BILL ANALYSIS Ó
AB 2372
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Date of Hearing: April 19, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2372
(Burke) - As Amended April 13, 2016
SUBJECT: Health care coverage: HIV specialists.
SUMMARY: Designates an Human immunodeficiency virus (HIV)
specialist as an eligible primary care provider (PCP).
Specifically, this bill:
1)Requires a health care service plan (health plan) or health
insurance policy (health policy) that is issued, amended, or
renewed on or after January 1, 2017, that provides hospital,
medical or surgical coverage, to include HIV specialists as an
eligible PCP, provided that the provider requests inclusion
and meets the health plan or health insurer's eligibility
criteria for all specialists seeking PCP status.
2)Defines a PCP as a physician, or a non-physician provider who
has the responsibility for providing initial and primary care
to patients, for maintaining the continuity of patient care,
and for initiating referral for specialist care. Provides
that this means providing care for the majority of health care
problems, including, but not limited to, preventive services,
acute and chronic conditions, and psychological issues.
3)Clarifies that accessibility to HIV specialists is subject to
existing regulations and will be included in the reports and
other information required under existing law.
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4)Defines an HIV specialist as a physician or a nurse
practitioner who meets the criteria for an HIV specialist as
published by the American Academy of HIV Medicine or the HIV
Medicine Association, or who is contracted to provide
outpatient medical care under the federal Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990, as
specified.
5)Excludes specialized health care service plans from this
bill's requirements.
EXISTING LAW:
1)Regulates health plans under the Knox-Keene Health Care
Service Plan Act of 1975 through the Department of Managed
Health Care (DMHC) and regulates health insurers under the
Insurance Code through the California Department of Insurance
(CDI).
2)Requires every health plan contract that provides hospital,
medical, or surgical coverage, that is issued, amended,
delivered, or renewed in this state, to include
obstetrician-gynecologists (OB/GYNs) as eligible primary care
physicians, provided they meet the plan's eligibility criteria
for all specialists seeking primary care physician status.
3)Defines a PCP as a physician, who has the responsibility for
providing initial and primary care to patients, for
maintaining the continuity of patient care, and for initiating
referral for specialist care. Includes in this definition,
providing care for the majority of health care problems,
including, but not limited to, preventive services, acute and
chronic conditions, and psychosocial issues.
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4)Requires the Insurance Commissioner to promulgate regulations
applicable to health insurers that contract with providers for
alternative rates for group policy holders to ensure that
insureds have the opportunity to access needed health care
services in a timely manner, as specified.
5)Requires that every policy of disability insurance that covers
hospital, medical, or surgical expenses and is issued,
amended, delivered, or renewed in this state to include
OB/GYNs as eligible primary care physicians provided they meet
the insurer's written eligibility criteria for all specialists
seeking primary care physician status.
6)Requires health plans to provide PCP access to all enrollee
within 30 minutes or 15 miles, as specified.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According the author, Californians
living with HIV should have access to care from physicians and
other providers with the training and experience required to
meet their complex needs. While health plans currently
include infectious disease specialists in their provider
networks, not all infectious disease specialists are HIV
specialists. Studies have shown that patients with HIV who
are managed by clinicians with greater HIV experience and
expertise have better health outcomes and receive more
appropriate and cost-effective care. By clearly defining
access to HIV specialists in statute, including them in the
category of specialty physicians, and allowing HIV specialists
to serve as PCPs for their patients, we can ensure that
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patients receive the care they need.
Additionally, the author states that prior to the advent of the
Patient Protection and Affordable Care Act (ACA), HIV
specialty care was frequently provided by professionals who
were contracted under the Ryan White CARE Act. As a result, a
network of providers grew across the country, ensuring
reasonable access to specialists who knew how to treat a
person with HIV. Following the implementation of the ACA,
health plans have generally relied upon infectious disease
specialists to meet their obligation to ensure that people
with HIV have appropriate access to specialty medical care.
While all HIV specialists are infectious disease specialists,
most infectious disease specialists are not HIV specialists
and do not have the training or experience to treat the
complex and unique needs of patients living with HIV. As a
result, the network of Ryan White CARE Act providers who are
HIV specialists and available to plan beneficiaries has
dwindled. People with HIV often do not have access to
providers who are well suited to provide medical care for this
unique medical condition. HIV specialty is a recognized
discipline with national certification standards that
physicians meet to be designated an HIV specialist.
2)BACKGROUND. California Health Benefits Review Program (CHBRP)
analysis. AB 1996 (Thomson), Chapter 795, Statutes of 2002,
requests the University of California to assess legislation
proposing a mandated benefit or service and prepare a written
analysis with relevant data on the medical, economic, and
public health impacts of proposed health plan and health
insurance benefit mandate legislation. CHBRP was created in
response to AB 1996. SB 125 (Hernandez), Chapter 9, Statutes
of 2015, added an impact assessment on essential health
benefits (EHBs), and legislation that impacts health insurance
benefit designs, cost sharing, premiums, and other health
insurance topics. In its analysis of this bill, CHBRP found
the following:
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a) Enrollees Covered. CHBRP estimates that in 2016, 25.2
million Californians have state-regulated coverage that
would be subject to this bill.
b) Benefit Coverage. This bill does not alter benefit
coverage, but could increase enrollees' choice of type of
PCPs who are HIV specialists.
c) Utilization. CHBRP is unable to estimate enrollee
utilization of designating an HIV specialist as a PCP.
d) Impact on expenditures. Unknown.
e) EHBs. This bill does not expand or mandate coverage for
services; the bill allows for HIV specialists to be
designated as PCPs.
f) Medical effectiveness. The preponderance of evidence
from moderate to strong studies also indicates that care
provided by physicians with more experience and expertise
with HIV results in worse outcomes for non-acquired
immunodeficiency syndrome (AIDS) comorbidities, such as
diabetes and hypertension, than care provided by physicians
with less experience/expertise in HIV.
g) Public health. There appear to be more than 800 HIV
specialists (some of whom are AAHVIM credentialed and many
more who likely meet this bill's definition of specialist)
who treat some of the 120,000 people living with HIV (PLWH)
in California. However, the use of primary care services
provided by HIV specialists and the resulting health
outcomes for PLWH is unknown.
3)CHBRP BACKGROUND. HIV attacks the body's immune system,
specifically the CD4 cells (T cells) that fight infections,
thus greatly increasing the risk of opportunistic diseases.
HIV infection leads to acquired immunodeficiency syndrome
(AIDS) if left untreated. Due to advances in drug treatment,
HIV/AIDS has progressed from an acute illness with a high
mortality rate to a manageable chronic illness where patients
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achieve close to normal life expectancy.
HIV providers may be physicians, nurse practitioners, or
physician assistants and may be credentialed as an HIV
specialist by the American Academy of HIV Medicine.
Pharmacists (who support medication adherence, identify drug
interactions, and provide medication management among multiple
providers) may also obtain HIV specialist credentialing. (See
Policy Context for description of credentialing.) PLWH may
see an HIV specialist who is in private practice, or practices
at an HIV clinic, general healthcare clinic, or a community
health center. Additionally, PLWH (especially those who are
underinsured or uninsured, and thus not subject to this bill)
may seek care at the clinics funded through the Ryan White
CARE Act. These clinics were foundational to the control of
the AIDS epidemic in the early 1990s, through their provision
of HIV treatment and management.
4)DEFINITIONS OF SPECIALTY PHYSICIAN. The CHBRP analysis sets
forth the HIV specialist designation according to the bill:
the published criteria established by AAHIVM; the HIV Medicine
Association; or, a provider who is contracted to provide
outpatient medical care under the federal Ryan White CARE Act.
5)EXISTING CALIFORNIA LAW AND REGULATIONS. In California,
primary care physicians are defined as a physician who has the
responsibility for providing initial and primary care to
patients, for maintaining the continuity of patient care, and
for initiating referral for specialist care. A primary care
physician is either a physician who has limited his or her
practice of medicine to general practice or who is a
board-certified or board-eligible internist, pediatrician,
OB/GYN, or family practitioner. Specialists are defined as a
physician who is board certified or board eligible in the
specialty of medical care provided. Additionally, regulations
require health plans to provide accessibility to all medically
necessary specialists and designate specialists as allergy,
anesthesiology, dermatology, cardiology and other internal
medicine specialists, neonatology, neurology, oncology,
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ophthalmology, orthopedics, pathology, psychiatry, radiology,
surgeries, otolaryngology, urology, and others designated as
appropriate. Existing law requires health plans to make
standing referrals to specialists when medically necessary.
Plans are not required to refer out of network, unless there
is no contracting specialist in that discipline within the
plan's network - in which case the plan would have to cover an
out-of-network specialist referral. Existing law specifically
recognizes HIV/AIDS as a specialty as defined by the federal
government or a national voluntary health organization.
Regulations also require that there are adequate full-time
equivalents of primary care and specialist providers in the
network accepting new patients covered by the policy to
accommodate anticipated enrollment growth.
6)SIMILAR REQUIREMENTS IN OTHER STATES. CHBRP is aware of two
other states that have regulations regarding the definition of
an HIV specialist similar to those proposed in this bill. New
York law requires that managed care organizations provide
treatment for those on HIV Special Needs Plans (SNPs) by HIV
specialists. An HIV specialist is defined by the New York
State Department of Health AIDS Institute; the result of an
expert panel. Maryland, in its administrative code, requires
that health insurers cover treatment by HIV/AIDS specialists.
An HIV specialist must either have an American Board of
Medical Specialties certification in infectious diseases, or
have performed a minimum amount of HIV care and completed an
HIV education requirement, which can be filled by passing the
American Academy of HIV Medicine credentialing exam.
7)SUPPORT. AIDS Healthcare Foundation (AHF) notes that health
plans and health insurers have relied on infectious disease
specialists to meet their obligation to ensure that people
with HIV have appropriate access to specialty medical care.
AHF contends that while all HIV specialists are infectious
disease specialists, most infectious disease specialists are
not HIV specialists and do not have training or experience to
treat this condition. AHF states that the HIV specialist
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becomes a patient's de facto PCP in that the HIV specialist
will be by the patient's side for the rest of his or her life,
however because not designated as a PCP, cannot order tests,
make referrals to other specialists, or any of the other
services a PCP can provide. AHF raises concerns with the flu
vaccine in that a PCP without the expertise of an HIV
specialist could order a partial live virus flu vaccine for a
person without being aware of the consequences. AHF also
notes that this bill's proposal regarding the definition of an
HIV specialist is consistent with state regulations and aligns
with a longstanding federal contracting process and with
national discipline bodies. Additionally similar to OB/GYN as
PCPs, AHF states that a similar situation, similar limitations
that affect the quality of medical care are occurring with HIV
specialists.
8)OPPOSITION. California Association of Health Plans (CAHP),
the Association of California Life and Health Insurance
Companies, and America's Health Insurance Plans contend that
health insurance mandates threaten efforts of all health care
stakeholders to provide consumers with meaningful health care
choices and affordable coverage options. They state that the
ACA requires the state to pay for the increased cost
associated with the mandate for those enrollees who purchase
health insurance on the Exchange. They also state that
benefit mandates eliminate the ability of health insurers and
HMOs to provide unique benefit packages aimed at the needs of
consumers by requiring individuals and employers to purchase
benefits prescribed by the Legislature, not driven by consumer
choice. Finally, they note that health benefit mandates
stifle the use of innovative, evidence based medicine.
CAHP additionally states that this bill will hinder a health
plan's ability to meet network adequacy requirements since
network requirements are more stringent for PCPs than for
specialists, including specific time and distance standards.
CAHP states that HIV specialists may not meet PCP
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qualifications, established by delegated medical groups in
certain instances, and therefore the health plan may not be
able to comply with this bill. Additionally, CAHP notes that
a person with HIV currently benefits from a standing order for
care that is provided by an HIV specialist, infectious disease
specialist of pulmonary/critical care specialists. CAHP also
notes that not all areas of the state have HIV specialists,
but may have other specialists qualified to treat HIV, and
with a shortage of HIV specialists available, it may be
difficult for health plans to implement the statewide mandate.
Finally CAHP states that this bill is similar to the existing
OB/GYN mandate and at the time, regulators required health
plans with delegated medical groups to reach out to every
OB/GYN in their network and invite them to be a PCP. CAHP
states that it will be difficult for health plans to comply
with the time and distance standards for PCPs due to the
limited number of HIV specialists throughout the state.
9)PREVIOUS LEGISLATION. AB 2168 (Gallegos), Chapter 426,
Statutes of 2000, requires standing referrals to an HIV
specialist.
10)POLICY COMMENT. This bill designates an HIV specialist as
eligible PCPs. Under existing law, PCPs are subject to
specific network adequacy requirements with respect to
geographic access and availability. Consequentially, health
plans may not be able to meet these PCP network adequacy
requirements especially for enrollees in rural areas.
REGISTERED SUPPORT / OPPOSITION:
Support
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AIDS Healthcare Foundation (sponsor)
Opposition
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Association of Health Plans
Analysis Prepared by:Kristene Mapile / HEALTH / (916) 319-2097