BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 848


                                                                    Page  1





          Date of Hearing:  April 14, 2015


                   ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS


                                Susan Bonilla, Chair


          AB 848  
           (Mark Stone) - As Amended April 6, 2015


          NOTE: Double Referral.  This bill is double referred, and if  
          passed by this Co0mmittee, it will be referred to the Assembly  
          Health Committee.  


          


          SUBJECT:  Alcoholism and drug abuse treatment facilities.





          SUMMARY:  Authorizes alcoholism and drug treatment facilities to  
          allow a licensed physician, or other health care practitioner,  
          to provide incidental medical services to a resident of the  
          facility and requires the Department of Health Care Services  
          (DHCS) to conduct an evaluation of the program on or before  
          January 1, 2019, and to report the results of the evaluation to  
          the appropriate fiscal and policy committees of the Legislature.  
           












                                                                     AB 848


                                                                    Page  2






          EXISTING LAW


          1)Provides for the licensure of physicians and surgeons, and the  
            enforcement of the disciplinary and criminal provisions of the  
            Medical Practice Act, by the Medical Board of California (MBC)  
            located within the Department of Consumer Affairs (DCA).  (BPC  
             2000; 2004) 


          2)Defines a "licensee" as the holder of a physician and surgeons  
            certificate who is engaged in the professional practice  
            authorized by the certificate under the jurisdiction of the  
            MBC.  (BPC  2041)


          3)Defines an "alcoholism or drug abuse recovery or treatment  
            facility" (facility) as a facility that provides 24-hour  
            residential non-medical services, defined as recovery  
            services, treatment services and detoxification services, to  
            adults who are recovering from problems related to alcohol,  
            drug, or alcohol and drug misuse or abuse.  (HSC  11834.02)


          4)Specifies that a licensee shall not operate such a facility  
            beyond the conditions of the license and if it does, the  
            facility is subject civil penalties, suspension or revocation  
            of the license.  (HSC  11834.15, 11834.16)


          5)Specifies that a license for a drug abuse recovery or  
            treatment facility is valid for two (2) years.  (HSC   
            11834.16)


          THIS BILL










                                                                     AB 848


                                                                    Page  3





          1)Specifies that a health care practitioner should submit a  
            signed certification form to a facility licensed by the DHCS  
            where they plan to provide alcoholism or drug abuse recovery  
            or treatment services.


          2)Defines "health care practitioner" as a healing arts  
            professional, licensed under BPC  500, and who is acting  
            within the scope of practice of his or her license or  
            certificate.  


          3)Specifies that the DHCS shall develop a standard certification  
            form, for use by a health care practitioner, that:


             a)   describes the alcoholism and drug abuse recovery or  
               treatment services provided, and 


             b)   certifies that the health condition or medical or  
               psychiatric history of the applicant does not require a  
               level of care that is higher than the level of care that  
               may legally be provided by a licensed facility.


          4)Specifies that on or before January 1, 2017, the DHCS shall  
            adopt emergency regulations that are exempt from review by the  
            Office of Administrative Law and shall be submitted for filing  
            with the Secretary of State. 


          5)Defines "incidental medical services" as services to address  
            the physical and mental health issues associated with either  
            detoxification from alcohol or drugs or the provisions of  
            alcoholism or drug abuse recovery or treatment services, that  
            in the opinion of a physician are not required to be performed  
            in a licensed clinic or health facility.









                                                                     AB 848


                                                                    Page  4






          6)Specifies that a facility may permit incidental medical  
            services to be provided to a resident at the facility by one  
            or more independent physicians and surgeons licensed by the  
            MBC or the Osteopathic Medical Board who are knowledgeable  
            about addiction medicine, or one or more other health care  
            practitioners acting within the scope of practice of his or  
            her license and under the direction of a physician and  
            surgeon, and are also knowledgeable about addiction medicine.


          7)States that the facility must comply with all other applicable  
            laws and regulations to meet the needs of a resident receiving  
            incidental medical services from a physician.


          8)Specifies that the physician and surgeon and any other health  
            care practitioner has signed an acknowledgment on a form  
            provided by the DHCS that he or she has been advised of and  
            understands the statutory and regulatory limitations on the  
            services that may legally be provided by the facility, and the  
            statutory and regulatory requirements and limitations for the  
            physician and surgeon or other health care professional and  
            for the facility.


          9)Requires that there is an agreed-upon written protocol between  
            the physician and surgeon and the facility signed by the  
            physician and surgeon and the licensee.





          10)Specifies that the facility, in its admissions agreement with  
            a client, shall clearly identify the individual financially  
            responsible for incidental medical services that are provided.










                                                                     AB 848


                                                                    Page  5






          11)States there should be ongoing communication between the  
            physician and the facility about the services provided to the  
            resident by the physician and surgeon and the frequency and  
            duration of incidental medical services to be provided.



          12)Requires initial and ongoing communication between the  
            physician and surgeon or other health care practitioner and  
            the resident's health plan or health insurer prior to the  
            provision of incidental medical services to ensure  
            coordination of care.



          13)Specifies that the facility will not provide incidental  
            medical services and will not assist with or interfere with  
            the physician and surgeon or other health care practitioner  
            providing incidental medical services.



          14)States that the resident must be authorized by the physician  
            and surgeon as medically appropriate to receive the incidental  
            medical services at the facility.



          15)Requires that before a facility resident receives incidental  
            medical services, the resident has signed an acknowledgment  
            and consent to receive those services on a form provided by  
            the DHCS.



          16)Specifies that once incidental medical services are initiated  
            for a resident, the physician and surgeon and the facility  
            shall continuously monitor the resident to ensure that the  








                                                                     AB 848


                                                                    Page  6





            services remain appropriate for the resident.



          17)Requires the facility to maintain in its files a copy of the  
            physician and surgeon's license or other written evidence of  
            licensure to practice medicine in the state.



          18)Requires the facility to report, in a timely manner, to the  
            DHCS, any violation or suspected violation by the physician  
            and surgeon of the regulations relating to providing  
            incidental medical services.



          19)Indicates that the DHCS shall not evaluate or have any  
            responsibility or liability with respect to evaluating  
            incidental medical services provided.



          20)States that a facility licensed and approved by the DHCS to  
            allow for the provision of incidental medical services shall  
            not be considered a clinic or health facility.



          21)Specifies that, other than incidental medical services, minor  
            first aid, or in the case of a life threatening emergency,  
            provision of medical or health care services or services that  
            require a higher level of care than the care that is permitted  
            to be provided at a facility, is not permitted at a facility.



          22)Indicates that if an applicant for facility licensure intends  
            to permit incidental medical services, the applicant shall  








                                                                     AB 848


                                                                    Page  7





            submit a copy of a valid license of the physician and surgeon  
            who will provide those services, and any other information the  
            DHCS deems appropriate, including, but not limited to, a copy  
            of the facility's accreditation by a nationally recognized  
            accrediting organization.



          23)Allows the DHCS to establish an additional licensure fee for  
            an application that includes a request for a facility to  
            provide detoxification services.



          24)Requires the DHCS to conduct an evaluation of the program  
            licensing those facilities and to submit a report to the  
            appropriate policy and fiscal committees of the Legislature on  
            or before January 1, 2019.



          25)Permits the director of DHCS to temporarily suspend any  
            license prior to any hearing when, in the opinion of the  
            director, the action is necessary to protect residents of the  
            facility from physical or mental abuse, abandonment, or any  
            other substantial threat to health or safety.



          26)Makes other findings and declarations.


          FISCAL EFFECT:  Unknown.  This bill is keyed fiscal by the  
          Legislative Counsel. 


          










                                                                     AB 848


                                                                    Page  8





          COMMENTS


          1)Purpose. This bill is co-sponsored by the  California Society  
            of Addiction Medicine  ,  Elements Behavioral Health  and  JANUS of  
            Santa Cruz  .  According to the author, "AB 848 protects the  
            physical and mental health of people seeking alcohol and drug  
            rehabilitation services in residential treatment facilities.   
            Under AB 848, physicians and other appropriate medical  
            personnel can be available on-site to provide 24-hour medical  
            services related to clients' addictions.  Clients of these  
            facilities often have a variety of medical needs related to  
            their addictions.  Because clients' medical needs can affect  
            and even interfere with their recovery, they may have better  
            recovery outcomes when they have on-site access to medical  
            care including vital sign monitoring, seizure risk assessment,  
            medication management, and psychiatric therapy?The measure  
            requires that facilities seeking licensure adhere to protocol  
            that protect client privacy, notify clients of financial  
            responsibility for medical care, and clearly define the level  
            of medical care to be provided.  The measure requires DHCS to  
            promulgate final regulations by July 1, 2017 to implement the  
            policy.  Additionally, the measure requires that DHCS perform  
            an evaluation of the law's effectiveness by 2019." 


          2)Background.  Alcoholism or drug abuse recovery or treatment  
            facilities provide 24-hour non-medical care and specialize in  
            providing services to chemically dependent adults who do not  
            require treatment in an acute-care medical facility on an  
            inpatient, intensive outpatient, outpatient, and partial  
            hospitalization basis.  These facilities range in size from  
            six-bed facilities in residential neighborhoods to centers  
            that accommodate more than 100 beds (California Senate Office  
            of Oversight and Outcomes report, Rogue Rehabs: State failed  
            to police drug and alcohol homes, with deadly results,  
            September, 2012).  










                                                                     AB 848


                                                                    Page  9








            The basic services provided by facilities include group,  
            individual and educational sessions, alcoholism or drug abuse  
            recovery and treatment planning.  Detoxification services are  
            also provided and are defined by the DHCS as, "? a service to  
            support and to assist and individual in the alcohol and/or  
            drug withdrawal process and to explore plans for continued  
            service."  These services can be provided by a variety of  
            health care providers such as alcohol and drug counselors,  
            mental health therapists, social workers, psychologists,  
            nurses and physicians.  





            Currently, the only medical care that facilities are allowed  
            to provide to clients is first aid and emergency care.  If a  
            patient requires medical care, they must leave the facility to  
            receive care from a medical professional and the patient must  
            pay the medical professional directly for services.





            Facility Licensing and Oversight.  Prior to July 1, 2013, the  
            Department of Alcohol and Drug Programs (ADP) was responsible  
            for oversight of alcoholism or drug abuse recovery or  
            treatment facilities.  Effective with the passage of the  
            2013-2014 Budget Act and associated legislation, all ADP  
            programs and staff, except the Office of Problem Gambling,  
            transferred to the DHCS.  Now, the DHCS is responsible for  
            oversight.  The DHCS licenses the facilities and conducts  
            reviews of their operations every two years.  As part of the  
            review process, the DHCS checks for compliance with a variety  
            of requirements including, whether staff has passed  








                                                                     AB 848


                                                                    Page  10





            tuberculosis tests, that residents have completed health  
            questionnaires and if at least one staff member is certified  
            in first aid and CPR.  





            The DHCS's Substance Use Disorder (SUD) Compliance Division  
            investigates complaints against facilities. The SUD Compliance  
            Division also investigates violations of the code of conduct  
            of registered or certified alcohol and drug counselors.   
            Additionally, facilities licensed or certified by DHCS are  
            required to report counselor misconduct to DHCS within 24  
            hours of the violation.  Facilities that do not comply with  
            existing requirements are subject to civil penalties and  
            license suspension or revocation.  


            Facility Accreditation.  Two national organizations, the Joint  
            Commission on Accreditation of Healthcare Organizations  
            (JCAHO) and the Joint Commission on Accreditation of  
            Rehabilitation Facilities (CARF), accredit facilities that  
            provide behavioral health care services such as addiction  
            treatment, opioid treatment and maintenance programs, crisis  
            stabilization, case management and care coordination,  
            employment services and vocational rehabilitation.  





            JCAHO and CARF each require facilities to demonstrate that  
            their programs meet the accrediting organizations' quality  
            standards in order to obtain accreditation.  These quality  
            standards evaluate functions relating to client care and  
            program management, including administrative requirements,  
            financial management, personnel qualifications, client  
            services, performance outcomes, client safety and information  








                                                                     AB 848


                                                                    Page  11





            privacy and security.  JCAHO requires accredited organizations  
            to reapply for accreditation every three years while CARF  
            accreditation ranges from one to five years, depending on the  
            type of facility.





            Senate Office of Oversight and Outcomes Report.  In 2012, the  
            Senate Office of Oversight and Outcomes (SOOO) published a  
            report, Rogue Rehabs: State failed to police drug and alcohol  
            homes, with deadly results. The report focused on "gaps" in  
            the ADP's regulation of residential programs as well as a  
            review of the state's ban on medical care at residential drug  
            and alcohol programs.  The SOOO advised that state law be  
            changed to "better reflect current treatment practices?[there  
            is a] mismatch between the department's regulation and the  
            industry's prevalent practices."  The SOOO recommended,  
            "?lifting the ban on medical care as long as it is accompanied  
            with more extensive oversight."  


            Other States.  As part of the SOOO's aforementioned  
            investigation in 2012, it contacted nine (9) other highly  
            populous states.  The SOOO found, "California is unusual among  
            populous states in prohibiting medical care."  All but one of  
            the nine states allowed physicians and other medical  
            professionals to work in residential rehabilitation  
            facilities.  





           --------------------------------------------------------------------------------------------------- 
          |         |Illinois |Indiana  |Massachus|New York |North    |Ohio     |Pennsylva|Texas    |Washingto|
          |         |         |         |etts     |         |Carolina |         |nia      |         |n        |
          |         |         |         |         |         |         |         |         |         |         |








                                                                     AB 848


                                                                    Page  12





          |         |         |         |         |         |         |         |         |         |         |
          |---------+---------+---------+---------+---------+---------+---------+---------+---------+---------|
          |Allows   |Y        |Y        |N*       |Y        |Y        |Y        |Y        |Y        |Y        |
          |medical  |         |         |         |         |         |         |         |         |         |
          |care in  |         |         |         |         |         |         |         |         |         |
          |residenti|         |         |         |         |         |         |         |         |         |
          |al       |         |         |         |         |         |         |         |         |         |
          |rehabilit|         |         |         |         |         |         |         |         |         |
          |ation    |         |         |         |         |         |         |         |         |         |
          |facilitie|         |         |         |         |         |         |         |         |         |
          |s        |         |         |         |         |         |         |         |         |         |
          |         |         |         |         |         |         |         |         |         |         |
          |         |         |         |         |         |         |         |         |         |         |
           --------------------------------------------------------------------------------------------------- 
          NOTE: This data is from the SOOO report: Rogue Rehabs: State  
          failed to police drug and alcohol homes, with deadly results,  
          September, 2012.  
           http://sooo.senate.ca.gov/sites/sooo.senate.ca.gov/files/Rogue%20 
          Rhab%209_4_12.pdf  


          *Rehabilitation homes refer clients to local doctors; nurses are  
          available at homes


          3)Prior Related Legislation.  AB 395 (Fox) of 2013, would have  
            expanded the types of facilities licensed by the ADP to  
            include any facility that has a nationally accredited program  
            that uses a multidisciplinary team to provide 24-hour  
            residential medical services to adults recovering from alcohol  
            and drug abuse problems. NOTE: This bill died on the Senate  
            Appropriations Committee suspense file.


            AB 972 (Butler and Beall) of 2011, would have expanded, until  
            January 1, 2017, the category of residential treatment  
            facilities licensed by the ADP to include facilities that  
            provide limited medical services to adults recovering from  
            alcohol and drug abuse, provided that the facility is not  








                                                                     AB 848


                                                                    Page  13





            otherwise required to have a separate health facility license.  
             Would have established a fee for facilities that provide  
            limited medical services and makes other changes to the  
            licensing fees for residential treatment facilities. NOTE:  
            This bill was held in the Senate Appropriations Committee.  





            AB 2221 (Beall) of 2010, would have permitted 24-hour  
            residential treatment facilities that provide services to  
            adults recovering from alcohol and drug abuse that are  
            licensed by the ADP to provide unspecified medical services  
            and would have provided that such a facility would not require  
            a health facility license.  NOTE: This bill died on the Senate  
            Appropriations Committee suspense file.





            AB 1055 (Chesbro) of 2009, would have expanded the ADP  
            licensure authority for alcohol and drug treatment facilities  
            to include 24-hour facilities that do not require a health  
            facility license.  NOTE: This bill died on the Assembly  
            Appropriations Committee suspense file.


          ARGUMENTS IN SUPPORT 


          The  California Society of Addiction Medicine  also writes in  
          support and notes in its letter, "Passage of this bill will make  
          it clear that physicians may provide appropriate medical  
          services to persons undergoing withdrawal in residential  
          treatment facilities?[the current] ban precludes facilities from  
          meeting a variety of on-site medical needs of their clients,  
          including emergency care, psychiatric treatment, or medical  








                                                                     AB 848


                                                                    Page  14





          conditions related to clients' addictions.  Instead, when  
          clients have medical needs during the course of their  
          residential treatment, facility staff must send them to doctors'  
          offices of hospital emergency departments, which inefficient and  
          costly." 


           Elements Behavioral Health  , a division of Promises Treatment  
          Centers states its concern with the implications of current  
          statute in its letter of support, "Until very recently the  
          state's Alcohol and Drug Program (ADP) interpreted "non-medical"  
          licensure language to distinguish licensed residential  
          facilities from hospitals.  Patients of these facilities  
          routinely were provided with basic medical care which, much less  
          a house call, included the prescription ad monitoring of  
          medicine, taking blood samples and blood pressure, the  
          provisions of psychiatric evaluations, administration of public  
          health inoculations and the general oversight of a patient's  
          health conditions.  A few years ago ADP began threatening loss  
          of licensure if such basic medical care was provided."


           JANUS of Santa Cruz  writes in support, "Alcoholism or drug abuse  
                                                             recovery and treatment facilities like Janus provide 24-hour  
          residential non-medical care to clients...Under current law,  
          DHCS cannot license facilities that provide on-site medical  
          personnel to evaluate or provide medical care to  
          clients?Instead, if clients have medical needs during the course  
          of their residential treatment, facility staff must transport  
          them to doctors' offices, clinics, or hospital emergency rooms,  
          which can be inefficient, costly, and potentially even  
          dangerous."


          The  California Naturopathic Doctors Association  supports the  
          bill and writes, "The CNDA urges your support of AB 848?as a  
          means of improving patients' access to their chosen primary care  
          provider."









                                                                     AB 848


                                                                    Page  15






          The  California Narcotic Officers' Association  also writes in  
          support, "Alcoholism or drug abuse recovery and treatment  
          facilities?are required to offer?services that are designed to  
          help clients taper off or quit substances in a safe environment.  
          The challenge is that clients?often have a variety of medical  
          needs related to their addictions.  As a result, facility  
          clients may have better recovery outcomes when they have access  
          to medical care including vital sign monitoring, seizure risk  
          assessment, medication management, and psychiatric therapy." 


           Alkermes Inc.  supports the bill and writes, "As you know, the  
          treatment of substance abuse is complicated from both a  
          logistical and clinical perspective.  Additionally, the  
          landscape surrounding substance use disorder treatment in  
          California is in a state of transformation?AB 848 provides the  
          opportunity to expand access to treatment and care for those  
          receiving services."


          ARGUMENTS IN OPPOSITION


          None on file.


          IMPLEMENTATION ISSUES


          As indicated above, there have been a number of bills that have  
          attempted to address the issue of removing the ban on provision  
          of medical services at alcoholism or drug abuse recovery or  
          treatment facilities.  While there have been recent changes to  
          these facilities, e.g. the licensing and oversight of these  
          facilities was transferred to the DHCS in 2013, the Committee  
          may wish to consider requiring additional implementation  
          safeguards should this bill pass.  









                                                                     AB 848


                                                                    Page  16






          As noted in the SOOO report, it is recommended that the DHCS,  
          the facility and/or the accrediting organization implement  
          regulations requiring that the credentials and malpractice  
          insurance for medical professionals providing medical treatment  
          be checked before they contract with the facility.  It may also  
          be beneficial to set up a system to require a yearly review of  
          the medical professional's credentials and insurance to assure  
          ongoing compliance and patient protection.  


          As is consistent with practices in other states, it may also be  
          beneficial for programs that offer any type of medical  
          detoxification to hire a medical director to oversee the  
          administration of this treatment. 


          To safeguard against the state's prohibition against the  
          corporate practice of medicine, physicians should contract with  
          the facilities instead of working directly for them.  This would  
          necessitate that the employment contract specify that the  
          program cannot control or interfere with the physician's  
          practice and that the physician retains the ability to make  
          decisions.  The contract should also clearly state that the  
          physician is not paid for the types or amount of services  
          provided. 


          


          REGISTERED SUPPORT / OPPOSITION




          Support:










                                                                     AB 848


                                                                    Page  17





          California Society of Addiction Medicine (co-sponsor)


          Elements Behavioral Health (co-sponsor)


          JANUS of Santa Cruz (co-sponsor)


          Alkermes Inc.


          California Naturopathic Doctors Association


          California Narcotic Officers' Association


          County Behavioral Health Directors Association




          Opposition:


          None on file.




          Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /  
          (916) 319-3301














                                                                     AB 848


                                                                    Page  18