BILL ANALYSIS Ó
AB 2372
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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