BILL ANALYSIS                                                                                                                                                                                                    Ó


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                                 UNFINISHED BUSINESS

          Bill No:  SB 494
          Author:   Monning (D)
          Amended:  9/6/13
          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

           SENATE FLOOR  :  38-0, 5/29/13
          AYES:  Anderson, Beall, Berryhill, Block, Calderon, Cannella,  
            Corbett, Correa, De León, DeSaulnier, Emmerson, Evans, Fuller,  
            Gaines, Galgiani, Hancock, Hernandez, Hill, Hueso, Huff,  
            Jackson, Knight, Lara, Leno, Lieu, Liu, Monning, Nielsen,  
            Padilla, Pavley, Price, Roth, Steinberg, Torres, Walters,  
            Wolk, Wright, Wyland
          NO VOTE RECORDED:  Yee, Vacancy

           ASSEMBLY FLOOR  :  Not available

           SUBJECT  :    Health care providers

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

           DIGEST  :    This bill requires a health care service plan (health  
          plan) licensed by the Department of Managed Health Care (DMHC)  


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          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 non-physician medical practitioner  
          supervised by that PCP until January 1, 2019.

           Assembly Amendments  (1) establish a sunset date; (2) delete a  
          provision that added to Medi-Cal law authority for a physician  
          to be assigned up to an additional 1,000 beneficiaries for each  
          full-time non-physician medical practitioner supervised by that  
          physician; (3) deletes the provision permitting a PCP, if he/she  
          supervises one or more non-physician medical practitioners, to  
          be assigned an average of an additional 1,750 enrollees, as  
          specified; and (4) clarify that a primary care provider includes  
          a "non-physician practitioner," as defined.

           ANALYSIS  :    

          Existing law:

          1. Provides for the licensure and regulation of health plans by  
             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  

          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. Requires a health 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  



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             full-time equivalent non-physician medical practitioner  
             supervised by that PCP.

          2. Defines a non-physician 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, non-physician 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 performing services under physician supervision  
             in compliance with existing law.

          4. 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.

          According to the author's office, current Medi-Cal regulations  
          specify that MCMC plans are required to ensure the provider  
          network satisfies a ratio of one full-time equivalent PCP for  
          every 2,000 plan members, further regulations specify full-time  
          equivalent non-physician medical practitioners are permitted to  
          maintain a caseload of 1,000 plan members.  The author's office  
          states, given California's primary care provider workforce  
          shortage, which will become further complicated by additional  
          individuals eligible for coverage under the 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's office 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."  The  
          author's office further states, 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's office further notes 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's office 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.

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

          According to the Assembly Appropriations Committee:

           One-time costs of under $50,000 to DMHC (Managed Care Fund)  
            for review of licensees' documents verifying compliance with  
            these standards. 

           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.  

           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.

           SUPPORT  :   (Verified  9/11/13)

          California Academy of Physician Assistants (co-source)
          California Association of Physician Group (co-source)
          Bay Area Council
          California Association of Health Underwriters
          California Medical Association
          California Optometric Association
          California Physical Therapy Association



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          California Primary Care Association
          Latino Coalition for a Healthy California
          Union of Health Care Professionals
          United Nurses Association of California/Union of Health Care  

           ARGUMENTS IN SUPPORT  :    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  
          non-physician 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 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 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  
          health care system.



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          JL:d  9/11/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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