BILL ANALYSIS Ó
SB 494
Page 1
SENATE THIRD READING
SB 494 (Monning)
As Amended September 6, 2013
Majority vote
SENATE VOTE :38-0
HEALTH 18-0 APPROPRIATIONS 17-0
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|Ayes:|Pan, Ammiano, Atkins, |Ayes:|Gatto, Harkey, Bigelow, |
| |Bonilla, Bonta, Chesbro, | |Bocanegra, Bradford, Ian |
| |Gomez, | |Calderon, Campos, |
| |Roger Hernández, | |Donnelly, Eggman, Gomez, |
| |Lowenthal, Maienschein, | |Hall, Holden, Linder, |
| |Mansoor, Mitchell, | |Pan, Quirk, Wagner, Weber |
| |Nazarian, Nestande, | | |
| |V. Manuel Pérez, Wagner, | | |
| |Wieckowski, Wilk | | |
| | | | |
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SUMMARY : Requires a health care service plan licensed by the
Department of Managed Health Care (DMHC) to ensure one primary
care physician (PCP) for every 2,000 enrollees and authorizes up
to an additional 1,000 enrollees for each full-time equivalent
nonphysician medical practitioner supervised by that PCP until
January 1, 2019. Specifically, this bill :
1)Requires a health care service plan to ensure there is at
least one full-time equivalent PCP for every 2,000 enrollees
of the plan and authorizes the number of enrollees per PCP to
be increased by up to 1,000 additional enrollees for each
full-time equivalent nonphysician medical practitioner
supervised by that PCP.
2)Defines a nonphysician medical practitioner as a physician
assistant (PA) performing services under supervision of a PCP
in compliance with existing law or a nurse practitioner (NP)
performing services in collaboration with a physician pursuant
to existing law.
3)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
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with a physician pursuant to existing law, or a certified
nurse-midwife (CNM) performing services under physician
supervision in compliance with existing law.
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 to administer California's Medicaid program
(Medi-Cal), the Medical Board of California which licenses and
regulates physician and surgeons, the Board of Registered
Nursing which licenses and regulates nurses, including NPs,
and the Physician Assistant Board to license and regulate PAs.
2)Requires pursuant to MCMC regulations that each plan in a
designated region to 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 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
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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.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1)One-time costs of under $50,000 to DMHC (Managed Care Fund)
for review of licensees' documents verifying compliance with
these standards.
2)Minor potential ongoing costs, in the tens of thousands of
dollars annually to DMHC (Managed Care Fund), for enforcement
of new rules related to the size of physician panels.
3)It is unclear if this bill will trigger a review of network
adequacy requirements in regulation, given the new definitions
and authorizations. If it does, both the CDI and DMHC may
incur associated special fund costs. Costs would depend on
the depth of review and revision of regulations.
COMMENTS : 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 Patient Protection and Affordable Care Act (ACA), this
bill proposes that a PCP panel or 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.
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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), one of
the sponsors of this bill, 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. CAPA
believes this bill will significantly increase the number of
lives a practice or 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
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
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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.
Analysis Prepared by : Teri Boughton / HEALTH / (916) 319-2097
FN: 0002549