinated. 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.
ARGUMENTS IN 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
CONTINUED
AB 1208
Page
9
the individual.
ASSEMBLY FLOOR : 62-12, 5/13/13
AYES: Achadjian, Alejo, Atkins, Bigelow, Bloom, Blumenfield,
Bocanegra, Bonilla, Bonta, Bradford, Brown, Buchanan, Ian
Calderon, Campos, Chau, Chávez, Chesbro, Conway, Cooley,
Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier, Garcia,
Gatto, Gomez, Gordon, Gorell, Gray, Hall, Roger Hernández,
Jones-Sawyer, Levine, Linder, Maienschein, Medina, Mitchell,
Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan, Perea, V.
Manuel Pérez, Quirk, Quirk-Silva, Rendon, Salas, Skinner,
Stone, Ting, Torres, Weber, Wieckowski, Wilk, Williams,
Yamada, John A. Pérez
NOES: Donnelly, Beth Gaines, Grove, Hagman, Harkey, Jones,
Logue, Mansoor, Melendez, Morrell, Wagner, Waldron
NO VOTE RECORDED: Allen, Ammiano, Holden, Lowenthal, Patterson,
Vacancy
JL:d 7/2/13 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED