BILL ANALYSIS Ó AB 2084 Page 1 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 AB 2084 Page 2 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 AB 2084 Page 3 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 AB 2084 Page 4 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 AB 2084 Page 5 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. AB 2084 Page 6 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 AB 2084 Page 7 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 AB 2084 Page 8 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 Page 9