BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 848
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|AUTHOR: |Mark Stone |
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|VERSION: |July 2, 2015 |
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|HEARING DATE: |July 15, 2015 | | |
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|CONSULTANT: |Reyes Diaz |
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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 :
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|Assembly Floor: |74 - 3 |
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|Assembly Appropriations Committee: |12 - 0 |
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|Assembly Business and Professions |12 - 2 |
|Committee: | |
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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 ?
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