BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1696
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|AUTHOR: |Holden |
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|VERSION: |May 31, 2016 |
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|HEARING DATE: |June 22, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: tobacco cessation services
SUMMARY : Requires tobacco cessation services to be a covered benefit
under the Medi-Cal program, subject to utilization controls.
Requires tobacco cessation services to include all intervention
recommendations assigned a grade A or B by the United States
Preventive Services Task Force (USPSTF). Requires the Department
of Health Care Services (DHCS) to issue guidelines and enter
into an agreement that authorizes the California Smokers'
Helpline to directly furnish at least one form of
over-the-counter nicotine replacement therapy, as described by
the USPSTF, to Medi-Cal beneficiaries enrolled in smoking
cessation services provided by the helpline. Requires DHCS to
include medical assistance with smoking and tobacco use
cessation rates among adults enrolled in Medi-Cal managed care
plans in its Healthcare Effectiveness Data and Information Set
quality measures.
Existing law:
1)Establishes the Medi-Cal program, administered by the DHCS
under which basic health care services are provided to
qualified low-income persons.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes the purchase of prescribed drugs, subject to
the Medi-Cal List of Contract Drugs and utilization controls.
3)Requires that preventive services assigned a grade of A or B
by the U.S. Preventive Services Task Force be provided to
Medi-Cal beneficiaries without any cost sharing by the
beneficiary in order for the state to receive increased
federal contributions for those services, as specified.
AB 1696 (Holden) Page 2 of ?
4)Authorizes a pharmacist to furnish nicotine replacement
products approved by the federal Food and Drug Administration
(FDA) for use by prescription only, in accordance with
standardized procedures and protocols developed and approved
by both the California Board of Pharmacy and the Medical Board
of California in consultation with other appropriate entities,
if specified conditions are met.
This bill:
1)Requires that tobacco cessation services are covered benefits
under the Medi-Cal program, subject to utilization controls.
Requires tobacco cessation services to include all
intervention recommendations assigned a grade A or B by the
USPSTF, as periodically updated.
2)Requires tobacco cessation services to include a minimum of
four quit attempts per year, with no required break between
attempts, for all beneficiaries 18 years of age and older who
use tobacco.
3)Requires tobacco cessation services to be provided in
accordance with the American Academy of Pediatrics guidelines
and the intervention recommendations, as periodically updated,
assigned a grade A or B by the USPSTF for Medi-Cal
beneficiaries under 18 years of age.
4)Requires, in addition to the services described above, and
only to the extent consistent with the intervention
recommendations assigned a grade A or B by the USPSTF, tobacco
cessation services to include:
a) At least four tobacco cessation counseling sessions
per quit attempt that may be conducted in person or by
telephone and individually or as part of a group, at the
beneficiary's option;
b) A 12-week treatment regimen of any medication
approved by the federal Food and Drug Administration for
tobacco cessation, including prescription and
over-the-counter (OTC) medications.
c) At least one prescription medication and all OTC
medications to be available without prior authorization.
Requires a prescription from a provider with authority to
prescribe and proof of Medi-Cal coverage to be sufficient
documentation to fill a prescription for OTC tobacco
cessation medications.
AB 1696 (Holden) Page 3 of ?
1)Prohibits Medi-Cal beneficiaries from being required to
receive a particular form of tobacco cessation service as a
condition of receiving any other form of tobacco cessation
service.
2)Requires DHCS, effective January 1, 2017, to seek any federal
approvals necessary to implement this bill that DHCS
determines are necessary.
3)Requires DHCS, by December 31, 2017, to issue guidelines and
enter into an agreement that authorizes the California
Smokers' Helpline or its successor, as administered by the
Department of Public Health (DPH), to directly furnish at
least one form of over-the-counter nicotine replacement
therapy, as described by the USPSTF, to Medi-Cal beneficiaries
enrolled in smoking cessation services provided by the
helpline. Requires the guidelines, at a minimum, to address
requirements for pharmacists and physicians in furnishing
nicotine replacement products under this bill consistent with
existing law authorizing pharmacist to furnish prescription
nicotine products. Defines "directly furnish" as providing
directly to the beneficiary by mail with no further action
required on the part of the beneficiary.
4)Requires DHCS, by December 31, 2017, to include medical
assistance with smoking and tobacco use cessation rates among
adults enrolled in Medi-Cal managed care plans in its
Healthcare Effectiveness Data and Information Set (HEDIS).
Permits DHCS to use data collected under this bill for quality
improvement projects to increase cessation by Medi-Cal
enrollees who use tobacco products. Prohibits tobacco use
status from being used by DHCS or a Medi-Cal managed care plan
to deny coverage or treatment of tobacco-related illnesses.
5)Requires this bill to be implemented only to the extent that
federal financial participation is available and not otherwise
jeopardized, and any necessary federal approvals have been
obtained.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1) Increased costs due to increased utilization of smoking
cessation services. Under current practice, about 30,000
AB 1696 (Holden) Page 4 of ?
Medi-Cal beneficiaries access smoking cessation services at a
total annual cost of about $4 million per year. Assuming that
the expanded benefits required in the bill result in
increased demand for smoking cessation services of 10% to
20%, the bill would result in increased costs of $400,000 to
$800,000 per year (General Fund [GF]/federal).
2) Short-term cost savings due to reduced smoking-related health
care costs for Medi-Cal beneficiaries. A review of a smoking
cessation benefit in the Massachusetts Medicaid program
indicates that reducing smoking by beneficiaries led to a net
reduction in health care costs of about $2 for each $1 spent
on the program. Using the assumptions for utilization
increase above, potential cost savings of $800,000 to $1.6
million per year. The long-term health care spending impacts
of reduced tobacco use are less clear, because reduced health
care spending on smoking-related conditions will be offset by
people living longer, though such "costs" are generally
considered societally beneficial.
3) Minor administrative costs to update existing Medi-Cal
policies for the provision of smoking cessation services (GF/
federal).
PRIOR
VOTES :
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|Assembly Floor: |63 - 14 |
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|Assembly Appropriations Committee: |14 - 6 |
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|Assembly Health Committee: |17 - 1 |
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COMMENTS :
1)Author's statement. According to the author, quitting tobacco
products is a difficult feat that many attempt every year.
Tobacco products are still the leading preventable cause of
death in the United States. Though the dangers of smoking are
better understood now than 50 years ago, cigarettes are more
addictive and smoking rates in the Medi-Cal population are
AB 1696 (Holden) Page 5 of ?
still too high. In addition to efforts to discourage people
from smoking, This bill gives smokers the tools to fight the
addiction. The coverage ensured by this bill would guarantee
Medi-Cal patients have access to clinically proven treatments.
Studies have shown that the comprehensive coverage of these
treatments has led to decreases in the smoking population. As
a state, we must remove barriers to treatments that make
quitting possible.
2)Background. According to the Centers for Disease Control and
Prevention, tobacco use is the leading preventable cause of
death in the United States. Every year, smoking kills 480,000
Americans and costs the nation at least $130 billion in
medical care costs for adults and more than $150 billion in
lost productivity, imposing a heavy economic burden on private
employers, private health plans, and federal, state, and local
governments. The cost of tobacco use to California is
estimated to be $18.1 billion annually. According to data from
2001 to 2010 published by the Centers for Disease Control and
Prevention in 2011, most smokers want to quit smoking (69%),
and over half (52%) tried to quit in the previous year, but
only 6% were successful.
The USPSFT reviewed new evidence in the U.S. Public Health
Service's 2008 clinical practice guideline and determined that
the net benefits of tobacco cessation interventions in adults
and pregnant remain well established. The USPSTF found
convincing evidence that smoking cessation interventions,
including brief behavioral counseling sessions and
pharmacotherapy delivered in primary care settings are
effective in increasing the proportion of smokers who
successfully quit and remain abstinent for one year. The
USPSTF concluded that there is high certainty that the net
benefit of tobacco cessation interventions in adults is
substantial, and there is high certainty that the net benefit
of augmented, pregnancy-tailored counseling in pregnant women
is substantial.
3)Affordable Care Act Changes to Tobacco Cessation Coverage.
Section 2502 of the Patient Protection and Affordable Care Act
(ACA) prohibited drugs used to promote smoking cessation,
including agents approved by the FDA for over-the-counter for
purposes of promoting tobacco cessation, from being excluded
from Medicaid coverage. In addition, Section 4107 of the ACA
required Medicaid coverage of tobacco cessation counseling and
AB 1696 (Holden) Page 6 of ?
pharmacotherapy (FDA-approved OTC and prescription drugs) for
pregnant women, and prohibited cost-sharing for these
services.
The seven FDA-approved medications include five forms of
nicotine replacement therapy (NRT): the patch, gum, inhaler,
nasal spray, and lozenge, as well as two non-NRT medications,
bupropion SR (brand name Zyban if used for tobacco cessation
and Wellbutrin if used as an antidepressant), and varenicline
(brand name Chantix). Three forms of NRT (the patch, gum, and
the lozenge) are available OTC. The other two forms of NRT
(the inhaler and the nasal spray), as well as the two non-NRT
medications, are available by prescription. The patch is
available by prescription as well as OTC.
4)Current Medi-Cal coverage of tobacco cessation. Medi-Cal
beneficiaries have a higher prevalence of tobacco use than the
general California population. In the 2011-12 California
Health Interview Survey, 16.1% of adult and teen Medi-Cal
beneficiaries were current smokers, as compared to 12.1% of
adults and teens not covered by Medi-Cal. In the 2013 Medi-Cal
Managed Care Consumer Assessment of Healthcare Providers and
Systems survey, a median of 18.2% of respondents reported
current smoking (with a range of 10% to 27% among Medi-Cal
plans).
DHCS indicates expenditures on smoking deterrents in 2014 was $1
million in FFS and $3.1 million in managed care. Coverage of
tobacco cessation medication varies, depending upon whether
the beneficiary is in FFS Medi-Cal or Medi-Cal managed care
plan, and the particular Medi-Cal managed care plan the
beneficiary is enrolled in. In 2016-17, Medi-Cal is projected
to enroll 14.1 million individuals, of whom 75.89% (10.7
million people) are projected to be in managed care plans.
For FFS Medi-Cal, DHCS is required to use the following
criteria when adding a drug to the Medi-Cal contract drug
list: (a) the safety of the drug; (b) the effectiveness of the
drug; (c) the essential need for the drug; (d) the potential
for misuse of the drug; and, (e) the cost of the drug.
In September 2014, DHCS released Policy Letter 14-006 to
provide Medi-Cal managed care health plans with minimum
requirements for comprehensive tobacco cessation services. The
chart below shows the differences between this bill and
AB 1696 (Holden) Page 7 of ?
current DHCS policy set forth in the Policy Letter:
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|Tobacco | AB 1696 | DHCS Policy for |
|Cessation | | Medi-Cal Managed Care |
|Requirements | | Plans |
|-------------+-----------------+-----------------------|
|Number of | At least 4 per | At least 2 separate |
|quit | year |quit attempts per year |
|attempts | | |
|-------------+-----------------+-----------------------|
|Prohibition | Yes | Yes |
|on requiring | | |
|a break | | |
|between quit | | |
| attempts | | |
|-------------+-----------------+-----------------------|
|Number of | At least 4 per |At least 4 of at least |
|tobacco | quit attempt. | 10 minutes duration |
|cessation | | |
|counseling | | |
|services | | |
|-------------+-----------------+-----------------------|
|Counseling | In person, |Plans must ensure that |
|Session | telephone, | individual, group and |
| | individual or | telephone counseling |
| | group, at | is offered. Does not |
| | beneficiary |specify at beneficiary |
| | option | option |
|-------------+-----------------+-----------------------|
|Tobacco | 84 days (12 |90 |
|cessation | weeks) |days |
|drug | | |
|treatment | | |
|regimen | | |
|duration | | |
|-------------+-----------------+-----------------------|
|Coverage of |Any FDA-approved | Must cover 7 |
|tobacco | medication for | FDA-approved tobacco |
|cessation | tobacco |cessation medications, |
AB 1696 (Holden) Page 8 of ?
|approved by | cessation, | at least one without |
|the federal | including | prior authorization. |
|FDA for |prescription and | Must cover additional |
|tobacco |OTC medications. | medications once |
|cessation, | | FDA-approved. |
|including | | |
|prescription | | |
|and OTC | | |
|-------------+-----------------+-----------------------|
|Prior | At least one | Must cover 7 |
|authorization| prescription | FDA-approved tobacco |
|/ | medication and |cessation medications, |
|utilization | all OTC | at least one without |
|review |medications must | prior authorization. |
|limitations | be available | Does not otherwise |
| | without prior | prohibit utilization |
| | authorization. | review. |
|-------------+-----------------+-----------------------|
|Prohibition | Yes | Prohibits plans from |
|on receiving | | requiring |
|one form of | | beneficiaries to |
|tobacco | | attend classes or |
|cessation as | | counseling sessions |
|a condition | | prior to receiving a |
|of receiving | | prescription for an |
|any form of | | FDA-approved tobacco |
|tobacco | |cessation medication. |
|cessation | | |
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5)Tobacco Helpline. The state Tobacco Helpline (1-800-NO-BUTTS)
has been in existence since 1992. It provides free telephone
counseling, self-help materials, and online help in multiple
languages to help Californians quit smoking. It is
administered by the University of California San Diego via an
interagency agreements with CDPH using state special funds
(from the Health Education Account of Proposition 99, the
Tobacco Protection and Health Initiative from 1988) and
federal grant funds. The Helpline has also received funding
from other sources including various grants from First 5, and
Los Angeles County. The hotline serves approximately 40,000
individuals a year, more than half of whom are enrolled in
Medi-Cal.
AB 1696 (Holden) Page 9 of ?
DHCS received a five-year grant from the Centers for Medicare
and Medicaid Services (CMS) as part of the Medicaid Incentives
for the Prevention of Chronic Disease (MIPCD) Program. The
California project was called the Medi-Cal Incentives to Quit
Smoking (MIQS) Project. The MIQS project incentivized Medi-Cal
members who smoke to engage in counseling with the California
Smokers' helpline. Under the project (which has ended),
Medi-Cal members could receive a free, four -week supply of
nicotine patches mailed directly to their home. Helpline
counselors told Medi-Cal members if they qualified based on
how much they smoke (at least six cigarettes daily) and
determined the dosing. Refills of the nicotine patches were
provided as needed. Medi-Cal members could receive a $20 gift
card bonus, which was mailed after completion of the first
30-40 minute Helpline counseling session.
6)Health plan performance measures. The federal Centers for
Medicaid and Medicaid Services (CMS) requires states, through
their contracts with Medicaid 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 every two years, and requires Medi-Cal managed care
plans to report on the measures annually.
DHCS is not mandated by statute to collect particular HEDIS
measures in Medi-Cal managed care, and DHCS does not currently
require reporting on HEDIS measures related to tobacco use.
However, DHCS requires participation of Meid-Cal managed care
plans in the Consumer Assessment of Healthcare Providers and
Systems survey every three years, which does assess tobacco
use and cessation efforts. During the 2014 calendar year, DHCS
held contracts with 23 full-scope Medi-Cal managed care plans
and three specialty managed care plans. For 2015, DHCS
required reporting on 14 HEDIS measures for full-scope
Medi-Cal managed care plans and one measure developed by DHCS
and the managed care plans, with guidance from the external
quality review organization. Several of the HEDIS measures
include more than one indicator, bringing the total measure
rates required for Medi-Cal managed care plans reporting to
30. The required measures provide information on access to
AB 1696 (Holden) Page 10 of ?
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 beneficiaries with chronic diseases such as
diabetes; hospital readmissions rates; and utilization of
outpatient and emergency department care. In addition to
reporting HEDIS measures, Medi-Cal managed care plans were
required to report separate rates for their Seniors and
Persons with Disabilities (SPD) and non-SPD populations for a
selected group of measures.
7)Prior legislation. AB 1162 (Holden of 2015), was very similar
to this bill. AB 1162 would have required tobacco cessation
services to be a covered benefit under the Medi-Cal program,
as specified. AB 1162 was vetoed by the Governor along with
five other bills. The veto message stated that:
These bills unnecessarily codify certain existing health
care benefits or require the expansion or development of
new benefits and procedures in the Medi-Cal program.
Taken together, these bills would require new spending at a
time when there is considerable uncertainty in the funding
of this program. Until the fiscal outlook for Medi-Cal is
stabilized, I cannot support any of these measures.
SB 220 (Yee of 2010), would have required a health plans and
insurers to cover over a minimum of two courses of treatment
in a 12-month period for all smoking cessation treatments
rated "A" or "B" by the USPSTF, which includes counseling and
OTC medication and prescription pharmacotherapy approved by
the FDA. SB 220 also requested the California Health Benefits
Review Program to prepare an analysis of the state cost
savings as a result of the bill provisions. SB 220 was vetoed
by the Governor.
AB 2662 (Dymally of 2007), would have prohibited the provision
of one form of Medi-Cal covered tobacco cessation service
(either pharmacotherapy or counseling) as a condition of
receiving the other service. AB 2662 was held on the Senate
Appropriations Committee suspense file.
AB 1696 (Holden) Page 11 of ?
SB 576 (Ortiz of 2005), would have required health plans and
insurers to provide coverage for two courses of tobacco
cessation treatments per year, including counseling and
prescription and over-the-counter medications, and prohibited
plans and insurers from applying deductibles but allowed
specific co-payments for those benefits. SB 576 was vetoed by
the Governor.
8)Support. This bill is jointly sponsored by the American Heart
Association/American Stroke Association, the American Lung
Association, and the American Cancer Society Cancer Action
Network to ensure all Medi-Cal patients are able to access
tobacco cessation treatments. The sponsors argue that the
success rate of smokers quitting their addiction to tobacco is
still very low, due in part because many smokers try to quit
without the assistance of tobacco cessation services. The
sponsors noted that although the ACA has made tobacco
cessation treatments more accessible, current guidelines as to
how to implement these treatments are unclear, thereby
resulting in differences in coverage between health plans. In
addition, the sponsors state that Medi-Cal patients face
barriers to treatment services due to prior authorization and
step therapy treatment requirements. Supporters argue this
bill provides needed clarity for Medi-Cal participants on
tobacco cessation services and ensures access to comprehensive
insurance coverage for these services. Supporters conclude
that increased access to smoking cessation treatments and
eliminating barriers will reduce the incidence of
tobacco-related diseases and will lower health care costs.
9)Opposition. The California Association of Health Plans (CAHP)
writes in opposition that this bill will increase costs to the
state by requiring Medi-Cal managed care plans to pay for
tobacco cessation drugs in a manner that is inconsistent with
policies of DHCS. CAHP argues Medi-Cal managed care plans
already comply with the requirements of the DHCS policy
letter, and that weakening prior authorization requirements
designated to ensure the right care is delivered under
appropriate circumstances will drive up costs. CAHP also
argues tracking tobacco rates of enrollees would be difficult
and an unnecessary administrative burden. Finally, CAHP
objects to the provision in this bill making counseling
AB 1696 (Holden) Page 12 of ?
sessions at patient option may leave out some beneficiaries
who need the help most, including patients who have tried and
failed therapies several times.
10)Amendments. This bill authorizes the California Smokers'
Helpline to furnish OTC and prescription nicotine replacement
therapy. Amendments to this provision are needed to
distinguish between the authority to furnish OTC products and
the authority of physicians and pharmacists to furnish
prescription nicotine replacement therapy medication.
11) Policy issues. Recent DHCS policy. DHCS policy for Medi-Cal
managed care plans was released in September 2014 and has been
in effect for less than a year. This bill expands the scope of
that coverage in several ways. Has sufficient time elapsed to
know whether the provisions of that policy are adversely
affecting tobacco cessation services and should be expanded?
SUPPORT AND OPPOSITION :
Support: American Heart Association (co-sponsor)
American Cancer Society (co-sponsor)
American Lung Association (co-sponsor)
Association of California Healthcare Districts
California Academy of Physician Assistants
California Black Health Network
California Chapter of the American College of
Emergency Physicians
California Dental Association
California Life Sciences Association
California Optometric Association
California Pharmacists Association
County Health Executives Association
First 5 Association of California
Health Access California
Health Officers Association of California
March of Dimes
Mental Health America of California
Two individual physicians
Oppose: California Association of Health Plans
Local Health Plans of California
-- END --
AB 1696 (Holden) Page 13 of ?