BILL ANALYSIS Ó
SENATE HUMAN
SERVICES COMMITTEE
Senator Leland Y. Yee, Chair
BILL NO: AB 1231
A
AUTHOR: V. Manuel Pérez
B
VERSION: June 17, 2013
HEARING DATE: June 25, 2013
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FISCAL: Yes
2
3
CONSULTANT: Tepring Piquado
1
SUBJECT
Regional centers: telehealth
SUMMARY
This bill would require the Department of Developmental
Services (DDS) to inform all regional centers that any
appropriate health service, including behavioral health
treatment and dentistry, may be provided through the use of
telehealth to consumers with autism spectrum disorders
(ASD). Promotes the use of telehealth for consumers with
ASD in various ways. Requires regional centers to convene a
review to determine alternative, appropriate services if a
consumer asks to discontinue telehealth services. Requires
DDS to forward information about the effectiveness and
appropriateness of telehealth for ASD clients to the
appropriate committees of the Legislature. Includes a
sunset date of January 1, 2019.
ABSTRACT
Existing law:
1) Established Telehealth Advancement Act of 2011 and
defines "Telehealth" as the mode of delivering health
Continued---
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care services and public health via information and
communication technologies to facilitate the
diagnosis, consultation, treatment, education, care
management, and self-management of a patient's health
care while the patient is at the originating site and
the health care provider is at a distant site. (BPC §
2290.5 (a)(6))
2) Specifies that no health care service plan shall
require that in-person contact occur between a health
care provider and a patient before payment is made for
the covered services appropriately provided through
telehealth, subject to the terms and conditions of the
contract entered into between the enrollee or
subscriber and the health care service plan, and
between the health care service plan and its
participating providers or provider groups. (HSC §
1374.13(c))
3) Specifies that no health care service plan shall
limit the type of setting where services are provided
for the patient or by the health care provider before
payment is made for the covered services appropriately
provided through telehealth, subject to the terms and
conditions of the contract entered into between the
enrollee or subscriber and the health care service
plan, and between the health care service plan and its
participating providers or provider groups. (HSC §
1374.13(d))
4) Establishes the Lanterman Developmental
Disabilities Services Act, which declares California's
responsibility for providing an array of services and
supports to meet the needs of each person with
developmental disabilities in the least restrictive
environment, regardless of age or degree of
disability, and to support their integration into the
mainstream life of the community. (WIC § 4500 et seq.)
5) Establishes a system of nonprofit Regional Centers
(RCs) to provide fixed points of contact in the
community for all persons with developmental
disabilities and their families, to coordinate
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services and supports best suited to them throughout
their lifetime. (WIC § 4620)
6) Establishes an Individual Program Plan (IPP) and
defines that planning process as the vehicle to ensure
that services and supports are customized to meet the
needs of consumers who are served by RCs. (WIC § 4512;
§ 4546)
7) Requires in federal statute, for each infant or
toddler with a disability, and the infant's or
toddler's family, to receive a written individualized
family service plan (IFSP) developed by a
multidisciplinary team. (20 USC § 1436)
8) Requires in federal statute that the IFSP contain a
statement of the natural environments in which early
intervention services will appropriately be provided,
including a justification of the extent, if any, to
which the services will not be provided in a natural
environment. (20 USC § 1436(d)(5))
9) Defines "Behavioral health treatment" as
professional services and treatment programs,
including applied behavior analysis and evidence-based
behavior intervention programs, that develop or
restore, to the maximum extent practicable, the
functioning of an individual with pervasive
developmental disorder or autism, as specified. (HSC
§ 1374.73(c)(1))
10) Requires the behavioral health treatment to be
provided under a treatment plan prescribed by a
qualified autism service provider and administered by
either a qualified autism service provider, autism
service professional supervised and employed by the
qualified autism service provider or a qualified
autism service paraprofessional supervised and
employed by a qualified autism service provider. (HSC
§ 1374.73(c)(1)(B))
This bill:
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1) Makes a number of findings and declarations
regarding ASD, Behavioral health treatment, and lack
of dental care. Specifically,
a) ASD now affect one in every 88 children
of all ethnic, racial, and socioeconomic
backgrounds.
b) ASD is now the fastest growing
developmental disability in California and the
nation and is more common than childhood cancer,
juvenile diabetes, and pediatric AIDS combined.
c) Approximately two-thirds of all new
consumers who are entering the regional center
system are now diagnosed with ASD.
d) Behavioral health treatment (BHT), also
known as early intervention therapy or applied
behavior analysis, is established to improve
brain function, cognitive abilities, and
activities of daily living for a significant
number of individuals with ASD, but may not be
accessible or available in underserved
communities.
e) A significant number of individuals with
ASD suffer from inadequate dental care.
1) States legislative intent to do all of the
following:
a) Improve access to treatments and
intervention services, including behavioral and
dental health care services, for individuals with
ASD and their families in underserved
populations.
b) Provide more cost-effective treatments
and intervention services for individuals with
ASD and their families.
c) Maximize the effectiveness of the
interpersonal and face-to-face interactions that
are utilized for the treatment of individuals
with ASD.
d) Continue maintenance and support of the
existing service workforce for individuals with
ASD.
e) Utilize telehealth to improve services
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for individuals with ASD.
2) Requires DDS to do all of the following:
a) Inform all regional centers that any
appropriate health service, including, but not
limited to, behavioral health treatment may be
provided through the use of telehealth to
consumers with ASD.
b) Inform all regional centers that
dentistry may be provided through the use of
telehealth to consumers with ASD.
c) Request regional centers to include a
consideration of telehealth in each IPP and IFSP
for consumers with ASD that includes a discussion
of behavioral health treatment or dental health
care, or both.
d) Request regional centers to consider the
use of telehealth services for inclusion in
training programs for parents of consumers with
ASD, including, but not limited to, group
training programs.
e) Provide technical assistance to regional
centers regarding the use of telehealth to meet
the behavioral health and dental care needs of
individuals with ASD.
3) States that DDS may implement appropriate
vendorization sub-codes for telehealth services and
programs.
4) Requires that if, at any time, a consumer with ASD
or, as appropriate, the consumer's parent, legal
guardian, or conservator requests to discontinue the
provision of a service through the use of telehealth,
the regional center shall convene a review to
determine alternative, appropriate means for providing
the service.
5) Requires DDS to forward to the fiscal and
appropriate policy committees of the Legislature any
information provided by the regional centers to the
department to assess the effectiveness and
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appropriateness of providing telehealth services to
regional center consumers with ASD through the IPP and
IFSP processes. This must be done on or before
December 1, 2017.
6) Specifies that a provider of telehealth services
shall be responsible for all expenses and costs
related to the equipment, transmission, storage,
infrastructure, and other expenses related to
telehealth.
7) Defines a number of terms including "Behavioral
health treatment," and "Telehealth," as specified.
8) Includes a sunset date of January 1, 2019.
FISCAL IMPACT
Prior to recent amendments limiting the scope of the bill
to focus solely on the ASD population, an Assembly
Appropriations Committee analysis indicated that costs
associated with this legislation should be minor and
absorbable within existing DDS resources.
BACKGROUND AND DISCUSSION
Purpose of the bill
According to the author, regional centers historically are
reluctant to integrate new models of healthcare into
existing consumer services without specific direction from
DDS. The author states that telehealth, including dental
care, has the potential to expand access to vital services
for individuals with ASD, and to decrease the cost of
providing those services while maintaining the same quality
of service.
Regional Centers
California's 21 nonprofit regional centers are part of a
system of care for individuals with developmental
disabilities that is overseen by DDS. With a proposed
budget of $4.3 billion for community-based services in
2013-2014, DDS is responsible for coordinating care and
STAFF ANALYSIS OF ASSEMBLY BILL 1231 (V.Manuel Pérez) Page
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providing services for nearly 260,000 people who receive
services and supports to live in their communities, as well
as approximately 1,535 people who reside in developmental
centers.
Regional centers provide diagnosis and assessment of an
individual's eligibility for DDS services and help plan,
access, coordinate and monitor the services and supports
that are needed. Services for consumers are determined
through an IPP.
Telehealth
Telehealth can be used to facilitate the diagnosis,
consultation, treatment, education, care management, and
self-management of a patient's health care while the
patient is at the originating site and the health care
provider is at a distant site. According to Health
Resources and Services Administration (HRSA), within the
U.S. Health and Human Services Department, telehealth
technology can be a valuable addition to a wide variety of
care settings. Telehealth programs, for example, allow a
smaller hospital to draw on the knowledge of a much larger
one, which may be of particular interest to critical-access
hospitals and rural health clinics.
A 2008 report, "Meeting the Health Care Needs of
California's Children: the Role of Telemedicine," by the
Children's Partnership, stated that "Quality health care no
longer requires a health care provider and patient to be in
the same room at the same time. With the advancement of
information and communications technology, children and
adults can receive high-quality health care from a distance
through telemedicine. In fact, telemedicine is rapidly
becoming a viable solution to meeting the health care needs
of patients in rural and other underserved areas.
California was one of the first states to adopt legislation
to dene and support the role of telemedicine in health care
delivery. In 1996, California adopted the Telemedicine
Development Act of 1996, identifying telemedicine as a
legitimate means of providing health care. Currently, no
statute prohibits regional centers from providing consumers
with telehealth or teledentistry services.
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Teledentristy
The application and use of telehealth in dentistry are not
as well-developed as the use of telehealth technologies in
other aspects of the health care delivery system. However,
telehealth technologies have been available and used in the
delivery of oral health services for quite some time. Some
reports describe the use of teledentistry to facilitate
collaborative dental care to rural communities.
In 2003, an initiative based at the University of Southern
California demonstrated that dentists were able to work
with a dental hygienist at a remote location to decide on
preventive services that could be delivered by the
hygienist at that location. Participating hygienists also
were able to facilitate referrals to the USC mobile dental
clinic that delivered on-site dental services at a later
date.<1> A 2004 report reviewed available telehealth
technologies and outlined the potential for using these
technologies to foster collaboration between dentists and
dental hygienists in order to reach and improve oral health
of underserved populations.<2>
Licensing
California requires physicians to be licensed to practice
in the originating site's state. Therefore, with limited
exceptions, telehealth consultations with a physician
across state lines require licensing paperwork.
Autism
Autism spectrum disorders are complex neurological
disorders that have an onset in infancy and can cause mild
to severe difficulties in childhood development. Among the
challenges of ASD are language delays, communication
problems, limited social skills and repetitive or other
unusual behaviors. Nationally, ASD affects an estimated one
-------------------------
<1> Chang SW, Plotkin DR, et al (2003) Teledentistry in
rural California: a USC initiative. J Calif Dent Assoc
31(8):601-8.
<2> Sanchez Dils E, Lefebvre C, Abeyta K, (2004) Int J Dent
Hygiene 2, page 161-4.
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in 88 children and is present across all racial, ethnic and
socioeconomic backgrounds.
Experts believe there is more than one cause of autism
including genetic factors and growing evidence of
environmental influences. As of December 2012, more than a
quarter of all consumers served by DDS had a diagnosis of
autism, nearly 60,000 Californians. Another 2 percent of
the DDS population, or about 4,500 consumers, had a
diagnosis of pervasive developmental disorder, which is
associated with ASD.
Behavioral Health Treatment
Behavioral health treatments are professional services and
treatment programs, including applied behavior analysis
(ABA) and evidence-based behavior intervention programs,
which develop or restore the functioning of an individual
with ASD. Many believe that intensive behavioral challenges
are a common problem for children with ASD. Many children
with ASD have difficulty managing certain behaviors such as
aggression, have challenges with following directions, and
limitations in communication or social skills. ABA services
provided at a young age have the ability to nearly
eliminate many of the behavioral challenges of a child with
ASD.
Senate Hearing
The Senate Select Committee on Autism and Related Disorders
held an informational hearing on the use of technology on
February, 22 2012, to discuss the use of telehealth in
autism treatment. One panelist, Jenise Shin-Lee, executive
director of Capitol Autism Services, described two
telehealth pilot projects that she and her colleagues
developed in response to a shortage of qualified ABA
professionals, especially in the outlying areas. The goal
of the studies, which ran eight weeks to six months long
and included one to two hours of telehealth contact per
week, was to determine whether telehealth contact was able
to provide the same quality of care as the in-home contact.
The study's conclusions supported this notion.
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During those sessions, [the experimenters] were able
to do what [professionals] did in-home. [They]
provided direct feedback, guided intervention and
interactions between the parent and their child, and
provided training and all in the areas of the major
deficits-communication, self-help, social skills.
Blue Ribbon Commission Recommendations
SCR 51 (Perata, Chapter 124, Statutes of 2005) established
the California Legislative Blue Ribbon Commission on Autism
to study and investigate the early identification and
intervention of ASD, gaps in programs and services related
to the treatment and education of people with ASD. The
Blue Ribbon Commission's findings included the following:
1) A significant number of children with ASD have not
been screened, assessed, or referred to early
intervention services in an appropriate and timely
manner. In underserved communities, the delays are
longer and more frequent;
2) Highly effective programs and services for ASD
should be identified, analyzed, evaluated, and
replicated throughout the state.
Although this bill's intent language notes that underserved
communities may not have access to programs and services
such as behavioral health, the language of the bill does
not specify that telehealth be used for underserved
populations. Rather, the bill language requires that all
regional centers be informed that any appropriate health
service, including behavioral health treatment, may be
provided through telehealth for consumers with ASD.
Related Legislation
AB 318 (Logue, 2013) would have removed the face-to-face
requirement that prohibits the coverage of teledentistry
via store-and-forward (not real-time service) under
Medicaid plan. This bill was held in Assembly Health.
AB 809 (Logue, 2013) would permit the health care provider
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initiating the use of telehealth to request verbal consent
prior to the delivery of health care via telehealth. This
bill has been referred to the Senate Committees on Business
and Professions, Education and Health.
AB 764 (Steinberg, 2012) would have required regional
centers' IPP teams to consider the use of telehealth,
whenever applicable. That bill was vetoed by Governor
Brown. In his veto message, the governor wrote, "Mandating
every individual program planning team to consider
telehealth appears excessive. Where beneficial and
available, I expect they will consider it, without the
state telling them to do so."
COMMENTS
1.This bill addresses the needs of a subset of regional
center consumers - those with an autism spectrum disorder
diagnosis. By DDS estimates, this is a quarter of the
regional center population. In addition to consumers with
ASD, regional centers provide services to people with a
variety of developmental disorders including cerebral
palsy, intellectual disabilities, epilepsy and other
conditions. This bill does not provide the same direction
to regional centers to consider telehealth services for
those populations.
2.Current language does not ensure that telehealth services
will be discontinued immediately upon a request to
terminate made by the consumer or the family. This
legislation specifically states that "if, at any time, a
consumer with ASD or, as appropriate, the consumer's
parent, legal guardian, or conservator requests to
discontinue the provision of a service through the use of
telehealth, the regional center shall convene a review to
determine alternative, appropriate means for providing
the service." A prior version of the bill stated
explicitly that telehealth services may be discontinued
by the consumer or appropriate representative. Similarly,
a prior version of the bill required participation in the
telehealth program to be voluntary, but that language was
deleted from this version of the bill.
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3.Data reporting under this bill is unclear. Current
language does not identify the information to be
collected by the regional centers, the method of
collecting the information or how the information will be
reported to the Legislature.
4.As noted above, while the author identifies in the intent
language the need for telehealth to address the fact that
"behavioral health treatment? may not be accessible or
available in underserved communities," this legislation
does not target its use to those communities.
PRIOR VOTES
Assembly Floor: 74 - 0
Assembly Appropriations: 17 - 0
Assembly Health 19 - 0
Assembly Human Services: 7 - 0
POSITIONS
Support: Center for Autism and Related Disorders
(sponsor)
ACT Today!
Autism Research Group
Institute for Behavioral Training
Oppose: None on file
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