BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 848 --------------------------------------------------------------- |AUTHOR: |Mark Stone | |---------------+-----------------------------------------------| |VERSION: |July 2, 2015 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |July 15, 2015 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Reyes Diaz | --------------------------------------------------------------- SUBJECT : Alcoholism and drug abuse treatment facilities. SUMMARY : Allows alcoholism or drug abuse recovery or treatment facilities licensed by the Department of Health Care Services to provide incidental medical services, as specified, upon receiving a license to provide those services. Requires incidental medical services to be provided by a physician and surgeon or other health care practitioner who are knowledgeable about addiction medicine, as specified. Existing law: 1)Requires the Department of Health Care Services (DHCS) to license nonmedical adult alcoholism or drug abuse recovery or treatment facilities (RTFs), and specifies that a license is valid for two years. 2)Defines an RTF as a facility that provides 24-hour residential, nonmedical 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 an RTF beyond the conditions of the license, and if it does, the RTF is subject to civil penalties, suspension, or revocation of the license. 4)Allows DHCS's director to suspend or revoke any license, or deny an application for licensure, for extension of the licensing period, or to modify the terms and conditions of a license for specified reasons, including repeated violations of licensing laws or misrepresentation of any material fact in obtaining a license. AB 848 (Mark Stone) Page 2 of ? 5)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) within the Department of Consumer Affairs. This bill: 1)Allows RTFs to apply to DHCS to obtain a license to provide "incidental medical services (IMS)." Defines IMS as services, to be specified by DHCS in regulations, to address physical and mental health issues associated with either detoxification from alcohol or drugs or the provision 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 acute care hospital, as specified, or in a medically managed inpatient treatment program. 2)Requires, as a condition of providing IMS, an RTF to obtain from an applicant (a prospective resident) a signed certification from a health care practitioner that includes, but is not limited to, a description of the recovery or treatment services that the applicant needs. 3)Allows RTFs to permit IMS to a resident of the RTF on the premises by one or more independent physicians licensed by MBC or the Osteopathic Medical Board of California (OMBC) who are knowledgeable about addiction medicine, or one or more other health care practitioners acting within the scope of their license and under the direction of a physician, who are also knowledgeable about addiction medicine, when all of the following conditions are met: a) The RTF, in the judgment of DHCS, has the ability to comply with the licensing requirements and provide any level of care between Level 3.1 and Level 3.7 of the American Society of Addiction Medicine (ASAM) criteria; b) The physician and any other health care practitioner has signed and acknowledged on a form provided by DHCS that he or she has been advised of and understands the statutory and regulatory limitations on the IMS services allowed at the RTF; c) There is an agreed-upon written protocol between the physician and the RTF signed by the physician and the RTF that addresses, at a minimum, the respective areas of responsibility of the AB 848 (Mark Stone) Page 3 of ? physician and RTF and the need for communicating and sharing resident information related to IMS services; d) The RTF, in its admission agreement with a resident, clearly identifies the individual financially responsible for IMS and the manner in which those services are billed; e) There is ongoing communication between the physician and RTF about services provided to the resident, and the frequency and duration of IMS to be provided, pursuant to the Confidentiality of Medical Information Act; f) There is initial and ongoing communication between the physician or other health care practitioner and the resident's health plan or health insurer prior to the provision of IMS, to the extent allowable by state and federal privacy and confidentiality laws, to ensure coordination of care; g) The RTF does not interfere with the physician or other health care practitioner providing IMS; h) The RTF resident is authorized by a physician as medically appropriate to received IMS on the premises of the RTF; i) Before a resident received IMS, the resident acknowledges and consents to receiving IMS on a form provided by DHCS. Requires the form, at a minimum, to describe the IMS that the RTF may permit to be provided and states that the permitted IMS will be provided by a physician or other health care practitioner working under the direction of a physician; j) Once IMS are initiated for a resident, the physician continuously monitors the resident to ensure that the resident remains appropriate to receive IMS. Requires, if the physician determines a change in the resident's medical or psychiatric condition requires other medical or psychiatric services or a higher level of care than what an RTF may provide, the physician to immediately notify the RTF and to assist the RTF in initiating emergency care, urgent care, or other higher level of care, as appropriate. Requires an RTF to notify a physician or DHCS when the RTF believes a resident requires a higher level of care; aa) The RTF maintains in its files the physician's license or other written evidence of licensure to practice medicine in the state; and, AB 848 (Mark Stone) Page 4 of ? bb) The physician and RTF comply with DHCS's regulations for providing IMS 4)Requires an RTF to report to DHCS in a timely manner any violation of regulations related to IMS or the signed protocol. Requires DHCS to specify in regulations, at a minimum, the steps required to be taken when DHCS substantiates this information provided by the RTF. 5)Specifies that DHCS is not responsible for evaluating and does not have liability with respect to evaluating IMS. 6)Specifies that an RTF providing IMS is not considered a clinic or health facility, as specified. 7)Specifies that a license to provide IMS does not authorize an RTF to provide on the premises any medical or health care services or any other services that require a higher level of care than what the RTF can provide. 8)Requires an RTF that intends to apply to provide IMS to submit a copy of the written protocol, evidence of a physician's license who will provide the services, and any other information DHCS deems appropriate, including, but not limited to, a copy of the RTF's accreditation by a nationally recognized accrediting organization. 9)Requires DHCS to establish and collect an additional licensure fee for an RTF that includes a request to provide detoxification services or IMS. Requires the fee to be in an amount sufficient to cover DHCS's reasonable costs of regulating detoxification services and IMS. 10)Broadens DHCS's director's authority to suspend or revoke a license, or deny an application for licensure, extension of licensure period, or to modify the terms and conditions of a license to include the following: a) An RTF providing false information or documentation to DHCS; b) An RTF's refusal to allow DHCS to enter an RTF to determine compliance with licensing laws; and c) Violation by the RTF of any IMS regulations adopted by DHCS. AB 848 (Mark Stone) Page 5 of ? 11)Requires DHCS to adopt regulations to implement the provisions of this bill on or before July 1, 2017, and allows DHCS to implement, interpret, or make specific these provisions by means of provider bulletins, written guidelines, or similar instructions until regulations are adopted. FISCAL EFFECT : According to the Assembly Appropriations Committee: 1)Costs to adopt regulations, likely in the range of $200,000 over two years (licensing fees and Substance Abuse Prevention and Treatment Block Grant). 2)Unknown ongoing costs to oversee this new requirement as a component of licensure, possibly in the range of $100,000 annually (licensing fees). PRIOR VOTES : ----------------------------------------------------------------- |Assembly Floor: |74 - 3 | |------------------------------------+----------------------------| |Assembly Appropriations Committee: |12 - 0 | |------------------------------------+----------------------------| |Assembly Business and Professions |12 - 2 | |Committee: | | ----------------------------------------------------------------- COMMENTS : 1)Author's statement. According to the author, many patients seeking treatment at RTFs have physical and mental health needs related to their addictions when they arrive at these facilities, yet the state has barred RTFs from having medical personnel onsite to provide medical treatment related to addiction. Facility staff may provide basic first aid or emergency care, but these are the only exceptions to medical care. Instead, patients who have medical needs related to their addictions must be transported to a doctor's office or health care facility to receive care. This requirement to transport patients who could receive care in their RTFs is burdensome to patients, facilities, and physicians alike. RTFs should be able to provide the best possible care for AB 848 (Mark Stone) Page 6 of ? vulnerable people struggling to overcome addictions. Sometimes, the best possible care can include medical treatment related to addiction and recovery if that care has been determined in the view of a physician to be able to be provided onsite rather than in a health care facility. By allowing such care to be provided onsite, AB 848 allows thousands of vulnerable people to recover from addiction safely. 2)Background. RTFs licensed by DHCS, based on what is commonly referred to as the social model, are currently allowed to provide recovery, treatment, and detoxification services. (The Department of Public Health licenses medical model RTFs known as chemical dependency recovery hospitals.) Social model RTFs range in size from six-bed facilities in residential neighborhoods to centers that accommodate hundreds of beds. According to DHCS, there are 298 licensed social model RTFs that serve six or fewer people, and the largest RTF that DHCS licenses has a capacity of 309 beds. The services provided by these RTFs include group and individual counseling, educational sessions, and alcoholism or drug abuse recovery and treatment planning. Social model RTFs are allowed to provide clients first aid and emergency care. However, if a resident needs medical care (defined by DHCS as a service provided by a professional required to hold a professional license from the MBC, the OMBC, the Board of Registered Nursing, etc.), the resident must be referred to the proper facility to receive care from a medical professional, and the resident must pay the medical professional directly for services. According to the MBC and DHCS, nothing in current law prohibits a medical professional from conducting a house call at an RTF for a resident. MBC also states that social model RTFs can contract with a physician or a physician group to provide medical services, as long as the RTF contracts with, not employs, the medical professional. The contract also should contain language that makes it clear that the RTF cannot interfere with, control, or otherwise direct the medical professional and that the medical professional has decision-making authority. The contract should also specify AB 848 (Mark Stone) Page 7 of ? that the medical professional is paid a flat or hourly fee, not fees based on the kinds or amounts of services provided. 3)Facility Licensing and Oversight. Prior to July 1, 2013, the Department of Alcohol and Drug Programs (ADP) was responsible for oversight of RTFs. 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. As part of their licensing function, DHCS conducts reviews of social model RTF operations every two years, or as necessary. 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 prior to admission at an RTF, and if at least one staff member is certified in first aid and CPR. DHCS's Substance Use Disorder (SUD) Compliance Division investigates all complaints related to social model RTFs, including deaths, complaints against staff, and allegations of operating without a license. The SUD Compliance Division also investigates violations of the code of conduct of registered or certified alcohol and drug counselors. Additionally, RTFs licensed by DHCS are required to report counselor misconduct to DHCS within 24 hours of the violation. RTFs that do not comply with existing requirements are subject to civil penalties and license suspension or revocation. 4)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 privacy, AB 848 (Mark Stone) Page 8 of ? 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. 5)Reports about RTFs. 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 ADP's regulation of residential programs, as well as a review of the state's ban on medical care at RTFs. SOOO advised that state law be changed to better reflect current treatment practices and stated that there is a mismatch between ADP's regulation and the industry's prevalent practices. SOOO recommended lifting the ban on medical care as long as it is accompanied with more extensive oversight. An article published in Mother Jones in the May/June 2015 issue, "The Rehab Racket: The Way We Treat Addiction is a Costly, Dangerous Mess," written by the same author of the SOOO report, notes that deaths sometimes occur at RTFs not just because of the effects caused by a person's addiction but also from the treatment they receive at the RTF. The article cites a case at one RTF in California where a physician, who had been repeatedly investigated by and had several actions taken against his license over several years by the MBC, excessively prescribed medications to residents of the RTF with no regard for their health or safety, and despite the physician's history, he was allowed to continue to treat residents of the RTF. The article points out that the vast majority of people in need of treatment do not receive anything that approximates evidence-based care. The article further notes that while 18.7 million Americans needed alcohol treatment in 2010 only 1.7 million (or 8.8%) received it in specialized facilities. Issues that compound the problem include: a) out of 14,148 addiction treatment facilities in the U.S., only 26% are RTFs; b) only 15% of costs of addiction treatment are covered by private insurance (treatment can range from $1,800 a month at a government-subsidized RTF to $60,000 a month at an RTF that treats celebrities and other high-profile clients); and c) for every federal and state government dollar spent, 95.6 cents went to pay for consequences of substance abuse while only 1.9 cents were spent on any type of prevention or treatment. AB 848 (Mark Stone) Page 9 of ? 6)Other States. As part of its investigation, SOOO contacted nine other highly populous states and found that California is unusual in prohibiting medical care at social model RTFs. Eight of the nine states (IL, IN, NY, NC, OH, PA, TX, and WA) allowed physicians and other medical professionals to work in social model RTFs. One state, MA, refers RTF clients to local doctors, but nurses are available at the RTFs. 7)Prior legislation. AB 395 (Fox, 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. AB 395 died on the Senate Appropriations Committee suspense file. AB 972 (Butler and Beall, 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 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. AB 972 was held in the Senate Appropriations Committee. AB 2221 (Beall, 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. AB 2221 died on the Senate Appropriations Committee suspense file. AB 1055 (Chesbro, 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. AB 1055 died on the Assembly Appropriations Committee suspense file. 8)Support. The cosponsors and other supporters, comprised of RTFs and behavioral health advocates, argue that for too long the RTF licensing authority has prohibited RTFs from having onsite medical personnel to evaluate or provide medical care AB 848 (Mark Stone) Page 10 of ? to residents, which precludes RTFs from meeting residents' medical needs that could easily and efficiently be provided onsite. Supporters further argue that, currently, residents who need medical care have to be transported to a doctor's office or emergency room, which is inefficient, costly, and sometimes dangerous, and also disrupts a resident's recovery efforts. 9) Technical amendments. a) This bill provides that DHCS is not responsible for evaluating and does not have liability with respect to evaluating IMS. Although the bill does require a facility that opts to provide IMS to provide DHCS proof of accreditation by a nationally recognized accrediting organization, it is not clear who the entity responsible for evaluating the IMS provided at an RTF will be. The author may wish to clarify who the responsible entity for evaluating the IMS will be. b) This bill requires DHCS to establish an additional fee for RTFs that provide detoxification services and IMS. However, RTFs are already allowed to provide detoxification services. The author may wish to clarify if the intent it so establish an additional fee for a service that is already allowed. c) This bill references the American Society of Addiction Medicine by acronym only (ASAM). For clarity, the author may wish to amend to spell out ASAM where it is referenced. SUPPORT AND OPPOSITION : Support: California Society of Addiction Medicine (co-sponsor) Elements of Behavioral Health/Promises Treatment Centers (co-sponsor) Janus of Santa Cruz (co-sponsor) Alkermes, Inc. California Narcotic Officers' Association County Behavioral Health Directors Association of California San Francisco Department of Public Health Oppose: None received. AB 848 (Mark Stone) Page 11 of ? -- END --