BILL ANALYSIS                                                                                                                                                                                                    Ó



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          Date of Hearing:  May 4, 2016


                        ASSEMBLY COMMITTEE ON APPROPRIATIONS


                               Lorena Gonzalez, Chair


          AB  
          2372 (Burke) - As Amended April 25, 2016


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          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  








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          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  








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            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.  








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            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  








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            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  








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            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