BILL ANALYSIS Ó
AB 859
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Date of Hearing: May 13, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
AB
859 (Medina) - As Amended April 30, 2015
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill requires the Department of Health Care Services (DHCS)
to create an Obesity Treatment Action Plan (plan) to diagnose,
treat, and reduce the incidence of adult obesity in Medi-Cal
fee-for-service payment plans, and report the plan and
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recommendations to the Legislature, as specified. Specifically,
this bill:
1)Requires DHCS to create the plan by December 31, 2016 and
specifies required components.
2)Requires the plan to include evidence-based principles and
obesity treatment guidelines from five specified provider
associations.
3)Contains findings, including that obesity is a chronic disease
and is the only chronic disease for which Americans face
prohibitions on access to treatment, and that treatment should
be able to include medications, behavioral therapy, and
surgery as well as lifestyle changes.
FISCAL EFFECT:
1)Costs to DHCS in the low hundreds of thousands of dollars
(GF/federal) to conduct a review of current treatment options,
to assess and recommend additional obesity treatment services,
and to develop a plan for provider and patient outreach.
2)Unknown, significant cost pressure (GF/federal) for additional
coverage of treatments based on treatment guidelines developed
by the outside provider organizations specified in the bill.
It is unclear how coverage standards might change because of
this reliance on specified provider groups to define treatment
guidelines.
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COMMENTS:
1)Purpose. This bill is intended to expand treatments for
obesity. The author contends that Medi-Cal's coverage for
obesity treatments is inadequate. The author points to DHCS
studies that have shown the proportion of adults with obesity
is highest among adults enrolled in Medi-Cal, with rates
higher than individuals in the privately insured market and
the uninsured population. The author concludes this bill will
provide a plan to diminish obesity as an epidemic in
California, will improve state health, and ensure long-term
savings of taxpayer dollars.
2)Obesity. Approximately 61% of Californians are overweight, and
24% are obese. According to the World Health Organization
(WHO), obesity is largely preventable and is caused by an
energy imbalance between calories consumed and calories
expended. The WHO points to an increased intake of
energy-dense foods and an increase in physical inactivity
associated with development due to the increasingly sedentary
nature of many forms of work, changing modes of
transportation, and increasing urbanization. Obesity is a
multifaceted condition with social, economic, environmental,
and behavioral dimensions. There is widespread agreement in
the public health community that an "obesogenic" environment,
which influences food and activity choices people make, bears
much responsibility for the rapid rise in excess body weight
over the last several decades.
3)"Medicalization" of Obesity. In 2013, The American Medical
Association's House of Delegates approved a measure to label
obesity a disease. This designation was not without
controversy and continues to be controversial. The delegates
overruled their own Council on Science and Public Health in
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voting for the measure. The council's review noted the lack of
a clear definition of what constitutes a disease and whether
obesity would fit in this definition, as well as the lack of
reliable diagnostic test. The council also cited concern about
the medicalization of obesity detracting from collective
social solutions to environmental factors that shape people's
behaviors and impact a number of conditions besides obesity.
4)Obesity Treatment. According to the National Institutes of
Health, successful weight-loss treatments include setting
goals and making lifestyle changes, such as eating fewer
calories and being physically active. Medicines and
weight-loss surgery also are options for some people, if
lifestyle changes aren't enough. According to the Mayo Clinic,
increasing energy output and reducing caloric intake is
required in addition to any drug or surgical treatment in
order for the treatment to be successful.
5)Support. This bill's sponsor, Obesity Action Coalition, an
obesity advocacy organization that receives substantial
financial support from pharmaceutical and surgical industries
with interest in the coverage of obesity drugs and surgery,
states obesity is a chronic disease affecting nearly one in
three Americans, and that this bill will highlight gaps in
treatment that need to be addressed. The bill is supported by
biotechnology companies; the California chapter of the
American Society of Metabolic and Bariatric Surgery; the
Obesity Care Continuum, which includes the sponsor, bariatric
surgeons, and other groups; and California Communities United
Institute.
6)Staff Comments.
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a) Clarity of Duties. Staff suggests this bill, at a
minimum, be clarified to better define terms and the
responsibilities of DHCS. The bill requires DHCS to create
an action plan to diagnose, treat, and reduce the incidence
of obesity. It then requires the plan to include "evidence
based principles and treatment guidelines." Finally, it
requires the plan to include: a plan for educating
fee-for-service physicians about obesity screening and
treatment, a plan for screening patients, a review of
current coverage, and recommendations "with evidence-based
rationale on the continuum of coverage of additional
obesity treatment services, including nutritional,
exercise, and lifestyle counseling and pharmacotherapy."
a. Staff suggests removing references to the
"continuum of coverage" unless this term is defined.
b. It is unclear what evidence-based principles
must be included. Does the term "evidence-based'
apply to the treatment guidelines? Are treatment
guidelines from all five referenced societies
necessarily evidence-based? This should be clarified.
c. DHCS is primarily a payer for health care
services. DHCS does not have a direct relationship
with patients nor management of provider offices,
making it ill-suited to developing a plan to identify
and screen patients.
b) Too prescriptive. Furthermore, the prescriptive nature
of the language presupposes what types of coverage are
needed, and does not defer to DHCS to define this based on
their review of medical evidence and sound management of
the Medi-Cal program. Indeed, it does not even defer to
DHCS to choose which professional guidelines are relevant.
It instead requires the inclusion of treatment guidelines
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developed by several specific groups detailed in statute
and lists what services should be covered. This poses
unknown fiscal risk. The bill would benefit from removing
the references to "nutritional, exercise, and lifestyle
counseling and pharmacotherapy" and the professional
societies, and instead require DHCS to report on coverage
and treatment available through the Medi-Cal program as
compared to other state's Medicaid programs and commercial
coverage, including indications for treatment and
restrictions on treatment, as well as compared to
evidence-based clinical guidelines and best practices.
c) Medical focus on a complex issue. Finally, this bill
focuses on medical treatment for obesity and ignores the
social and environmental root causes of obesity many
leading public health groups like the WHO have identified.
According to the Mayo Clinic, even medical treatment for
obesity is unsuccessful without lifestyle changes to reduce
caloric intake or expend additional energy. The bill
addresses a very small aspect of a very big issue. It is
silent on how treatment for obesity potentially interacts
with the well-documented social, environmental, behavioral,
and economic aspects of the obesity epidemic that are both
at the core of the issue and pose risks for successful
treatment. The author may wish to consider how this bill
fits into the overall context of the state's efforts to
address obesity.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081
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