BILL ANALYSIS                                                                                                                                                                                                    



                                                                    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



















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