BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1004
AUTHOR: Hernandez
AMENDED: May 5, 2014
HEARING DATE: May 7, 2014
CONSULTANT: Boughton
SUBJECT : Health facilities: hospice care.
SUMMARY : Requires the Department of Health Care Services to
request a federal Medicaid waiver to conduct a pilot project and
evaluate whether an adult pediatric palliative care benefit
should be offered in the Medi-Cal program.
Existing law:
1.Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), which provides
health care to children, seniors, persons with disabilities,
people also eligible for Medicare, and low-income individuals
and families.
2.Establishes the Nick Snow Children's Hospice and Palliative
Care Act of 2006, which requires DHCS, in consultation with
interested stakeholders, to develop a pediatric palliative
care pilot project to evaluate whether and to what extent
Medi-Cal beneficiaries under age 21 should be offered a
pediatric palliative care benefit. Requires the project to be
implemented only to the extent that federal financial
participation is available.
3.Defines "palliative care" as a medical treatment,
interdisciplinary care, or consultation provided to a patient
or family members, or both, that has as its primary purpose
the prevention of, or relief from, suffering and the
enhancement of the quality of life, rather than treatment
aimed at investigation and intervention for the purpose of
cure or prolongation of life as described. In some cases,
disease-targeted treatment may be used in palliative care.
4.Defines "hospice care" as a specialized form of
interdisciplinary health care that is designed to provide
palliative care, alleviate the physical, emotional, social,
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and spiritual discomforts of an individual who is experiencing
the last phases of life due to the existence of a terminal
disease, and provide supportive care to the primary caregiver
and the family of the hospice patient, and that meets all of
the following criteria:
a. Considers the patient and the patient's family, in
addition to the patient, as the unit of care;
b. Utilizes an interdisciplinary team to assess the
physical, medical, psychological, social, and spiritual
needs of the patient and the patient's family;
c. Requires the interdisciplinary team to develop an
overall plan of care and to provide coordinated care that
emphasizes supportive services, including, but not
limited to, home care, pain control, and limited
inpatient services. Limited inpatient services are
intended to ensure both continuity of care and
appropriateness of services for those patients who cannot
be managed at home because of acute complications or the
temporary absence of a capable primary caregiver;
d. Provides for the palliative medical treatment of
pain and other symptoms associated with a terminal
disease, but does not provide for efforts to cure the
disease;
e. Provides for bereavement services following death to
assist the family in coping with social and emotional
needs associated with the death of the patient;
f. Actively utilizes volunteers in the delivery of
hospice services; and,
g. To the extent appropriate, based on the medical
needs of the patient, provides services in the patient's
home or primary place of residence.
5.Establishes requirements for licensure as hospice, including
that the licensee provides the following services:
a. Skilled nursing services;
b. Social services/counseling services;
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c. Medical direction;
d. Bereavement services;
e. Volunteer services;
f. Inpatient care arrangements; and,
g. Home health aide services.
6.Authorizes licensed hospices to provide, in addition to
hospice services, any of the following preliminary services
for any person in need of those services, as determined by the
physician and surgeon, if any, in charge of the care of a
patient, or at the request of the patient or family:
a. Preliminary palliative care consultations;
b. Preliminary counseling and care planning; or,
c. Preliminary grief and bereavement services.
7.Authorizes preliminary services to be provided concurrently
with curative treatment to a person who does not have a
terminal prognosis or who has not elected to receive hospice
services only by licensed and certified hospices. Requires
these services to be subject to the schedule of benefits under
the Medi-Cal program.
This bill:
1.Requires DHCS, in consultation with interested stakeholders,
to develop, as a pilot project, a palliative care benefit to
evaluate whether and to what extent, such a benefit should be
offered under the Medi-Cal program. Requires the project to
be implemented only to the extent that federal financial
participation is available.
2.Requires beneficiaries eligible to receive the palliative care
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benefit to be 21 years of age or older, and authorizes DHCS to
further limit the population served by the pilot project to a
size deemed sufficient to evaluate the project.
3.Requires services covered under the palliative care benefit to
include those types of services that are available through the
Medi-Cal hospice benefit, and also include:
a. Hospice services that are provided at the same
time that curative treatment is available, to the
extent that the services are not duplicative;
b. Hospice services provided to individual's
whose conditions may result in death, regardless of
the estimated length of the individual's remaining
period of life; and,
c. Any other services that DHCS determines to be
appropriate.
4.Requires DHCS, in consultation with interested stakeholders,
to determine the medical conditions and prognoses that render
a beneficiary eligible for the benefit.
5.Requires providers authorized to provide services under the
pilot to include licensed hospice agencies and home health
agencies licensed to provide hospice care, subject to criteria
developed by DHCS for provider participation.
6.Requires DHCS to submit any necessary application to the
federal Center for Medicaid and Medicare Services (CMS) for a
waiver to implement the pilot. Requires DHCS to determine the
most appropriate form of waiver, and submit a request or
application within 12 months after the effective date of this
bill. Requires DHCS to implement the waiver within 12 months
of the date of approval.
7.Requires the waiver to be designed to cover a period of time
necessary to evaluate the medical necessity for, and
cost-effectiveness of, a palliative care benefit, and requires
the result of the pilot to be made available to the
Legislature and appropriate policy and fiscal committees to
determine effectiveness of the benefit.
8.Authorizes DHCS to implement the waiver by provider bulletin.
9.Prohibits this bill from resulting in the elimination or
reduction of any covered benefits or services under the
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Medi-Cal program.
10.Prohibits this bill from affecting an individual's
eligibility to receive, concurrently with the palliative care
benefit, any services, including home health services, for
which the individual would have been eligible in the absence
of this bill.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, as noted in the
California State Health Care Innovation Plan (SHIP), an
abundance of recent evidence suggests that an expansion of
patient and family centered palliative care has the potential
to change health outcomes for many Californians, while
reducing costs associated with inpatient care. Palliative
care is designed to better address patient preferences for
patients facing advanced illness. California has already
demonstrated success in Medi-Cal with pediatric palliative
care where a preliminary analysis indicates that the program
improves quality of life for the child and family, average
days in the hospital fell by one-third, and shifting care from
the hospital to in-home community based care resulted in cost
savings of $1,677 per child per month on average. With
palliative care, patients can live longer with a higher
quality of life and fewer hospitalizations. Establishing a
Medi-Cal palliative care program for patients with serious
advanced illness is good policy and promotes better health
outcomes for patients with a serious illness.
2.What is Palliative Care? According to the Center to Advance
Palliative Care, palliative care is specialized medical care
for people with serious illnesses. It is focused on providing
patients with relief from the symptoms, pain, and stress of a
serious illness, whatever the diagnosis. The goal is to
improve quality of life for both the patient and the family.
Palliative care is provided by a team of doctors, nurses, and
other specialists who work together with a patient's other
doctors to provide an extra layer of support. It is
appropriate at any age and at any stage in a serious illness
and can be provided along with curative treatment.
3.Partners for Children program. According to an August 2012,
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UCLA Center for Health Policy Research brief, Better Outcomes,
Lower Costs: Palliative Care Program Reduces Stress, Costs of
Care for Children with Life-Threatening Conditions, California
was one of the first states to respond to the need for
comprehensive pediatric palliative care. Under the Nick Snow
Children's Hospice and Palliative Care Act of 2006,
established by AB 1745 (Chan), Chapter 330, Statutes of 2006,
eligible children receive in-home coordinated family-centered
care including pain and symptom management, access to a 24/7
nurse line, family education, respite care, expressive
therapies and family counseling. Eleven counties have been
part of the pilot: Monterey, San Diego, Santa Clara, Santa
Cruz, Marin, Alameda, Orange, San Francisco, Sonoma, Los
Angeles, and Fresno. According to the brief, preliminary
findings include a one-third reduction in hospital days per
child, 11 percent reduction in average costs, and survey data
showed high satisfaction with the program overall and with
each of the individual services among families and providers.
The brief concludes that these preliminary results must be
interpreted with caution until a full analysis at the end of
the three-year program is conducted because of the small
number of participants and the wide variability of cost among
children. The evaluation is due this summer. According to
DHCS, this pilot falls under a 1915(c) Home and Community
Based Waiver, which ran from April 2009 through March 2012.
The waiver has been renewed through March 2017. Since its
inception 206 patients ages one through 20 have been enrolled
for an average of approximately 12 months' time in the
program. Conditions of patients include neoplasm, muscular
dystrophy, cystic fibrosis, cerebral palsy, and metabolic
disorders. Seventy percent of patients have been
Latino/Hispanic. Most families have rated the services 9 to
9.8 out of 10 with regard to satisfaction. The preliminary
evaluation shows a total savings per member per month of
$2,848 across inpatient, outpatient and pharmacy.
4.Additional Research. According to a 2011 article published in
Health Affairs, Palliative Care Consultation Teams Cut
Hospital Costs for Medicaid Beneficiaries, which examined data
to determine the effect on hospital costs of palliative care
team consultations for patients enrolled in Medicaid at four
New York State Hospitals, on average, patients who received
palliative care incurred $6,900 less in hospital costs during
a given admission than a matched group of patients who
received usual care. These reductions included $4,098 in
hospital costs per admission for patients discharged alive,
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and $7,563 for patients who died in the hospital. Estimates
suggest New York State could reduce Medicaid hospital spending
from $84 million to $252 million annually if every hospital
with 150 or more beds had a fully operational palliative care
consultation team. This article highlights many benefits of
palliative care, including reducing intensive care expenses
and the palliative care team's contributions toward getting
post-discharge care plans right the first time. This is key
to reducing readmissions, emergency department visits, and
unnecessary inpatient and outpatient services. An August 2010
New England Journal of Medicine article, Early Palliative Care
for Patients with Metastatic Non-Small-Cell Lung Cancer, found
that patients assigned to early palliative care had a better
quality of life than did patients assigned to standard care,
and median survival was longer among patients receiving early
palliative care. Another 2003 study in the Journal of
Palliative Medicine, Effectiveness of a Home-Based Palliative
Care Program for End of Life, concludes integrating palliative
care into curative care practices earlier in the disease
trajectory, chronically ill patients nearing the end of life
report improved satisfaction with care and demonstrate less
acute care use resulting in lower costs of care.
5.California's State Health Care Innovation Plan. SHIP was
prepared in response to a federal State Innovation Model
design grant. The California Health and Human Services Agency
Let's Get Healthy California Task Force set an overall target
of bringing California's health care expenditures growth rate
in line with that of the gross state product by 2022, along
with establishing targets for 38 health indicators. SHIP
includes advancements toward these two goals, as well as a
third goal of reforming payments that reward value. SHIP
centers around four initiatives, which focus on different
aspects of the health care system that experience particularly
high costs-uncoordinated care for people with complex chronic
conditions, maternity care, end of life care, and accountable
care communities. Through the greater use of team-based care
and care coordination (including linking with community and
social services), implementation of best practices,
incorporation of lower-cost health providers where
appropriate, and respecting patient preferences for care
options, these initiatives will lower costs while improving
health outcomes. SHIP includes a recommendation for a
palliative care initiative, together with a Health Homes for
Complex Patients Initiative, which aims to identify patients
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in hospitals, long-term care facilities, or the community, who
may benefit from and desire palliative care services, and
offer them comprehensive palliative care by people who are
trained in this area. SHIP indicates that there are only
1,045 physicians who are board certified in Hospice and
Palliative Medicine and 878 nurses who are certified by the
National Board for Certification of Hospice and Palliative
Nurses. Additionally, the SHIP states that there are 525
licensed hospice agencies across California. The California
State University of San Marcos has established an Institute
for Palliative Care, including a nurse practitioner palliative
care fellowship. SHIP also describes several health plan and
hospital systems working to deliver new models of care for
people near end of life. Sharp HealthCare in San Diego has a
pre-hospice program for patients with cancer, congestive heart
failure, cirrhosis, chronic obstructive pulmonary disease, and
dementia, which has reported savings on average of $27,000 per
patient.
6.Related legislation. SB 1357 (Wolk) would establish a
Physician Orders for Life Sustaining Treatment registry at the
California Health and Human Services Agency. This bill is
currently in the Senate Appropriations Committee.
AB 2452 (Pan) would require, commencing on January 1, 2016,
the Secretary of State to establish and maintain access, as
specified, to a secure portion of the Secretary of State's
Internet Web site that provides an electronic reproduction of
an advance health care directive and other specified documents
submitted to the registry system. This bill is currently
pending in the Assembly Health Committee.
7.Prior legislation. SB 1745 (Chan) of 2006 requires the
Department of Health Services (DHS) to develop, as a pilot
project, a pediatric palliative care benefit covered under
Medi-Cal. Requires DHS to submit a waiver to CMS to implement
the pilot project.
8.Support. The Association of Northern California Oncologists
believes this bill proposes a meaningful solution to help ease
the pain and suffering of cancer patients who are seriously
and terminally ill, and will support curative treatment
concurrently with hospice services for all eligible
beneficiaries. The Alliance of Catholic Health Care writes
that catholic hospitals are leaders in the provision of
palliative care and pain management, helping improve the
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quality of life for seriously ill patients. Among several
important provisions, this bill would include hospice services
that are provided at the same time that curative treatment is
available, to the extent the services are not duplicative, and
are provided regardless of the estimated length of time a
beneficiary may be expected to live. This bill proposes a
meaningful solution to help ease the pain and suffering of
patients who are seriously and terminally ill, and will
support curative/life prolonging treatment concurrently with
hospice services for all eligible beneficiaries. The
California Hospital Association supports this bill as an
excellent opportunity to evaluate the potential benefit of
access to palliative care for Medi-Cal beneficiaries.
SUPPORT AND OPPOSITION :
Support: Alliance of Catholic Health Care
Association of Northern California Oncologists
California Hospice and Palliative Care Association
California Hospital Association
Children's Hospice
Medical Oncology Association of Southern California
Providence Health & Services, Southern California and
Providence TrinityCare Hospice
American Federation of State, County and Municipal
Employees, AFL-CIO (prior version)
California Commission on Aging (prior version)
California Dialysis Council (prior version)
Health Access California (prior version)
Oppose: None received
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