BILL ANALYSIS Ó AB 690 Page 1 Date of Hearing: April 7, 2015 ASSEMBLY COMMITTEE ON HEALTH Rob Bonta, Chair AB 690 (Wood) - As Introduced February 25, 2015 SUBJECT: Medi-Cal: federally qualified health centers: rural health clinics. SUMMARY: Adds marriage and family therapist (MFT) to the list of health care providers that qualify for a face-to-face encounter with a patient at a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) for purposes of a per visit Medi-Cal payment under the prospective payment system (PPS). EXISTING LAW: 1)Establishes the Medi-Cal program to provide comprehensive health benefits to low-income persons. 2)Establishes a statutory structure for Medi-Cal payments being made under the PPS. These payments are for services provided by FQHCs on a per-visit basis with rates determined prospectively. Federal law requires states to use a PPS system to pay clinics. 3)Existing law also identifies those services that may be reimbursed as services identified in federal law as covered benefits for FQHCs and requires FQHCs to be reimbursed on a AB 690 Page 2 per-visit basis with rates determined prospectively. 4)Defines visit as a face to face encounter with a physicians, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker (LCSW), visiting nurse, osteopath, podiatrist, dentist, dental hygienists, optometrist, chiropractor, comprehensive perinatal services practitioner, adult day health care center. Authorizes other providers if identified in the state plan. 5)Allows only one visit per day to be reimbursed by Medi-Cal, except for a subsequent visit by a patient to a dental provider FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee. COMMENTS: 1)PURPOSE OF THIS BILL. The author argues that community clinics and health centers provide health care to one in seven Californians and this figure is even higher in rural or remote areas that struggle to attract and retain health care providers. Mental health and substance abuse services are part of the essential health care benefits under Patient Protection and Affordable Care Act (ACA). As such they are a part of Medi-Cal. Along with the expansion of these benefits, the expansion of the Medi-Cal program overall has increased the number of beneficiaries to over 12 million. By adding MFT to the list of PPS billable providers, this bill brings parity throughout the delivery system in the ability to utilize all qualified mental health providers regardless of how or where you are receiving treatment. The author notes that as of February 2012, there were 19,009 LCSW and 16,228 licensed psychologists; as well as 31,865 MFTs in California. Allowing full access to the entire population of qualified mental health providers for all aspects of the health care delivery AB 690 Page 3 system will help to meet the increased demands of the Medi-Cal population. The author concludes that integration has taken place in other settings, including Medi-Cal managed care. It is time to remove the financial and workforce barrier that exists in many rural and remote areas of California. 2)BACKGROUND. a) Clinics. FQHCs and RHCs serve a significant portion of the uninsured and underinsured in California. They are open-door providers that treat patients on a sliding fee scale basis and make their services available regardless of a patient's ability to pay. Currently, there are approximately 600 FQHCs and 350 RHCs in California. All FQHCs, and a majority of the RHCs, either are non-profit community clinics or government entities. Because clinics are safety net providers, their continued survival depends heavily on the stability and adequacy of revenues from the Medi-Cal program. FQHCs and RHCs are paid by Medi-Cal on a per visit basis in an amount equal to the clinic's cost of delivering services. Essentially, the department calculates the annual cost of care provided by each clinic and divides the total by the number of visits to determine a per visit rate. b) Rural Mental Health. According to a 2010 Behavior Risk Factor Survey, a higher proportion of rural residents self-declare a mental health issue compared to urban county residents. Additionally, within a primary care setting, up to 26% of patients have some mental health disorder. Further complicating the care environment is the fact that while chronic conditions, such as heart disease and diabetes are common among the adult population, adults with mental health needs have an even higher incidence of chronic disease. Adults with mental health needs are 1.5 times more likely to have high blood pressure, heart disease or asthma. This situation reinforces the value of integrating mental health services into the primary care AB 690 Page 4 settings or rural clinics and FQHCs. c) MFTs and Medi-Cal. A state plan amendment allows MFTs to provide Medi-Cal services in County mental health plans, MediCal managed care plans and as Medi-Cal fee-for-service providers. Their services are not included as those that can be billed as a face-to-face encounter with a qualified provider type. MFTS can still be employed by clinics. If the cost of the MFT is included in the PPS rate calculation initially, although the clinic cannot bill for a visit, since the MFT is part of the cost structure, each time the clinic is paid their PPS they are reimbursed a portion of the cost. In the aggregate, with all visits included, the cost of the MFT would be completely reimbursed to the clinic, provided the cost of hiring the MFT was part of the costs used to calculate the PPS rate. 3)SUPPORT. The sponsor, the California Primary Care Association (CPCA), argues by adding MFTs to the list of PPS billable providers will help solve existing gaps in workforce capacity by providing FQHCs and RHCs with an adequate source of funding for their employment and will help to meet the demand for mental health services in the public health setting. CPCA notes that as part of California's implementation of health care reform, mental health and substance abuse disorder services are deemed an essential health benefit for Medi-Cal managed care plans. In addition, they state, that along with the expansion of behavioral health benefits for Medi-Cal, the significant expansion of the Medi-Cal program itself has increased demands for mental health services. Supporters argue that MFTS are uniquely qualified to address and resolve familial and contextual issues that arise from, or contribute to, mental and emotional distress. They also argue that many low income people on Medi-Cal may require a marriage and family therapist in order to receive treatment for a AB 690 Page 5 mental illness or to discuss a personal and possibly dangerous matter that is affecting their physical and mental well-being. 4)OPPOSITION. The National Association of Social Workers-California Chapter (NASW-CA) opposes the bill because they believe there is a sufficient workforce of social workers and only social workers have the training and skills necessary to treat this community. NASW-CA maintains these clinics serve a population that is very diverse and in poverty and while both MFT's and social workers have mental health training, only social workers are properly trained to provide a full range of services to this community. A social worker is trained to view clients from the person-in-the-environment/whole person perspective, as opposed to simply focusing on the pathology of mental illness, according to NASW-CA. As an example, they cite the possible case of a homeless person who is exhibiting signs of a mental illness. A clinical social worker can provide clinical services to that person, but they will also look at that person's immediate needs, such as the need for food and shelter. NASW-CA argues that social workers are trained and very experienced in obtaining services that their clients need to survive and if a person who has a mental illness is homeless, even if you alleviate some of their mental health issues, if they remain homeless, they are in a very unstable environment that could easily put them into a downward spiral. 5)RELATED LEGISLATION. AB 858 (Wood) provides that a maximum of two visits taking place on the same day at a single clinic location shall be reimbursed, as specified. AB 858 is in the Assembly Health Committee. 6)PREVIOUS LEGISLATION. AB 1785 (Lowenthal) of 2012 was similar to this bill. AB 1785 was held on the Suspense file of the Assembly Appropriations Committee. AB 690 Page 6 REGISTERED SUPPORT / OPPOSITION: Support California Primary Care Association (Sponsor) Alameda Health Consortium American Association for Marriage and Family Therapy, California Division American Federation of State, County and Municipal Employees Ampla Health California Association of Marriage and Family Therapists California Association of Rural Health Centers California Council of Community Mental Health Agencies California Immigrant Policy Center California Medical Association AB 690 Page 7 California School-Based Health Alliance Central Valley Health Network Clinica Sierra Vista Community Clinic Consortium Community Health Partnership County Behavioral Health Directors Association Family HealthCare Network Family Health Centers of San Diego Hill Country Community Clinic Livingston Community Health Mendocino Coast Clinics Mountain Valleys Health Centers North Coast Clinics Network AB 690 Page 8 Northeast Valley Health Corporation Ritter Health Center San Francisco Community Clinic Consortium San Ysidro Health Center SEIU California Opposition National Association of Social Workers-California Chapter Analysis Prepared by:Roger Dunstan / HEALTH / (916) 319-2097 AB 690 Page 9