BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 494
AUTHOR: Monning
AMENDED: April 3, 2013
HEARING DATE: April 24, 2013
CONSULTANT: Moreno
SUBJECT : Health care providers.
SUMMARY : Permits a primary care physician (PCP), if the
assignment of health care service plan (health plan) enrollees
or Medi-Cal managed care beneficiaries to a PCP is authorized
under existing law or contract promulgated thereunder, to be
assigned up to 2,000 enrollees. Permits a PCP, if he or she
supervises one or more non-physician medical practitioners, to
be assigned up to an additional 1,750 enrollees for each
full-time equivalent non-physician medical practitioner
supervised by that physician.
Existing law:
1.Provides for the licensure and regulation of health plans by
the Department of Managed Health Care (DMHC) under the
Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene).
2.Requires health plans, under regulation, to maintain a ratio
of at least one primary care provider (on a full-time
equivalent basis) to each 2,000 enrollees.
3.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
Establishes a schedule of benefits for Medi-Cal beneficiaries.
4.Defines a "primary care physician" as a physician who has the
responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and
for initiating referral for specialist care.
This bill:
1.Permits a PCP, if the assignment of health plan enrollees or
Medi-Cal managed care beneficiaries to a primary care
physician is authorized under existing law or contract
promulgated thereunder, to be assigned up to 2,000 enrollees.
Continued---
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2.Permits a PCP, if he or she supervises one or more
non-physician medical practitioners, to be assigned up to an
additional 1,750 enrollees or beneficiaries for each full-time
equivalent non-physician medical practitioner supervised by
that physician.
3.Defines "non-physician medical practitioner" as a physician
assistant (PA) performing services under physician supervision
in compliance with existing law or a nurse practitioner (NP)
performing services in collaboration with a physician pursuant
to existing law.
4.Prohibits this bill from requiring a PCP to accept an
assignment of enrollees that would be contrary to existing law
that protects against a provider accepting additional patients
if it would endanger patients' access to, or continuity of,
care.
5.Deletes the definition in existing law of "primary care
physician" and instead defines a "primary care practitioner"
as a physician or non-physician medical practitioner who has
the responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and
for initiating referral for specialist care.
6.Makes other technical, conforming changes.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. California is in the midst of a
well-documented shortage of primary care providers and a
serious misdistribution of specialists throughout the state.
Current health care workforce deficits compromise access to
care in many areas throughout the state and impede adherence
to state-imposed timely access. Further complicating the
health workforce capacity challenges is the impending increase
of an estimated 4 to 6 million people in California who will
become eligible for (private or governmental) coverage in
January 2014 as a result of the Patient Protection and
Affordable Care Act (ACA). SB 494 conforms to the ACA
definitions and expands workforce to more effectively use PA
and NPs as primary care providers. The bill does not make
changes to clinical skills or alter existing relationship
between the supervising physician and the PA or NP employed.
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By essentially increasing the size a physician's panel, a
health plan will immediately add providers to the
physician-led team and begin to address the need for more
primary care providers.
2.Primary Care Physician Workforce Shortage. According to a
report commissioned by the California Health Care Foundation,
the number of PCPs actively practicing in California is at the
very bottom range of, or below, the state's need. The
distribution of these physicians is equally as poor. In 2008,
there were 69,460 actively practicing physicians in California
(this includes Doctors of Medicine and Doctors of Osteopathic
Medicine) with only 35 percent of these physicians reported
practicing primary care. This equates to 63 active primary
care physicians per 100,000 persons. According to the Council
on Graduate Medical Education, a range of 60 to 80 primary
care physicians is needed per 100,000 persons to adequately
meet the needs of the population. When the same metric is
applied regionally, only 16 of California's 58 counties fall
within the needed supply range for PCPs.
3.The ACA. As a result of implementation of the ACA, it is
estimated that 3 to 7 million Californians will be newly
eligible for health insurance starting in 2014. The ACA aims
to change how care is delivered. It will provide incentives
for expanded and improved primary care, which may affect
demand for some health care professionals more than others,
and create team-based models of service delivery. Research
indicates that health care reform will place higher skill
demands on all members of the health care workforce as systems
try to improve quality while limiting costs. Studies have also
found that insured persons use more health care services than
uninsured persons, particularly in primary care and preventive
services. This was the experience in Massachusetts, which saw
a substantial increase in demand for primary care services as
a result of its 2006 health reform.
4.Healthy Families program transfer to Medi-Cal. According to a
June 2012 California Association of Health Plans fact sheet,
Medi-Cal provides coverage for approximately 7.5 million
Californians (60% of whom are enrolled in health plans) and is
expected to enroll an additional 2 million who will become
eligible for coverage in 2014. AB 1494 (Committee on Budget),
Chapter 28, Statutes of 2012, will transition approximately
875,000 Healthy Families enrollees into Medi-Cal beginning
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January 1, 2013. The combination of new enrollees and the
transition of Healthy Families enrollees into Medi-Cal will
likely exacerbate the existing shortage of providers willing
to treat Medi-Cal patients.
5."Primary care provider" definitions. The federal definition
of a "primary care provider" acknowledges PCPs, PAs and NPs.
However, existing state law that defines primary care
providers for purposes of Medi-Cal managed care defines them
as only including PCPs. The ACA also contains a provision
allowing for Choice of Health Care Provider and includes
Patient-Centered Medical Home Standards which encourage
team-based care and recognize PAs as primary care providers.
The National Committee on Quality Assurance (NCQA), The Joint
Commission, and Utilization Review Accreditation Commission
each recognize PAs as primary care providers who are qualified
to manage members of Medicaid and other managed care plans,
including responsibility for their own panels, under physician
supervision. A 2011 NCQA policy includes new eligibility
requirements, expressly stating that for practices that
utilize mid-level practitioners, "patients must be able to
choose the nurse practitioner or physician assistant as their
primary care practitioner - Nurse practitioners or physician
assistants must have their own panel of patients."
6.Support. According to the sponsor, the California Academy of
Physician Assistants (CAPA), this bill will significantly
increase the number of patients a practice/physician can be
assigned based on the use of a PA or other specified medical
provider. CAPA states that PAs are licensed health
professionals who practice medicine as members of a
physician-led team, delivering a broad range of medical and
surgical services to diverse populations in rural, urban and
suburban settings. California Association of Physician Groups
states that this bill provides an important and long-overdue
modification of Knox-Keene to provide both adequate networks
of providers in geographic areas and also under timely access
regulatory standards. UNAC writes that PAs have long been
recognized as a solution to access to care problems in all
settings, and recognizing them as primary care providers and
utilizing the profession to its fullest potential will have
tangible results in increasing access to care throughout
California.
SUPPORT AND OPPOSITION :
Support: California Academy of Physician Assistants (sponsor)
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California Association of Physician Groups (sponsor)
California Primary Care Association
United Nurses Association of California
Union of Health Care Professionals
Oppose:None received
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