BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    THIRD READING


          Bill No:  SB 494
          Author:   Monning (D)
          Amended:  5/28/13
          Vote:     21

           
           SENATE HEALTH COMMITTEE  :  9-0, 4/24/13
          AYES:  Hernandez, Anderson, Beall, De León, DeSaulnier, Monning,  
            Nielsen, Pavley, Wolk

           SENATE APPROPRIATIONS COMMITTEE  :  7-0, 5/23/13
          AYES:  De León, Walters, Gaines, Hill, Lara, Padilla, Steinberg


           SUBJECT  :    Health care providers

           SOURCE  :     California Academy of Physician Assistants
                      California Association of Physician Group


           DIGEST  :    This bill permits a primary care physician (PCP), if  
          he/she supervises one or more non-physician medical  
          practitioners, to be assigned an average of an additional 1,750  
          enrollees for each full-time equivalent non-physician medical  
          practitioner supervised by that physician.

           ANALYSIS  :    

          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).
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          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 he/she supervises one or more non-physician  
             medical practitioners, to be assigned an average of 1,750  
             enrollees, as specified.

          2. 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.

          3. Prohibits this bill from requiring a PCP to accept an  
             assignment of enrollees if it endangers patients' access to,  
             or continuity, care.

          4. Deletes the definition in existing law of "primary care  
             physician" and instead defines a "primary care practitioner."

          5. Clarifies that nothing in the bill shall be interpreted to  
             modify the Business and Professions Code, as specified.

          6. Makes other technical, conforming changes.

           Comments
           
           PCP workforce shortage  .  According to a report commissioned by  
          the California Health Care Foundation, the number of PCPs  

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          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% of these physicians reported practicing primary care.   
          This equates to 63 active PCP per 100,000 persons.  According to  
          the Council on Graduate Medical Education, a range of 60 to 80  
          PCP 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.  

           The Affordable Care Act  .  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.  Studies  
          have 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.  

           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 two million who will become  
          eligible for coverage in 2014.  AB 1494 (Assembly Budget  
          Committee, Chapter 28, Statutes of 2012) will transition  
          approximately 875,000 Healthy Families enrollees into Medi-Cal  
          beginning 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. 

          " 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  

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          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."

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  Yes


          According to the Senate Appropriations Committee:


           One-time costs of $600,000 to review plan filings by the DMHC.


           Potential ongoing enforcement cost in the tens of thousands  
            per year by the DMHC.

           One-time costs of $80,000 to update regulations by the  
            Department of Insurance (Insurance Fund).

           SUPPORT  :   (Verified  5/23/13)

          California Academy of Physician Assistants (co-source)
          California Association of Physician Group (co-source)
          Bay Area Council
          California Optometric Association
          California Physical Therapy Association
          California Primary Care Association
          Union of Health Care Professionals
          United Nurses Association of California


           ARGUMENTS IN SUPPORT  :    According to the author's office,  
          California is in the midst of a well-documented shortage of  
          primary care providers and a serious misdistribution of  
          specialists throughout the state.  Further complicating the  
          health workforce capacity challenges is the impending increase  

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          of an estimated four to six million people in California who  
          will become eligible for (private or governmental) coverage in  
          January 2014 as a result of the ACA.  This bill conforms to the  
          ACA definitions and expands workforce to more effectively use PA  
          and NPs as primary care providers.  This bill does not make  
          changes to clinical skills or alter the existing relationship  
          between the supervising physician and the PA or NP employed.  

          According to the sponsor, the California Academy of Physician  
          Assistants (CAPA), 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.  


          JL:d  5/28/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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