BILL ANALYSIS �
SB 494
Page 1
Date of Hearing: August 13, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 494 (Monning) - As Amended: August 5, 2013
SENATE VOTE : 38-0
SUBJECT : Health care providers.
SUMMARY : Authorizes health plans licensed by the Department of
Managed Health Care (DMHC) and managed care plans participating
in the Medi-Cal program to permit the assignment of an average
of an additional 1,000 enrollees for each full-time equivalent
nonphysician medical practitioner supervised by a primary care
physician (PCP). Establishes differing definitions for
nonphysician medical practitioners in the Health and Safety,
Insurance, and Welfare and Institutions Codes. Specifically,
this bill :
1)Authorizes, notwithstanding any other state law or regulation,
if a PCP supervises one or more nonphysician medical
practitioners, the physician to be assigned an average of an
additional 1,000 enrollees for each full-time equivalent
nonphysician medical practitioner supervised by that
physician, in addition to the number of enrollees assigned to
that physician pursuant to current law and approved by the
DMHC.
2)States that this bill does not require a PCP to accept an
assignment of enrollees by a health plan without his or her
approval or that would be contrary to the Health Care
Providers' Bill of Rights.
3)States that this bill cannot be interpreted to modify existing
law regarding supervision of physician assistants (PAs).
4)Defines a nonphysician medical practitioner as a 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.
5)Establishes, for purposes of insurers who contract with
providers for alternate rates (Preferred Provider
Organizations), a definition of a nonphysician medical
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practitioner as a PA performing services under physician
supervision in compliance with existing law or a NP performing
services in collaboration with a physician pursuant to
existing law, and adds that in accordance with existing
Medi-Cal law, a nonphysician medical practitioner is to be
considered a primary care provider.
6)States that this bill does not require a PCP to accept the
assignment of a number of insureds that would exceed standards
of good health care as provided in existing law related to
timely access to health care services.
7)States for purposes of Medi-Cal managed care (MCMC) plans, as
defined, nonphysician medical practitioner means a PA
performing services under physician supervision in compliance
with existing law, a NP performing services in collaboration
with a physician pursuant to existing law, or a certified
nurse-midwife (CNM) performing services under physician
supervision in compliance with existing law.
8)States that if the assignment of beneficiaries enrolled in any
type of MCMC plan to a PCP is authorized or required by a
provision in Medi-Cal law, or any regulation, contract, or
policy promulgated thereunder, each full-time equivalent PCP
may be assigned up to 2,000 beneficiaries. Permits,
notwithstanding any other state law or regulation, if a PCP in
that plan, supervises one or more nonphysician medical
practitioners, the physician may be assigned up to an
additional 1,000 beneficiaries for each full-time equivalent
nonphysician medical practitioner supervised by that
physician.
9)Replaces the term "primary care physician" with "primary care
practitioner" in the definition of PCP in Medi-Cal law and
includes as a primary care practitioner a nonphysician medical
practitioner.
EXISTING LAW :
1)Establishes the California Department of Insurance (CDI) to
regulate health and other insurance, the DMHC to license and
regulate health care service plans, the Department of Health
Care Services (DHCS) to administer California's Medicaid
Program (Medi-Cal), the Medical Board of California (MBC)
which licenses and regulates physician and surgeons, the Board
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of Registered Nursing which licenses and regulates nurses,
including NPs, and the Physician Assistant Board to license
and regulate PAs.
2)Requires pursuant to Medi-Cal managed care regulations that
each plan in a designated region retain sufficient
professional medical staff to provide access to preventive and
managed health care services to its members. Requires access
to physicians or physician extenders as follows:
a) Requires each plan to ensure its provider network
satisfies a ratio of at least one full-time equivalent PCP
for every 2,000 members;
b) Requires each plan to ensure its provider network
satisfies a ratio of at least one full-time equivalent
physician for every 1,200 plan members;
c) Prohibits plans that utilize nonphysician medical
practitioners from allowing a full-time equivalent
nonphysician medical practitioner to maintain a caseload of
more than 1,000 plan members; and,
d) Authorizes, if utilized by a plan, members to select a
nonphysician medical practitioner as their PCP. Requires
nonphysician medical practitioner practitioners, including
CNMs, NPs and PAs, to meet the requirements of existing
practice and licensure standards for mid-level
practitioners, as specified.
3)Defines, "primary care physician" in California law affecting
MCMC, as a physician who has the responsibility for providing
initial and primary care to patients, maintaining the
continuity of patient care, and initiating referral for
specialist care. Requires a PCP to be either a physician who
has limited his or her practice of medicine to general
practice or who is a board-certified or board-eligible
internist, pediatrician, obstetrician-gynecologist, or family
practitioner.
4)Requires services provided by a certified NP to be covered
under Medi-Cal to the extent authorized by federal law and
subject to utilization controls. Requires DHCS to permit a
certified NP to bill Medi-Cal independently for his or her
services. If a certified NP chooses to bill Medi-Cal
independently for his or her services, requires DHCS to make
payment directly to the certified NP.
5)Requires services provided by a PA to be covered under
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Medi-Cal to the extent authorized by federal law and subject
to utilization controls. Requires all services performed by a
PA within his or her scope of practice that would be a covered
benefit if performed by a physician and surgeon to be a
covered benefit under Medi-Cal and prohibits DHCS from
imposing chart review, countersignature, or other conditions
of coverage or payment on a physician and surgeon supervising
PAs that are more stringent than requirements imposed by
existing law or regulations of the MBC.
6)Requires pursuant to DMHC regulations, health plans to ensure
enrollees have a residence or workplace within 30 minutes or
15 miles of a contracting or plan-operated PCP in such numbers
and distribution as to accord to all enrollees a ratio of at
least one PCP (on a full-time equivalent basis) to each 2,000
enrollees.
7)Prohibits for DMHC regulated health plans as part of the
Health Care Providers' Bill of Rights a contract between a
plan and a health care provider from containing a provision
that requires a health care provider to accept additional
patients beyond the contracted number or in the absence of a
number, if in the reasonable professional judgment of the
provider, accepting additional patients would endanger
patients' access to, or continuity of, care.
8)Includes a NP or PA as a qualified primary care provider in
the definition of "Advanced Access" pursuant to DMHC
regulations on Timely Access to Non-Emergency Health Care
Services.
9)Prohibits a physician and surgeon from supervising more than
four PAs at any one time, except as specified. Permits the
MBC to restrict a physician and surgeon to supervising
specific types of PAs including, but not limited to,
restricting a physician and surgeon from supervising PAs
outside of the field of specialty of the physician and
surgeon.
10)Prohibits a physician and surgeon from supervising more than
four NPs at one time.
11)Defines "primary care provider" in federal law pursuant to
the federal Patient Protection and Affordable Care Act (ACA)
Primary Care Extension Program as a clinician who provides
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integrated, accessible health care services and who is
accountable for addressing a large majority of personal health
care needs, including providing preventive and health
promotion services for men, women, and children of all ages,
developing a sustained partnership with patients and
practicing in the context of family and community, as
recognized by a state licensing or regulatory authority,
unless otherwise specified.
12)Requires under the ACA, if a group health plan or a health
insurance issuer offering group or individual health insurance
coverage requires or provides for designation by a
participant, beneficiary, or enrollee of a participating
primary care provider, the plan or issuer to permit each
participant, beneficiary, and enrollee to designate any
participating primary care provider who is available to accept
such individual.
13)Defines "primary care practitioner" in federal law pursuant
to ACA Medicare incentive payments for primary care services
as an individual who is a physician, as described, who has a
primary specialty designation of family medicine, internal
medicine, geriatric medicine, or pediatric medicine; or, is a
NP, clinical nurse specialist, or PA and for whom primary care
services accounted for at least 60% of the allowed charges for
such physician or practitioner in a prior period as determined
appropriate by the Secretary of the federal Department of
Health and Human Services (DHHS).
14)Requires CDI to adopt regulations to ensure that insureds
have the opportunity to access needed health care services in
a timely manner, and that these regulations are designed to
assure accessibility of provider services in a timely manner
to individuals comprising the insured or contracted group,
including adequacy of number of professional providers, and
license classifications of such providers, in relationship to
the projected demands for services covered under the group
policy or plan.
FISCAL EFFECT : According to the Senate Appropriations Committee
analysis, one-time costs of $600,000 to review plan filings by
the DMHC (Managed Care Fund). Potential ongoing enforcement
cost in the tens of thousands per year by the DMHC (Managed Care
Fund). One-time costs of $80,000 to update regulations by the
CDI (Insurance Fund).
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COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, current
Medi-Cal regulation specifies that managed care plans are
required to ensure the provider network satisfies a ratio of
one full-time equivalent PCP for every 2,000 plan members,
further the regulation specifies full-time equivalent
nonphysician medical practitioners are permitted to maintain a
caseload of 1,000 plan members. The author states, given
California's primary care provider workforce shortage, which
will become further complicated by additional individuals
eligible for coverage under the ACA, this bill proposes that a
PCP panel/practice should be allowed to increase up to an
additional 1,000 patients based on the use of a PA or NP. The
author adds recognizing PAs and NPs as PCPs while still
keeping the existing relationship between a supervising
physician and the patient would also align federal and state
definitions of a "primary care provider." According to the
author, the federal definition of a "primary care provider" in
the ACA acknowledges PCPs, PAs, and NPs as primary care
providers. However, California law, which defines primary
care providers for purposes of MCMC, defines them as only
PCPs.
The author states that 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 ACA. The author believes by
essentially increasing the size of a physician's panel, a
health plan will immediately add providers to the
physician-led team and begin to address the need for more
PCPs.
The California Academy of Physician Assistants (CAPA)
indicates that some MCMC organizations assign panels to PAs,
and although this practice is widespread in 18 other states,
the current predominant practice in California is to only
empanel physicians.
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2)BACKGROUND . On March 23, 2010, the federal government enacted
the ACA (Public Law 111-148), which was further amended by the
Health Care Education Reconciliation Act (H.R. 4872). Much of
the ACA is geared toward expanding public and private health
insurance coverage and it includes incentive payments for
primary care services. The ACA establishes a 10% Medicare
bonus for services furnished on and between January 1, 2011
and January 1, 2016 by a "primary care practitioner," which is
defined as a physician who has primary specialty designation
in family medicine, internal medicine, geriatric medicine, or
pediatric medicine, or is a NP, clinical nurse specialist, or
PA and for whom primary care services accounted for at least
60% of the allowed charges for such physician or practitioner
in a prior period, as determined by the DHHS Secretary. The
ACA also provides for a temporary increase in Medicaid
payments for certain primary care services furnished in 2013
and 2014 by a physician with a primary specialty designation
of family medicine, general internal medicine, or pediatric
medicine such that the new rates for those years would be at
least 100% of the applicable rate paid for such services under
Medicare. The requirement applies to MCMC plans. The
additional cost of the increased payment (for the difference
between the Medicare rate and the Medicaid payment rate for
such services in effect as of July 1, 2009) is fully funded by
the federal government. Physician extenders, such as NPs,
PAs, and CNMs who work under supervision of an eligible
physician are eligible for the increased Medicaid payment.
According to a January 8, 2013 presentation by DHCS,
physicians self-attest their eligibility and identify specific
eligibility criteria. The state will audit a statistically
valid sample of providers, and plans may also be required to
audit a sample of their providers.
3)NPS AND PAS AND PRIMARY CARE . An August 2011 issue brief
published by the University of California San Francisco (UCSF)
Center for Health Professions, called "Nurse Practitioners and
Physician Assistants Providing Primary Care in California
Community Clinics," indicates that most of the primary care
provided at one-fifth of the state's Federally Qualified
Health Centers (FQHCs) and FQHC look-alike clinics is being
provided by NPs and PAs. The study found strong support for
staffing models that include significant reliance on NPs
and/or PAs to provide primary care; most clinics reported
limited availability of clinicians willing to work at these
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sites; they found that they needed to define their pool of
potential clinicians broadly to include NPs and PAs as well as
physicians; all the study clinics faced extremely high patient
demand and having NPs and/or PAs on staff allowed the clinics
to, for the most part, meet patient primary care needs.
Additionally, one of the key reasons why PAs and NPs play
significant roles in community clinics as PCPs is their cost
effectiveness. Finally, while respondents reported that the
current range of services NPs and PAs are authorized to
provide was appropriate for practice needs, several clinic
leaders questioned the usefulness of some requirements such as
physician chart reviews for PAs.
4)SUPPORT . One of this bill's sponsors, CAPA, believes this
bill will significantly increase the number of lives a
practice/physician can be assigned based on the use of a PA or
other specified licensed nonphysician medical practitioner.
According to 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.
CAPA states that PAs have long been recognized as a solution
to access to care problems in all settings. The California
Association of Physician Groups (CAPG), also a sponsor of this
bill, indicates that this bill provides an important and
long-overdue modification of the Knox-Keene Health Care
Service Plan Act of 1975 (Knox-Keene) to allow a greater
maximum empanelment of managed care enrollees to a
physician-led care team. CAPG asserts that the maximum
empanelment ratio is merely that, and most organizations
determine internally what their true maximum enrollment ratio
should be based on a variety of factors, so it is important to
note that this change to Knox-Keene does not mean that all
panels across the state will automatically float to the
proposed maximums. CAPG adds that the current ratios have
been in place for over 30 years, and modern care management
and health information technology allow new capabilities to
expand access, shrink wait times, and to increase value of
encounters that patients have with their health care system.
The Bay Area Council asserts that the business community
recognizes that strengthening the team-based approach to
primary care and allowing these teams of providers to take on
additional patients will improve efficiency, help control
costs, and create additional capacity in our state's
increasingly overburdened healthcare system.
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5)SUGGESTED AMENDMENTS . This bill has some inconsistencies in
definitions and in several places contains provisions that
state "notwithstanding any other state law or regulation"
which are not necessary. The author and sponsor have agreed to
technical amendments to address these issues. Further, it is
not clear what impact this change to the physician to enrollee
ratio may have on capacity and access at individual practices.
Therefor the committee may wish to include a sunset date of
December 31, 2018 to give stakeholders an opportunity to
revisit the impacts of this policy change.
6)RELATED LEGISLATION .
a) SB 491 (Ed Hernandez) permits a NP to practice
independently after a period of physician supervision if
the NP has national certification and liability insurance,
and authorizes the NP to perform various other specified
tasks related to the practice of nursing without protocols.
SB 491 failed passage in the Assembly Business,
Professions and Consumer Protection Committee and was
granted reconsideration, therefore could be given an
additional hearing and voted on by that committee once
more.
b) SB 352 (Pavley) authorizes medical assistants to perform
technical supportive services in any medical setting upon
specific authorization of a PA, NP, or CNM without a
physician on the premises. SB 352 is currently pending on
the Assembly Floor.
7)PREVIOUS LEGISLATION .
a) SB 2348 (Mitchell), Chapter 460, Statutes of 2012,
allows registered nurses (RNs) to dispense and administer
hormonal contraceptives under a standardized procedure, as
specified, and allows RNs to dispense drugs and devices
upon an order by a physician and surgeon, a CNM, a NP, or a
PA while functioning within specified clinic settings.
b) SB 819 (Yee), Chapter 308, Statutes of 2009, among other
things, expands the authorized functions that may be
performed by a NP practicing under standardized procedures
to include: ordering durable medical equipment, as
specified; certifying disability, as specified, after
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performance of a physical examination by the NP and in
collaboration with a physician and surgeon; and, approving,
signing, modifying, or adding to a plan of treatment or
plan of care for individuals receiving home health services
or personal care services, after consultation with the
treating physician and surgeon.
c) AB 3 (Bass), Chapter 376, Statutes of 2007, increases
the maximum number of PAs that may be supervised by a
physician and surgeon from two to four, and specifies that
services provided by a PA are a covered Medi-Cal benefit if
that same service would be a covered benefit if it were
performed by a physician and surgeon.
d) AB 1591 (Chan), Chapter 719, Statutes of 2006, permits
any certified NP to bill Medi-Cal independently for his or
her services.
e) AB 2560 (Monta�ez), Chapter 205, Statutes of 2004,
expands the locations and types of conditions for which NPs
can furnish or order prescription drugs or devices under
physician protocols.
f) AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires
DMHC and CDI to develop and adopt regulations to ensure
that enrollees have access to needed health care services,
referred to as timely access to services.
REGISTERED SUPPORT / OPPOSITION :
Support
California Academy of Physician Assistants (cosponsor)
California Association of Physician Groups (cosponsor)
AARP
Bay Area Council
California Association of Health Underwriters
California Chiropractic Association
California Medical Association
California Optometric Association
California Physical Therapy Association
California Primary Care Association
Latino Coalition for a Healthy California
United Nurses Associations of California/Union of Health Care
Professionals
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Opposition
None on file.
Analysis Prepared by : Teri Boughton / HEALTH / (916) 319-2097