BILL ANALYSIS �
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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 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
SENATE FLOOR : 38-0, 5/29/13
AYES: Anderson, Beall, Berryhill, Block, Calderon, Cannella,
Corbett, Correa, De Le�n, 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
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. 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.
Comments
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)
AARP
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
Professionals
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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