BILL ANALYSIS                                                                                                                                                                                                    Ó






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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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