BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 848|
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THIRD READING
Bill No: AB 848
Author: Mark Stone (D)
Amended: 8/31/15 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-1, 7/15/15
AYES: Hernandez, Hall, Mitchell, Monning, Nielsen, Pan, Roth,
Wolk
NOES: Nguyen
SENATE APPROPRIATIONS COMMITTEE: 6-1, 8/27/15
AYES: Lara, Beall, Hill, Leyva, Mendoza, Nielsen
NOES: Bates
ASSEMBLY FLOOR: 74-3, 6/3/15 - See last page for vote
SUBJECT: Alcoholism and drug abuse treatment facilities
SOURCE: California Society of Addiction Medicine
Elements of Behavioral Health/Promises Treatment
Centers
Janus of Santa Cruz
DIGEST: This bill 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. This bill
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.
ANALYSIS:
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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.
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
that are in compliance with the community standard of
practice and are not required to be performed in a licensed
clinic or licensed health facility, as specified. Specifies
that IMS includes obtaining medical histories, monitoring
health status, overseeing patient self-administration of
medications, and other services to be further defined by DHCS
by regulation.
2) Requires, as a condition of providing IMS, an RTF to obtain
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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 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 or supervision 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;
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) The RTF resident is authorized by a physician as
medically appropriate to received IMS on the premises of
the RTF;
d) Before a resident received IMS, the resident signs an
admission agreement to receive IMS. Requires the admission
agreement, 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, or under the supervision of, a
physician or other health care practitioner working under
the direction of a physician;
e) Once IMS are initiated for a resident, the physician
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 condition
requires other medical 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; and
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f) The RTF maintains in its files the physician's license
or other written evidence of licensure to practice
medicine in the state.
1) Specifies that DHCS is not responsible for evaluating and
does not have liability with respect to evaluating IMS.
2) Specifies that an RTF providing IMS is not deemed a clinic
or health facility, as specified.
3) 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.
4) Requires an RTF that intends to apply to provide IMS to
submit evidence of a physician's license who will provide the
services, and any other information DHCS deems appropriate.
5) Requires DHCS to establish and collect an additional
licensure fee for an RTF that includes a request to provide
IMS. Requires the fee to be in an amount sufficient to cover
DHCS's reasonable costs related to IMS, including processing
applications, issuing licenses, and investigating reports of
noncompliance with licensing regulations.
6) Broadens DHCS's director's authority to suspend or revoke a
license, or deny an application for licensure, extension of
licensure period, or modify a license to include, but not
limited to, 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.
7) Requires DHCS to adopt regulations to implement the
provisions of this bill on or before July 1, 2018, and allows
DHCS to implement, interpret, or make specific these
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provisions by means of provider bulletins, written
guidelines, or similar instructions until regulations are
adopted.
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 that
the medical professional is paid a flat or hourly fee, not fees
based on the kinds or amounts of services provided.
Comments
1)Author's statement. According to the author, many patients
seeking treatment at RTFs have physical and mental health
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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
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)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.
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3)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.
4)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.
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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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
One-time costs of about $550,000 to develop program
requirements and adopt regulations by DHCS (General Fund).
Ongoing costs of about $550,000 per year to perform ongoing
licensing, inspection, and enforcement activities relating to
facilities licensed to provide IMS by DHCS, offset by fee
revenues (Residential and Outpatient Program Licensing Fund).
Unknown additional legal costs relating to future enforcement
actions that may result in appeals or litigation (Residential
and Outpatient Program Licensing Fund). DHCS has indicated
that there could be significant additional legal costs due to
enforcement activity and the complexities of determining
appropriate medical care for residents. Whether or not such
costs will occur is not known at this time.
SUPPORT: (Verified8/28/15)
California Society of Addiction Medicine (co-source)
Elements of Behavioral Health/Promises Treatment Centers
(co-source)
Janus of Santa Cruz (co-source)
Alkermes, Inc.
California Narcotic Officers' Association
California Naturopathic Doctors Association
CalNet
County Behavioral Health Directors Association of California
San Francisco Department of Public Health
OPPOSITION: (Verified8/28/15)
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City of Long Beach
ARGUMENTS IN 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 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.
ARGUMENTS IN OPPOSITION: The City of Long Beach writes to
oppose allowing medical treatment in residential neighborhoods
on a routine basis. The City argues that medical treatment
should be performed in areas of the city that are zoned and
permitted for medical facilities-not in local neighborhoods.
ASSEMBLY FLOOR: 74-3, 6/3/15
AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom,
Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang,
Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle,
Daly, Dodd, Eggman, Frazier, Beth Gaines, Cristina Garcia,
Eduardo Garcia, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove,
Hadley, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer,
Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,
McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon,
Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark
Stone, Ting, Wagner, Waldron, Weber, Williams, Wood, Atkins
NOES: Gallagher, Gatto, Wilk
NO VOTE RECORDED: Harper, Mayes, Thurmond
Prepared by:Reyes Diaz / HEALTH /
8/31/15 11:43:35
**** END ****
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