BILL ANALYSIS Ó AB 848 Page 1 Date of Hearing: April 28, 2015 ASSEMBLY COMMITTEE ON HEALTH Rob Bonta, Chair AB 848 (Mark Stone) - As Amended April 6, 2015 SUBJECT: Alcoholism and drug abuse treatment facilities. SUMMARY: Authorizes alcoholism and drug treatment facilities to allow a licensed physician, or other qualified health care practitioner, to provide incidental medical services to a resident of the facility. Specifically, this bill: 1)Requires a health care practitioner to submit a signed certification form to a facility licensed by the Department of Health Care Services (DHCS) where they plan to provide alcoholism or drug abuse recovery or treatment (treatment facility) services. 2)Defines "health care practitioner" as a licensed healing arts professional, who is acting within the scope of practice of his or her license or certificate. 3)Requires DHCS to develop a standard certification form, for use by a health care practitioner, that: AB 848 Page 2 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)Requires DHCS, on or before January 1, 2017, to adopt emergency regulations that are only effective for 180 days or once final regulations are adopted, whichever comes first. 5)Exempts emergency regulations adopted by DHCS from review by the Office of Administrative Law and requires them to be submitted for filing with the Secretary of State. 6)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. 7)Allows a treatment facility to provide incidental medical services to a resident at the treatment facility by one or more independent physicians and surgeons or other health care practitioners acting within the scope of practice of his or her licensure, as specified. 8)Requires the treatment facility to comply with all other applicable laws and regulations to meet the needs of a AB 848 Page 3 resident receiving incidental medical services from a physician. 9)Requires the physician and surgeon and any other health care practitioner to sign their acknowledgment on a form provided by 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 treatment facility, and the statutory and regulatory requirements and limitations for the physician and surgeon or other health care professional. 10)Requires an agreed-upon written protocol between the physician and surgeon and the treatment facility signed by the physician and surgeon and the licensee. 11)Requires the treatment facility, in its admissions agreement with a client, to clearly identify the individual financially responsible for incidental medical services that are provided. 12)Requires ongoing communication between the physician and the treatment 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. 13)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. AB 848 Page 4 14)Prohibits the treatment facility from providing incidental medical services and from assisting or interfering with the physician and surgeon or other health care practitioner providing incidental medical services. 15)Requires that before a treatment facility resident receives incidental medical services, the resident has signed an acknowledgment and consent to receive those services on a form provided by DHCS. 16)Requires that, once incidental medical services are initiated for a resident, the physician and surgeon and the treatment facility continuously monitor the resident to ensure that the services remain appropriate for the resident. 17)Requires the treatment 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 treatment facility to report, in a timely manner, to DHCS any violation or suspected violation by the physician and surgeon of the regulations relating to providing incidental medical services. 19)Absolves DHCS from any responsibility or liability with respect to evaluating incidental medical services provided. AB 848 Page 5 20)Specifies that a treatment facility licensed and approved by DHCS to allow for the provision of incidental medical services is not considered a clinic or health facility. 21)Prohibits medical or health care services or services that require a higher level of care than can be provided at a treatment facility from being provided at a treatment facility. 22)Requires that, if an applicant for treatment facility licensure intends to permit incidental medical services, the applicant submit a copy of a valid license of the physician and surgeon who will provide those services, and any other information DHCS deems appropriate. 23)Allows DHCS to establish an additional licensure fee for an application that includes a request for a treatment facility to provide detoxification services. 24)Requires DHCS to conduct an evaluation of the program licensing treatment 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 the action is necessary to AB 848 Page 6 protect residents of the treatment facility from physical or mental abuse, abandonment, or any other substantial threat to health or safety. EXISTING LAW: 1)Requires DHCS to license adult alcoholism or drug abuse recovery treatment facilities and specifies that a license for a drug abuse recovery or treatment facility is valid for two years. 2)Defines an "alcoholism or drug abuse recovery or treatment 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. 3)Prohibits a licensee from operating 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. FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee. COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, this bill protects the physical and mental health of people seeking alcohol and drug rehabilitation services in residential AB 848 Page 7 treatment facilities. Under the provisions of this bill, 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 author states that unfortunately, alcohol and drug rehabilitation facilities cannot be licensed by DHCS if they use on-site doctors or other medical personnel to evaluate or provide medical care to facility clients. This prohibition precludes facilities from meeting the medical needs of clients that could easily and efficiently be provided on-site. Instead, under current law, 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 and costly. Further, when clients are removed from facilities in the midst of their treatment, their recovery efforts may be disrupted. By failing to allow these residential rehabilitation facilities to have medical personnel on-site, the state reduces the effectiveness of the critical services being provided to people suffering from substance addiction. The author further states that to help ensure that people recovering from addiction remain safe during their stay at treatment facilities and to improve their recovery outlook, facilities should be allowed to use medical personnel to provide appropriate on-site physical and mental health services. This bill allows DHCS to license a facility that uses a physician or other eligible medical practitioner to provide incidental medical services to treat conditions associated with drug and alcohol addiction and recovery and that are deemed to be treatable on-site rather than in a clinic or hospital. This bill requires that facilities AB 848 Page 8 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, this bill requires that DHCS perform an evaluation of the law's effectiveness by 2019. The author concludes that residential alcohol and drug treatment facilities should provide the best possible care for vulnerable people struggling to overcome addictions, which can include medical treatment related to addiction and recovery. This bill will allow thousands of vulnerable people to recover from addiction safely. 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. 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 services 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 AB 848 Page 9 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. a) Drug Medi-Cal Waiver Amendment. On November 21, 2014, DHCS submitted a proposal to amend the Special Terms and Conditions the California Section 1115 Bridge to Reform Waiver. California's Drug Medi-Cal Organized Delivery System (DMC-ODS) 1115 demonstration waiver provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services. The waiver amendment is intended to make improvements to the DMC service delivery system, create more local control and accountability in selection of high quality providers, improve local coordination of case management services, ensure implementation of evidence based practices in substance abuse treatment, and increase coordination with other systems of care including physical health. The DMC-ODS waiver amendment is intended to demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs. Participation for providing services under this waiver is voluntary; eight to 12 counties are expected to initially opt-in to waiver participation. This waiver amendment would allow the state to extend the DMC Residential Treatment Service, as an integral aspect of the continuum of care, to additional beneficiaries. Historically, the Residential Treatment Service was only available to pregnant / postpartum beneficiaries in facilities with a capacity of 16 or less beds. This waiver will create a Residential Treatment Service operable in facilities with no bed capacity limit. Should the terms of this waiver be approved, this provisions provided for in this bill will be necessary in order to achieve the DMC-ODS goals of improving and increasing care coordination for individuals recovering from an alcohol or substance abuse disorder in a treatment facility. AB 848 Page 10 b) Senate Office of Oversight and Outcomes Report. A September 2012 investigative report by the Senate Office of Oversight and Outcomes (SOOO) identified gaps in the Department of Drug and Alcohol Program's (DADP's) regulation of residential programs, including failure to pursue evidence of problems, slow investigative responses to deaths and other serious incidents, and reluctance to use the full spectrum of its statutory powers to shut down programs that pose a danger to the public. The report also documents widespread flouting of the state's prohibition against residential programs providing medical care. The regulation responsibility of these residential programs now lies with DHCS. The report points out that DADP interprets state law to mean that medical professionals who operate in residential treatment settings must maintain a separate relationship with clients and not receive payments from the program. However, SOOO surveyed websites, press releases, and non-profit tax returns, and identified 34 programs that made claims that appeared to violate state law and regulations barring medical care. Additionally, program directors interviewed for the report asserted that they must twist themselves into knots to comply with the state ban while also satisfying insurers and accrediting agencies that often require the involvement of medical professionals. The report notes that California is unusual among populous states in prohibiting medical care in residential treatment programs. SOOO contacted nine other states and found that all but one of them allowed physicians and other medical professionals to work in such settings. Several, according to the report, required the involvement of physicians in programs providing detoxification. AB 848 Page 11 Among the recommendations in the report is for the Legislature to consider approving a bill allowing medical care in residential treatment facilities, given that many experts believe that medical care is an integral part of successful treatment. However, the report adds that it would not be enough to simply lift the ban and the state may have to strengthen other laws and regulations to make sure that medical care is safe and effective, for instance, and address the question of whether the involvement of doctors would violate a law prohibiting the corporate practice of medicine. c) Facility Licensing and Oversight. Prior to July 1, 2013, DADP 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 DHCS. DHCS licenses the facilities and conducts reviews of their operations every two years. As part of the review process, DHCS checks for compliance with a variety of requirements including whether staff has passed tuberculosis tests, that residents have completed health questionnaires and if at least one staff member is certified in first aid and CPR. DHCS investigates complaints against facilities and 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. d) Facility Accreditation. Two national organizations, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Joint Commission on AB 848 Page 12 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 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. 3)SUPPORT. The California Society of Addiction Medicine, (CSAM), cosponsors of this bill, state that passage of this bill will make it clear that physicians may provide appropriate medical services to persons undergoing withdrawal in residential treatment facilities. For many years now, CSAM has been working to resolve the problem in law in which the state licenses residential facilities that treat people addicted to drugs or alcohol, but the licensure requirements do not explicitly allow residential facilities to employ physicians who would provide medical services to a facility's clients. Such a ban precludes facilities from meeting a variety of on-site medical needs of their clients, including emergency care, psychiatric treatment, or medical 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 or hospital emergency departments, which is inefficient and costly. AB 848 Page 13 Janus of Santa Cruz, also cosponsors of this bill, state under current law, DHCS cannot license facilities that provide on-site medical personnel to evaluate or provide medical care to facility clients. This prohibition precludes facilities from meeting clients' medical needs that could easily and efficiently be provided on-site. 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. By failing to allow facilities to have medical personnel on-site, the state reduces the effectiveness of the critical services being provided to people suffering from addiction. Janus of Santa Cruz states that to help ensure that people recovering from addiction remain safe during their stay and to improve their recovery outlook, facilities should be allowed to use medical personnel to provide appropriate on-site physical and mental health services. Janus of Santa Cruz concludes that this bill accomplishes this goal by allowing DHCS to license facilities that use on-site doctors or other approved medical personnel to provide to facility clients incidental medical services related to recovery and addiction. Promises Treatment Centers, also cosponsors of this bill, state that this bill follows the findings of a recent California Senate report that showed the failure to allow appropriate medical treatment of sick patients resulted in greater illness and even death. Promises Treatment Centers concludes that this bill simply seeks to allow licensed physicians to treat these individuals when the situation calls for it while remaining consistent with the state's interest in supporting residential care facilities without jeopardizing the residential nature of such facilities. 4)OPPOSITION. The City of Burbank writes in opposition that this bill will allow regular and ongoing medical treatment and procedures to be administered on site at group homes within AB 848 Page 14 their community. Although the City of Burbank understands the goal of this bill to provide treatment and medical services to the residents of these homes, this would be a fundamental change in the character on scope of activities that would be allowed to take place in our neighborhoods. The City of Burbank has a large concentration of homes and in many areas they have substantially changed the nature and quality of life of our community. Under current law, group homes are supposed to behave and be exactly like any other family residence and that is the rationale for the absence of local control. This bill will fundamentally change the rules of the game by making group homes quasi-residences and medical treatment facilities. There are existing regulations and requirements including local zoning for medical facilities for good reasons. The City of Burbank argues that this bill changes the balance from behaving like every other residence, and thus not meriting local control, to behaving like a quasi-medical/quasi residential structure. 5)PREVIOUS LEGISLATION. a) AB 395 (Fox) of 2013 would have expanded the types of facilities licensed by DADP 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. AB 395 was held on the Senate Appropriations Committee Suspense File. b) AB 972 (Butler and Beall) of 2011 would have expanded, until January 1, 2017, the category of residential treatment facilities licensed by the DADP to include facilities that provide limited medical services to adults recovering from alcohol and drug abuse, provided that the facility is not otherwise required to have a separate AB 848 Page 15 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. AB 972 was held on the Senate Appropriations Committee Suspense File. c) 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 DADP to provide unspecified medical services and would have provided that such a facility would not require a health facility license. AB 2221 was held on the Senate Appropriations Committee Suspense File. d) AB 1055 (Chesbro) of 2009 would have expanded the DADP licensure authority for alcohol and drug treatment facilities to include 24-hour facilities that do not require a health facility license. This bill was held on the Assembly Appropriations Committee suspense file. 6)POLICY COMMENT. Various versions of this bill have been attempted numerous times. This year, this bill is being presented while the state is also adopting a new alcohol and drug treatment system through the DMC-ODS Waiver Amendment. Should the terms of this waiver be approved, the provisions provided for in this bill will be necessary in order to achieve the DMC-ODS goals of improving and increasing care coordination for individuals recovering from an alcohol or substance abuse disorder in a treatment facility. 7)DOUBLE REFERRAL. This bill is double referred; it passed the AB 848 Page 16 Assembly Business and Professions Committee on a vote of 12-2 on April 14, 2015. REGISTERED SUPPORT / OPPOSITION: Support California Society of Addiction Medicine (cosponsor) Elements Behavioral Health (cosponsor) JANUS of Santa Cruz (cosponsor) Alkermes Inc. California Naturopathic Doctors Association California Narcotic Officers' Association County Behavioral Health Directors Association Opposition AB 848 Page 17 City of Burbank Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097