BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                    AB 1177


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          Date of Hearing:  April 21, 2015


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


          AB 1177  
          (Gomez) - As Introduced February 27, 2015


          SUBJECT:  Primary care clinics:  written transfer agreements


          SUMMARY:  Requires the Department of Public Health (DPH) to  
          repeal the regulation requiring primary care clinics to enter  
          into a written transfer agreement with a nearby hospital as a  
          condition of licensure, no later than July 1, 2016.  


          EXISTING STATE LAW:


          1)Licenses and regulates clinics, including primary care clinics  
            and specialty clinics, such as surgical clinics, by DPH. 

          2)Defines a primary care clinic as a clinic operated by a  
            tax-exempt nonprofit corporation that is supported and  
            maintained in whole or in part by donations, bequests, gifts,  
            grants, and government funds or contributions.  In a community  
            clinic, any charges to the patient must be based on the  
            patient's ability to pay, utilizing a sliding fee scale.

          3)Permits DPH to issue a permit to authorize a clinic to offer  
            one or more special services, which is a type of care for  
            which DPH has established special standards for ensuring the  
            quality of care, including birth services and abortion  








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            services.

          4)Provides for exemptions from licensing requirements for  
            certain types of clinics, including federally operated  
            clinics, local government primary care clinics, clinics  
            affiliated with an institution of higher learning, clinics  
            conducted as outpatient departments of hospitals, and  
            community or free clinics.

          5)Authorizes DPH to take various types of enforcement actions  
            against a primary care clinic that has violated state law or  
            regulation, including imposing fines, sanctions, civil or  
            criminal penalties, and suspension or revocation of the  
            clinic's license.

          EXISTING STATE REGULATIONS:  Require primary care clinics, as a  
          condition of licensure, to have a written transfer agreement  
          with a nearby hospital.  Allows all licensed clinics, except for  
          those providing abortion services or birthing services, to  
          request that DPH waive the requirement to maintain a written  
          transfer agreement, if the clinic can show that no hospital  
          would agree to enter into a transfer agreement.
          
          EXISTING FEDERAL LAW:  The Emergency Medical Treatment and  
          Active Labor Act, (EMTALA) is an act of the United States  
          Congress, passed in 1986 as part of the Consolidated Omnibus  
          Budget Reconciliation Act.  It requires hospitals that accept  
          payments from Medicare to provide emergency health care  
          treatment to anyone needing it regardless of citizenship, legal  
          status, or ability to pay.  There are no reimbursement  
          provisions.  Participating hospitals may not transfer or  
          discharge patients needing emergency treatment except with the  
          informed consent or stabilization of the patient or when their  
          condition requires transfer to a hospital better equipped to  
          administer the treatment.  EMTALA applies to "participating  
          hospitals."  The statute defines participating hospitals as  
          those that accept payment from the Department of Health and  
          Human Services, Centers for Medicare and Medicaid Services under  
          the Medicare program.  Because there are very few hospitals that  








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          do not accept Medicare, the law applies to nearly all hospitals.


          FISCAL EFFECT:  This bill has not been analyzed by a fiscal  
          committee.


          COMMENTS:


          1)PURPOSE OF THIS BILL.  According to the author, under current  
            California law, clinics are obliged to obtain a hospital  
            transfer agreement (HTA) from a nearby hospital as a condition  
            of licensure in order to begin performing services.  DPH  
            regulations allow clinics who cannot get an HTA from a nearby  
            hospital to apply for a waiver to this requirement. However,  
            clinics that provide abortions or birthing services are not  
            allowed to apply for a waiver, even if a local hospital won't  
            agree to enter into an HTA.  The author states that this  
            effectively allows a hospital that does not want to enter into  
            an HTA to prevent an abortion clinic from opening.  The author  
            notes that if this bill is enacted, this regulation will be  
            repealed and unenforceable, and will give Californians equal  
            access to reproductive services and the ability to choose. 

          2)BACKGROUND.  As required by Title 22, Division 5, Chapter 7,  
            Article 6 of the California Code of regulations, primary care  
            clinics must have an HTA with a local hospital as a condition  
            of licensure.  Should a patient undergoing a procedure at a  
            clinic require transport to the hospital, an HTA facilitates  
            the timely transfer of the patient between the hospital and  
            the facility.  The agreements delineate the responsibilities  
            of both the clinic and the hospital, including the required  
            sharing of vital information such as the current medical  
            findings regarding the patient, diagnoses, transfer of medical  
            records, and the patients' personal effects.

          When a patient goes to the emergency department it is critical  
            for emergency physicians to understand the condition and what  








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            treatment the patient has received which has led them to be  
            brought into the emergency department.  It is also very  
            helpful when the physician from the clinic speaks to the  
            emergency physician as many times notations in medical records  
            are not clear. This can all be built into an HTA.

          3)SUPPORT.  Planned Parenthood Affiliates of California (PPAC)  
            are the sponsors of this bill and they state by requiring  
            hospital transfer agreements as a condition of licensure, DPH  
            has essentially delegated some of its licensure authority to  
            the hospitals, because any hospital corporation with either a  
            moral objection or desire to secure a competitive edge can  
            refuse to sign a transfer agreement and bring a clinic's  
            license application to a halt.  PPAC notes they believe the  
            decision of whether to grant a clinic a license should rest  
            exclusively with the state.   PPAC also notes the existing  
            transfer agreement requirement acts as a targeted restriction  
            on abortion providers, or TRAP law, because only abortion  
            clinics and birthing centers are ineligible to receive a  
            waiver from the requirement, even in the event that they are  
            unable to secure a transfer agreement.

            The California Primary Care Association is also in support of  
            this bill, noting, some of their members have found it  
            difficult to secure these agreements, and patient safety is  
            already protected by standards of care.


          4)OPPOSITION.  The California Chapter of the American College of  
            Emergency Physicians is opposed to this bill unless it is  
            amended to make all clinics equal by allowing community  
            clinics providing birthing or abortion services to apply for  
            an exemption.
            The California Right to Life Committee, Inc. (CRCL), is  
            opposed to this bill because it would remove the necessity of  
            having a written transfer agreement with one or more nearby  
            hospital when a primary care clinic seeks licensure.  CRLC  
            believes this would be a very serious regulation change and  
            would threaten the physical safety of patients at these  








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            primary care clinics.  It would seem to be a logical  
            requirement for any facility performing surgery or any  
            treatment with potential medical complications.  


          5)RELATED LEGISLATION.  AB 941 (Wood) expands the exemption from  
            licensure by DPH to certain clinics operated by a federally  
            recognized tribe or tribal organization.

          6)PREVIOUS LEGISLATION. AB 980 (Pan), Chapter 663, Statutes of  
            2013, required the California Building Standards Commission to  
            adopt emergency regulations to delete a provision of the 2013  
            California Building Standards Code that establishes building  
            standards for primary care clinics that provide abortion  
            services, and prohibited the Commission from adopting any  
            building code standards for clinics providing medication or  
            aspiration abortion services that differ from construction  
            standards applicable to other primary care clinics.   

          REGISTERED SUPPORT / OPPOSITION: 


          Support



          Planned Parenthood Affiliates of California
          California Family Health Council
          California Primary Care Association
          Planned Parenthood of  Los Angeles County
          Planned Parenthood of the Pacific Southwest
          Planned Parenthood of Santa Barbara, Ventura, & San Luis Obispo  
          Counties
          Planned Parenthood of Orange and San Bernardino Counties


          










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          Opposition

          California Chapter of the American College of Emergency  
          Physicians (unless amended)
          California Right to Life Committee, Inc.


          Analysis Prepared by:Lara Flynn / HEALTH / (916) 319-2097