BILL ANALYSIS Ó
AB 2084
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Date of Hearing: April 5, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2084
(Wood) - As Introduced February 17, 2016
SUBJECT: Medi-Cal: comprehensive medication management.
SUMMARY: Provides Medi-Cal coverage for comprehensive
medication management (CMM). Specifically, this bill:
1)Defines CMM as the process of care that ensures each
beneficiary's medications, whether prescription drugs and
biologics, over-the-counter medication, or nutritional
supplements, are individually assessed to determine that each
medication is appropriate for the beneficiary, effective for
the medical condition, and safe given the comorbidities and
other medications being taken, and all medications are able to
be taken by the patient as intended.
2)Identifies CMM goals as improving quality outcomes for
beneficiaries and lowering overall health care costs as
specified.
3)Provides that CMM services are to be offered to a beneficiary
who meets one or more of the following criteria:
a) Is taking three or more prescription drugs or biologics
to treat or prevent one or more chronic medical conditions,
or who has been identified by a treating prescriber as high
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risk for medication-related problems and who has one or
more chronic diseases;
b) Has been discharged from a hospital, rehabilitation
facility, or long-term care setting with one or more
chronic medical conditions, with a need for a plan to
enhance care coordination efforts, as specified;
c) Has been referred by the beneficiary's treating
prescriber as having a medical condition or gap in care
that could benefit from the provision of CMM services; and,
d) Any other criteria established by the Department of
Health Care Services (DHCS) that is consistent with CMM
goals.
4)Provides that CMM services, as utilized by a primary care
physician or pharmacist, in collaboration with other
appropriate providers and in direct communication with the
beneficiary, include the following:
a) Assessment of the beneficiary's health status;
b) Documentation of the beneficiary's current clinical
status and goals of therapy;
c) Assessment of each medication for appropriateness,
effectiveness, safety, and adherence;
d) Identification of all medication therapy programs;
e) Development and implementation in collaboration with the
beneficiary of a written treatment plan;
f) Resources designed to enhance the beneficiary's
adherence to, and appropriate use of, medication; and,
g) Follow-up evaluation and monitoring with the beneficiary
to determine any changes to the treatment plan, reassess
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actual outcomes, and recommend or implement further changes
to achieve desired clinical outcomes.
5)Specifies that CMM services include an average of three to
four visits per year with a CMM primary care physician or
pharmacist, as appropriate, to monitor and evaluate medication
therapy progress and problems and make recommended resolutions
or changes consistent with a collaborative practice agreement.
6)Requires DHCS to evaluate the effectiveness of CMM on quality
of care, patient outcomes, and total program costs. Requires
DHCS to include a description of any savings attributed to CMM
services, as specified, and allows DHCS to use patient and
prescriber surveys to assess CMM services.
EXISTING LAW:
1)Provides for the Medi-Cal program, administered by DHCS, under
which qualified low-income individuals receive health care
services and is, in part, governed and funded by federal
Medicaid Program provisions.
2)Provides for a schedule of benefits under the Medi-Cal
program, which includes outpatient prescription drugs, subject
to utilization controls and the Medi-Cal list of contract
drugs.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. The California Pharmacists Association
(CPhA), sponsor of this bill, states that this bill will
address the current problem of poor treatment of chronic
disease and high health expenditures due to the cost of
treating chronic disease patients with worsening health
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outcomes. Patients with chronic disease often visit an array
of health care providers and take multiple medications and the
insufficient coordination among those providers has resulted
in an overwhelming need for ongoing assessment of patients'
medications.
2)BACKGROUND.
a) Other states and Medicare. While no previous
legislation has been introduced in California, there are at
least 15 Medicaid programs in other states that provide
beneficiaries with some form of medication management
services. Of the 15 states, there are six that have
enacted CMM programs. This bill is similar to the programs
in Washington and Minnesota.
Medicare offers a Medication Therapy Management (MTM)
program, for those enrolled in a Medicare drug plan and
take medications for different medical conditions, in which
a pharmacist or other health professional gives patients a
comprehensive review of all medications. Patients receive
a written summary of discussion, including an action plan
that recommends how to make the best use of medications.
According to CPhA, CMM is different from MTM in that CMM
services, as defined in this bill, are more comprehensive
and designed to provide ongoing disease-oriented care, with
a requirement to assess or obtain the patient's clinical
status and goals of therapy, develop a treatment plan, and
provide ongoing follow-up to monitor and adjust the
treatment plan as necessary.
b) White paper. A 2015 white paper published by the
California Department of Public Health describing CMM
programs notes that as health care for patients with
chronic disease consumes a growing proportion of overall
expenditures, better disease management and education is
crucial. The white paper further states that not only
should health care delivery improve access to skilled
professional resources, but services should be
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evidence-based, and result in better health outcomes. The
white paper also reports that improvements to health care
quality and safety can be realized if health systems
embrace and promote innovative care models that provide
adequate support for patients and other health care
providers while simultaneously promoting proper medication
use and adherence, medication safety, optimal prescribing,
and care coordination. CPhA states that CMM's definition
originated with the Medication Management Task Force of the
Patient Centered Primary Care Collaborative and further
elaborated on by the American College of Clinical Pharmacy.
c) California Health Benefits Review Program. On February
26, 2016, this bill was forwarded to the California Health
Benefits Review Program (CHBRP) for review. The focus of
the CHBRP review is costs and the analysis will be
available when this bill is heard in Assembly
Appropriations Committee.
3)SUPPORT. CPhA writes that this bill will help improve health
outcomes and reduce costs within the Medi-Cal program by
utilizing pharmacists and physicians to better manage
prescription drug treatment for chronic disease patients.
CPhA contends that chronic disease is expensive and patients
with chronic disease utilize a disproportionate share of
health care resources. For example, DHCS reports that as many
as 48.3% of Medi-Cal's nonelderly adult population has one or
more chronic diseases. CPhA also raises concerns with respect
to poor management of patient prescription drug therapy
leading to costs in avoidable medical spending and deaths
every year. Finally, CPhA notes that CMM services (via U.S.
Public Health Service experiences and compilations of nearly
60 peer reviewed studies of medication management programs)
have shown consistent improvement in health outcomes and an
average return on investment of at least $4 saved for every $1
spent.
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Mental Health Systems (MHS) states that the U.S. Centers for
Disease Control and Prevention reports that about 50% of all
adults have one or more chronic diseases and 25% of adults
have multiple chronic conditions. Chronic disease represents
seven of the top 10 causes of death and accounts for 86% of
all health care spending nationally. MHS states that many
patients do not take their medications as prescribed, stop
taking their medications altogether, experience drug
interactions, or are on the wrong dose for optimal therapeutic
effect. One common thread connecting all these problems is
that few patients receive follow-up care specific to their
medications. MHS contends that CMM services are designed to
ensure each patient's medications are assessed to determine
appropriateness for the patient, effectiveness for the medical
condition, safety, and ability for the patient to take as
prescribed. CMM programs have a proven track record of
increasing medication adherence, improving patient outcomes,
and reducing health care expenditures.
Project Inform states that the Medi-Cal program is faced with
providing better care to more patients with fewer resources,
and needs to implement innovative programs such as CMM that
simultaneously improve health outcomes and reduce costs
thereby increasing value to the system.
The American Federation of State, County and Municipal Employees
states that this bill ensures that those who depend on
Medi-Cal, have full and comprehensive treatments. The
Congress of California Seniors states that CMM services will
improve medication adherence among Medi-Cal patients, thus
improving patient outcomes and saving the state of California
millions of dollars annually in avoidable medical spending.
The Arthritis Foundation states that CMM programs have a
proven track record of increasing medication adherence,
improving patient outcomes, and reducing health care
expenditures.
4)PREVIOUS LEGISLATION. AB 361 (Mitchell), Chapter 642,
Statutes of 2013, authorizes DHCS, subject to federal
approval, to create a health home program for enrollees with
chronic conditions, as prescribed, as authorized under federal
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law. "Health home" means a provider or team of providers
designated by DHCS that satisfies all of the following: meets
the criteria described in federal guidelines; offers a whole
person approach, including, but not limited to, coordinating
other available services that address needs affecting a
participating individual's health; and, offers services in a
range of settings, as appropriate, to meet the needs of an
individual eligible for health home services.
5)POLICY COMMENTS.
a) Collaborative Practice. This bill specifies that CMM
services must monitor and evaluate medication therapy
progress and problems and make recommended resolutions or
changes consistent with a collaborative practice agreement.
However, this measure does not define collaborative
practice. To assist in implementation, as this bill moves
forward the sponsor may wish to consider defining these
terms.
b) Narrow the application of this bill. Depending on the
costs associated with implementation, the sponsor may also
wish to consider limiting application of this bill to
managed care plans initially to assist with the integration
of the team based and patient centered focus of the CMM
program.
REGISTERED SUPPORT / OPPOSITION:
Support
California Pharmacists Association (sponsor)
Arthritis Foundation
American Federation of State, County and Municipal Employees
(AFSCME), AFL-CIO
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Congress of California Seniors
Disability Rights California
GlaxoSmithKline
Mental Health Systems
Project Inform
Opposition
None
Analysis Prepared by:Kristene Mapile / HEALTH / (916) 319-2097
AB 2084
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