BILL ANALYSIS �
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|SENATE RULES COMMITTEE | SB 494|
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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 Le�n, DeSaulnier, Monning,
Nielsen, Pavley, Wolk
SENATE APPROPRIATIONS COMMITTEE : 7-0, 5/23/13
AYES: De Le�n, 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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