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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