BILL ANALYSIS Ó
AB 1739
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Date of Hearing: April 27, 2016
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Lorena Gonzalez, Chair
AB
1739 (Waldron) - As Amended April 19, 2016
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill requires the Department of Health Care Services
(DHCS), in the evaluation of patients for allergy under
fee-for-service (FFS) Medi-Cal, to treat serologic-specific
immunoglobulin E (IgE) tests (blood tests) and skin tests as
equivalent confirmatory tests.
FISCAL EFFECT:
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Uncertain, likely minor overall fiscal effect in the FFS
Medi-Cal program (GF/federal). Blood testing utilization could
go up, while utilization of skin tests could go down. The net
effect is unknown.
COMMENTS:
1)Purpose. This bill is intended to ensure that Medi-Cal
patients with allergies receive timely diagnoses. Under
current practice, if a primary care physician wishes to
diagnose allergies, a referral to a specialist for skin
testing is allowed. However, if the primary care physician
wishes to order a blood test to diagnose allergies without a
referral, the physician can only do so under certain
circumstances. The author notes this bill will facilitate
reimbursement for blood tests offered by primary care
providers, which the author indicates will increase access to
allergy diagnostic testing.
2)Background. Allergy and asthma are prevalent in the general
population. In California, an estimated 2.5 million adults
have asthma along with about 700,000 children. With respect to
food allergies, a recent study estimates that food allergy
affects 5% of children under the age of five years and 4% of
teens and adults, and its prevalence appears to be on the
increase.
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DHCS and other payers often translate guidelines into medical
coverage specifications. Medi-Cal coverage for allergy testing
aligns with 2008 guidelines issued by the American Academy of
Allergy, Asthma & Immunology (AAAAI). Guidelines by other
organizations, such as the National Institutes of Health, also
address the effectiveness of allergy diagnostic tests. The
AAAAI guidelines upon which Medi-Cal's coverage policy are
based are being updated this year.
Proponents of this bill note the 2008 guidelines are out of
date, and also note practical considerations that Medi-Cal
patients face obtaining allergy skin testing, which requires
an appointment with an allergist. Unlike skin tests, blood
tests can be administered in a primary care setting.
This issue was the subject of an August 12, 2014 Assembly
Health Committee informational hearing, which focused broadly
on the potential for utilization controls to interfere with
providing access to the standard of care, as well as
specifically on reimbursement for allergy diagnostic testing.
Subsequent to the hearing, on May 15, 2015, Medi-Cal removed
the requirement that laboratories submit documentation of
medical necessity with claims for blood test reimbursement.
However, other limitations on Medi-Cal coverage for blood
tests remain.
It should be noted, however, that diagnostic tests are not a
slam dunk for diagnosing allergies. A 2012 article in the
journal Pediatrics providing guidelines to pediatricians
discusses the complexity of allergy diagnosis, and notes a
detection of sensitization to an allergen through a blood test
is not equivalent to a clinical diagnosis. Many children with
positive tests have no clinical illness when exposed to the
allergen. They indicate this limitation highlights the need
for the clinician to use a detailed medical history and have
knowledge of the features of the specific illness when
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selecting and interpreting tests. In essence, these tests
require a level of training in how to interpret them in light
of other relevant patient-level considerations outside of the
blood test results. Because test limitations often warrant
additional evaluation to confirm the role of specific
allergens, the article advises a consultation with a
board-certified allergist-immunologist should be considered.
3)Staff Comments. Evidence-based coverage guidelines generally
ensure care is provided in a manner supported by science and
medical consensus. These guidelines are constantly evolving
as new research is published and reviewed. This bill, as
written, would statutorily dictate specific coverage
parameters for certain tests, which is not common practice,
and has the disadvantage of being static and less flexible to
changing guidelines as well as lacking review by medical
professionals. Staff also notes the clinical guidelines upon
which Medi-Cal coverage is based are already in the process of
being updated, raising questions of whether this bill is
premature. On the other hand, if difficulty and hassle
accessing allergists and receiving skin tests delay or prevent
diagnosis of allergy where it would be helpful, there seems to
be merit to considering the real-world impact of coverage
guideline on access to timely and appropriate care in a
real-world setting.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081
AB 1739
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