BILL ANALYSIS Ó AB 2372 Page 1 Date of Hearing: May 4, 2016 ASSEMBLY COMMITTEE ON APPROPRIATIONS Lorena Gonzalez, Chair AB 2372 (Burke) - As Amended April 25, 2016 ----------------------------------------------------------------- |Policy |Business and Professions |Vote:|14 - 0 | |Committee: | | | | | | | | | | | | | | |-------------+-------------------------------+-----+-------------| | |Health | |18 - 0 | | | | | | | | | | | |-------------+-------------------------------+-----+-------------| | | | | | | | | | | | | | | | ----------------------------------------------------------------- Urgency: No State Mandated Local Program: YesReimbursable: No SUMMARY: This bill allows HIV specialists, as defined, to be included as an eligible primary care provider, if the provider requests primary care provider status and meets the health care service AB 2372 Page 2 plan's eligibility criteria for all specialists seeking primary care provider status. It also stipulates that access to HIV specialists is subject to regulations that govern network adequacy, consistent with the specialty designation. FISCAL EFFECT: 1)If this bill is interpreted to designate HIV specialists as a distinct specialty for the purposes of ensuring compliance with timely access standards, it would be difficult and costly for plans and insurers to meet such standards, given the California Health Benefits Review Program (CHBRP) found there are only 900 HIV specialists in the state that meet the bill's definition. Regulators have some discretion to decide how to apply these timely access standards, but it would appear very difficult to meet these existing specialty standards for HIV specialists, particularly in areas where there are few practicing specialists. Difficulty meeting these standards would lead to difficulty in negotiating fair prices for contracts, leading to a situation similar to an "any willing provider" clause, whereby plans would lose bargaining leverage because they would be essentially forced to accept any HIV specialist they could entice to join their network through high reimbursements, in order to meet the regulatory standards. Higher reimbursement rates for HIV specialists as a result of this market imbalance would be expected to lead to higher premiums. Although the amount is unknown, price hikes and statewide impacts on premiums across all payers could be significant, conceivably AB 2372 Page 3 in the millions of dollars statewide. 2)Difficulty (or impossibility) of meeting network standards would also potentially lead to a higher number of consumer complaints and enforcement actions, resulting in unknown, potentially significant costs to Department of Managed Health Care (DMHC) (Managed Care Fund) and California Department of Insurance (Insurance Fund). 3)Finally, this bill appears likely to require the California Department of Insurance (CDI), and possibly DMHC, to reopen regulations related to network adequacy. If this is the case, there would be additional legal and regulatory costs to both departments. COMMENTS: 1)Purpose. According to the author, as people living with HIV have entered managed care instead of relying on the network of Ryan White CARE Act providers who are HIV specialists, access to HIV specialists 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. They state HIV specialty is a recognized discipline with national certification standards that physicians meet to be designated an HIV specialist. The sponsor, AIDS Healthcare Foundation, notes that health plans and health insurers have, instead of contracting with HIV specialists, relied on infectious disease specialists to meet their obligation to ensure that people with HIV have appropriate access to specialty medical care. 2)Background. 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. AB 2372 Page 4 Pharmacists (who support medication adherence, identify drug interactions, and provide medication management among multiple providers) may also obtain HIV specialist credentialing. According to CHBRP, there are about 900 of these providers statewide. Other providers may care for people with HIV, including infectious disease specialists and primary care providers. 3)Existing Access Requirements. In California, a primary care physician is 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. A specialist is 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, 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. Regulations also require that there are adequate full-time equivalents of primary care and specialist providers in the AB 2372 Page 5 network accepting new patients. They also stipulate access standards for primary and specialty visits. Persons living with HIV have a standing order for HIV specialty care-they do not need a referral to access such care. 4)Support. AIDS Healthcare Foundation (AHF), the sponsor of this bill, notes health plans and 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. 5)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. 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. 6)Staff Comments. Allowing HIV specialists to be primary care providers pursuant to this bill's standards does not generate fiscal concern, but applying specialist standards would likely have a significant fiscal impact. Evidence of a widespread problem with quality of HIV care under current law has not been demonstrated. The intent of the language related to specialty standards appears to be to ensure the more stringent AB 2372 Page 6 primary care timely access standards do not apply to HIV specialists working as primary care providers. This language could be clarified to remove what appears to be a newly created standard for HIV specialists. Analysis Prepared by:Lisa Murawski / APPR. / (916) 319-2081