BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1117
---------------------------------------------------------------
|AUTHOR: |Cristina Garcia |
|---------------+-----------------------------------------------|
|VERSION: |June 1, 2015 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |July 1, 2015 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Scott Bain |
---------------------------------------------------------------
SUBJECT : Medi-Cal: vaccination rates.
SUMMARY : Requires the Department of Health Care Services (DHCS) to
establish and administer the California Childhood Immunization
Quality Improvement Fund (CCIQIF) program to improve childhood
immunization rates as a waiver or demonstration project.
Requires DHCS to allocate 33% of CCIQIF expenditures for use by
DHCS for administrative staff, training, and other resources to
support providers in employing strategies to improve
immunization rates in their practices, and 66.7% of CCIQIF
expenditures for $125 reward payments to Medi-Cal managed care
plans for each enrollee who receives all recommended
vaccinations by the time he or she reaches two years of age.
Sunsets this bill on the date that the DHCS director executes a
declaration stating that the demonstration project has
concluded.
Existing law:
1)Establishes the Medi-Cal program, which is administered by
DHCS, under which qualified low-income individuals receive
health care services. Children up to age 19 are eligible for
Medi-Cal in families with incomes up to 266% of the federal
poverty level (at or below $52,641 annually for a family of 3
in 2015).
2)Provides, under federal Medicaid law, coverage of "early and
periodic screening, diagnostic, and treatment services"
(EPSDT) for individuals under age 21, which includes coverage
for pediatric vaccines.
3)Requires DHCS to pay capitation rates to Medi-Cal managed care
plans using actuarial methods. Permits DHCS to establish
health-plan- and county-specific rates, and permits DHCS to
pay plans based on performance incentives, including quality
AB 1117 (Cristina Garcia) Page 2 of ?
indicators, access to care, and data submission.
This bill:
1)Requires DHCS to establish and administer the CCIQIF program
to improve childhood immunization rates.
2)Requires DHCS to submit an application to the federal Centers
for Medicare and Medicaid Services (CMS) for a waiver or
demonstration project to implement the CCIQIF program no later
than 270 days after the operative date of this bill. Requires
DHCS to determine the form of waiver most appropriate to
achieve the purposes of this bill. Requires the demonstration
project to operate for a period of five years.
3)Requires DHCS to develop a plan for the collection and
expenditure of CCIQIF moneys according to all of the following
guidelines:
a) Permits the CCIQIF program to be financed through
voluntary contributions from Medi-Cal managed care plans,
which are required to be used to draw down federal
financial participation (FFP) consistent with federal
law;
b) Requires DHCS to allocate 33.3% of CCIQIF
expenditures for use by DHCS for administrative staff,
training, and other resources to support providers in
employing strategies to improve immunization rates in
their practices, which may include patient reminders,
promotion of colocation vaccination delivery with other
services, and other strategies as specified. Requires the
funds to also be used to pay for DHCS staffing and
administrative costs directly attributable to
implementing this bill, including costs related to
developing and seeking federal approval for the CCIQIF
and administering the fund ;
c) Requires DHCS to allocate 66.7% of CCIQIF
expenditures for reward payments to Medi-Cal managed care
plans. Requires the rate of the reward to be $125 for
each enrollee who receives all recommended vaccinations
by the time he or she reaches two years of age, as
determined by the Childhood Immunization Status measure
of the Healthcare Effectiveness Data and Information Set
(HEDIS);
AB 1117 (Cristina Garcia) Page 3 of ?
d) Requires at least 20% of the 66.7% of CCIQIF
expenditures to be used for reward payments to be passed
through to contracted providers based on the number of
Medi-Cal enrollees who are under two years of age in each
provider's respective panel.
e) Requires any unearned reward payment expenditures to
roll over to the subsequent demonstration project year.
Requires, if all reward payment expenditures are earned
within a demonstration project year, no additional reward
payments to be distributed until the next demonstration
project year begins; and,
4)Requires DHCS, in developing the waiver or demonstration
project application, to consult with interested stakeholders,
including the Medi-Cal Children's Health Advisory Panel and
the Managed Care Advisory Workgroup, and to work with
stakeholders to incorporate public comment into the waiver or
demonstration project application.
5)Requires DHCS to contract with the University of California or
any other researchers to develop and submit to the Legislature
an evaluation of the effectiveness of the demonstration
project using data collected from the first three years of the
waiver period or demonstration project. Requires the
evaluation to be submitted within the fourth year of the
waiver period or demonstration project. Requires the
evaluation, at a minimum, to include an assessment of the most
effective administrative support strategies.
6)Requires the evaluation to be financed with no more than five
percent of the total annual CCIQIF program expenditure dollars
from the 66.7% of CCIFQI expenditures. Requires CCIQIF
provider support expenditures to be reduced, commensurate with
available funds, to offset the cost of the evaluation contract
during the waiver or demonstration project year that the
evaluation is commissioned.
7)Requires this bill to be implemented only if and to the extent
that FFP is available and any necessary federal approvals have
been obtained.
8)Sunsets this bill on the date that the Director of DHCS
executes a declaration stating that the demonstration project
AB 1117 (Cristina Garcia) Page 4 of ?
has concluded, and repeals this bill six months after the date
the declaration is executed.
9)Makes legislative findings and declarations regarding
vaccine-preventable diseases, vaccine rates for California
children between the ages of 19 to 35 months as compared to
national rates, the number of two-year olds who are not fully
immunized, the social and economic costs of ensuring each
child receives the recommended schedule of vaccines. States
legislative intent in implementing this bill to ensure that
all possible steps are taken to ensure that two-year-old
children who are enrolled in Medi-Cal managed care receive all
recommended immunizations.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)DHCS would incur costs in the range of low hundreds of
thousands of dollars (program revenues/federal funds), to
develop and seek federal approval for a program. The annual
administrative costs would be of a similar magnitude.
2)It is unclear precisely how much funding would be raised. A
successful incentive program could be about $30 million per
year (program revenues/federal funds), with $10 million
allocated to provider support.
PRIOR
VOTES :
-----------------------------------------------------------------
|Assembly Floor: |65 - 12 |
|------------------------------------+----------------------------|
|Assembly Appropriations Committee: |13 - 1 |
|------------------------------------+----------------------------|
|Assembly Health Committee: |18 - 0 |
| | |
-----------------------------------------------------------------
COMMENTS :
1)Author's statement. According to the author, Medi-Cal health
plans and providers need greater investments and supports to
provide the quality health care services that they are
AB 1117 (Cristina Garcia) Page 5 of ?
required to deliver to young children and that parents and
taxpayers deserve. This bill would bring additional resources
to the health care system to help improve California's
relatively low vaccination rates for 2-year-olds, without
impacting parents' ability to make decisions about their
children's health care.
2)Background. Of the 12.4 million individuals expected to enroll
in Medi-Cal in 2015-16, approximately 76% will be enrolled in
Medi-Cal managed care plans. DHCS contracts with 23
full-service Medi-Cal managed care plans to provide health
care services to Medi-Cal enrollees. Roughly half of
California children are enrolled in Medi-Cal, including
644,927 Medi-Cal managed care plan members 2 years of age or
younger as of January 1, 2015.
CMS requires states, through their contracts with managed care
plans, to measure and report on performance to assess the
quality and appropriateness of care and services provided to
members. DHCS implemented a monitoring system to provide an
objective, comparative review of Medi-Cal managed care plans
quality-of-care outcomes and performance measures called the
External Accountability Set (EAS). DHCS designates performance
measures annually, and requires Medi-Cal managed care plans to
report on them.
The DHCS 2013 EAS for the Medi-Cal managed care plans consisted
of 15 performance measures with 32 distinct indicators
providing information on access to care for women,
adolescents, and children; use of imaging studies for low back
pain; screening for diseases such as cervical cancer; weight
assessment and counseling for nutrition and physical activity
for children and adolescents; care provided to members with
chronic diseases such as diabetes; hospital readmissions
rates; and utilization of outpatient and emergency department
care. DHCS based all selected performance measures for
Medi-Cal on HEDIS, with the exception of an internally
developed measure (All-Cause Readmissions).
3)Immunization Rates by Plans/Regions. The HEDIS data set is a
nationally recognized and standardized set of performance
measures used by consumers, employers, government agencies,
legislators, advocates, and potential purchasers to assess the
quality of care provided within a managed care plan's
Medicare, Medicaid, and commercial lines of business. One of
AB 1117 (Cristina Garcia) Page 6 of ?
the HEDIS measures used to assess Medi-Cal managed care plans
is childhood immunization status for children under age two.
That measure calculates the percentage of children identified
as having the following vaccinations: four diphtheria,
tetanus, and pertussis (DTaP); three inactivated poliovirus
(IPV); one measles, mumps, and rubella (MMR); three
Haemophilus influenza type B (HiB); three hepatitis B; one
varicella -zoster virus (chicken pox or VZV); and four
pneumococcal conjugate vaccinations on or before the child's
second birthday.
The Medi-Cal managed care weighted average vaccination rate
was 78.2% in 2012 and 77.25% in 2013. In measuring plan
performance, Medi-Cal compares plans by region, so a plan that
is in multiple regions receives a rate for each region (for
example, Blue Cross is in 9 regions). In the 2013 rating,
seven plan rates were above the high performance level in 2013
(the high performance level is HEDIS 2012 national Medicaid
90th percentile) with vaccination rates above 82.84%. Four
rates scored below the minimum performance level in 2012 (the
minimum performance level is HEDIS 2012 national Medicaid 25th
percentile) or a vaccination rate below 64.72%. National HEDIS
figures for 2010-12 are as follows:
2010
2011 2012
National Medicaid Average 69.40%
69.90% 70.64%
National Commercial Average 73.40%
75.10% 75.66%
4)Pay-for-Performance in Medi-Cal. DHCS has the authority under
existing law to implement pay-for-performance in Medi-Cal
managed care, but does not currently pay quality bonuses or
otherwise have a pay-for-performance program for Medi-Cal
managed care plans, with the exception of quality withholds
for payments to Medi-Cal plans participating in the
CalMediConnect demonstration pilot program for individuals
dually eligible for Medicare and Medi-Cal. DHCS also does not
provide incentive payments to outpatient health care providers
AB 1117 (Cristina Garcia) Page 7 of ?
in fee-for-service Medi-Cal for achieving quality benchmarks.
DHCS does use plan performance to determine assignment rate of
Medi-Cal beneficiaries who are required to enroll in a managed
care plan but who do not affirmatively choose a plan (referred
to as "auto assignment"). Auto assignment is based in part on
plan performance on HEDIS measures and utilization of safety
net providers in a plan's network (specifically, the
percentage of hospital discharges at a disproportionate share
hospital for members residing within the county, and the
percentage of members assigned to primary care providers who
are safety net providers). As part of the state's Section 1115
waiver renewal, DHCS is proposing to include
pay-for-performance with its contracting health plans.
5)Related legislation. SB 277 (Pan and Allen), eliminates the
personal belief exemption from the requirement that children
receive specified vaccines for certain infectious diseases
prior to being admitted to any public or private elementary or
secondary school or day care center. SB 277 passed the
Assembly Floor on June 25, 2015.
6)Support. This bill is sponsored by Children NOW to provide
Medi-Cal health plans and health care providers with greater
investments and supports to provide the quality health care
services that they are required to deliver to young children
and that parents and taxpayers deserve. Children NOW argues
this bill would bring additional resources to the health care
system to help improve California's relatively low vaccination
rates for 2-year-olds, without impacting parents' ability to
make decisions about their children's health care. Children
NOW states vaccination rates for kids are not as high as they
need to be, posing a risk for all children, as demonstrated by
the 11,000+ cases of whooping cough in California in 2014 and
the more recent measles outbreak. Children NOW states the
social and direct economic costs of ensuring each child
receives the CDC Advisory Committee for Immunization
Practices' recommended schedule of vaccines far outweighs the
costs of not providing routine immunizations, as it is
estimated that for every $1 spent on immunizations, as much as
$29 can be saved in direct and indirect costs. Children NOW
concludes this bill is similar to successful programs in other
states to improve quality (in New York, Louisiana, and Maine),
and would improve preventive care delivery for California
AB 1117 (Cristina Garcia) Page 8 of ?
children enrolled in Medi-Cal.
7)Policy Questions:
a) What HEDIS measures should be used for
pay-for-performance? HEDIS is a standardized set of
performance measures used to provide health care
purchasers, consumers, and others with a reliable
comparison among health plans. The author indicates
childhood immunizations should be the basis for reward
payments because (1) childhood immunization is an area that
has been consistently identified for improvement based on
analysis of quality/HEDIS data by DHCS; (2) the low
childhood immunization rates are an underlying risk and
liability to the public health of the state, as experienced
by recent measles and whooping cough outbreaks; and (3)
incentives to better deliver childhood immunizations create
a motivation for health plans and providers and result in
better value for state health care dollars expended.
There is considerable variation in health plan performance on
a variety of HEDIS measures, and more variation on some
measures than there currently is for 2 year old vaccination
rates (the variation for child vaccination rates is 87.91%
to 54.6%). For example, weight assessment and counseling
for physical activity for children/adolescents varies from
94.11% to 30.41%, adolescent vaccinations vary from 89% to
51.46%, and medication management compliance for people
with asthma varies from 79.80% to 31.72%. If DHCS is going
to implement pay-for-performance in Medi-Cal managed care,
should immunization rates for children under age 2 be the
measure chosen? Should only one of the multiple HEDIS
performance measures be used in pay-for-performance?
b) Incentive payment amount. The incentive payment under
this bill is $125 for each enrollee who receives all
recommended vaccinations by the time he or she reaches age
two. The author's office indicates this reward amount was
arrived at based on experiences in other states proven to
change provider and plan behavior. The author indicated
they mocked up different amounts, and $125 was the amount
AB 1117 (Cristina Garcia) Page 9 of ?
that rewarded plans with better vaccination rates. To
provide a reward that is likely to change behavior, plans
and providers have to be paid more than they are currently.
However, the $125 amount is more than the monthly rate
plans are paid to cover children in Medi-Cal (referred to
as the "child only" rate). Is $125 the appropriate
incentive payment amount?
c) Can nongovernmental entities make voluntary
contributions to draw down federal Medicaid matching funds?
This bill authorizes the CCIQIF program to be financed
through voluntary contributions from Medi-Cal managed care
plans, which are required to be used to draw down FFP
consistent with federal law. Non-public voluntary
contributions can be matched with federal Medicaid funds
only to the extent that such contributions are considered
"bona fide provider-related donations." Contributions from
Medi-Cal managed care plans would be considered
provider-related. However, a donation is not considered
bona fide when it involves a hold harmless provision or
practice under which donations are returned in full or in
part to the provider. Donations occurring under these
conditions will not be approved by CMS for federal matching
funds. It is not clear if provider donations made by plans
under this bill would be eligible for FFP or if the
programs implemented in other states have relied on a
similar financing mechanism.
SUPPORT AND OPPOSITION :
Support: Children Now (sponsor)
American Academy of Pediatrics, California
American Federation of State, County and Municipal
Employees, AFL-CIO
California Academy of Family Physicians
California Children's Hospital Association
California Coverage and Health Initiatives
California Medical Association
California Pan-Ethnic Health Network
Children's Defense Fund California
Children's Specialty Care Coalition
Family Voices of California
First 5 Alameda County
First 5 Association of California
AB 1117 (Cristina Garcia) Page 10 of ?
First 5 Santa Cruz County
Los Angeles Trust for Children's Health
March of Dimes California Chapter
St. John's Well Child and Family Center
The Children's Partnership
United Ways of California
Vision y Compromiso
Oppose: None received
-- END --