BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON APPROPRIATIONS
                             Senator Ricardo Lara, Chair
                            2015 - 2016  Regular  Session

          AB 2439 (Nazarian) - HIV testing
          
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          |Version: August 1, 2016         |Policy Vote: HEALTH 7 - 0       |
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          |Urgency: No                     |Mandate: No                     |
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          |Hearing Date: August 8, 2016    |Consultant: Brendan McCarthy    |
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          This bill meets the criteria for referral to the Suspense File.

          Bill  
          Summary:  AB 2439 would create a pilot project to assess the  
          effectiveness of routinely offering HIV tests in the emergency  
          department of a hospital.


          Fiscal  
          Impact:  
           One-time costs of $305,000 in 2016-17 and $560,000 in 2017-18  
            for the Department of Public Health to oversee the pilot  
            project (General Fund).

           By requiring hospitals to offer additional HIV testing to  
            patients, the bill will increase the number of tests provided  
            and the number of previously undiagnosed individuals who will  
            be diagnosed with HIV, typically leading to treatment. The  
            number of additional tests provided and the number of  
            previously undiagnosed cases of HIV discovered through those  
            tests is subject to uncertainty. Based on information  
            developed by the Office of Statewide Planning and Development,  
            there are about 14 million emergency department patient  
            encounters per year. If 10% of the encounters in participating  







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            hospitals lead to an HIV test and the population accepting the  
            test has roughly the same rate of undiagnosed HIV as the  
            overall state population, there would be about 10-20 newly  
            diagnosed cases of HIV identified per year. This would result  
            in the following state costs:

               o      About $150,000 per year for additional HIV testing  
                 (including follow up testing for positive test results)  
                 by the Medi-Cal program (General Fund and federal funds).

               o      About $200,000 per year to provide medical care  
                 Medi-Cal enrollees newly diagnosed with HIV (General Fund  
                 and federal funds).

               o      About $50,000 per year to provide medical care to  
                 new Aids Drug Assistance Program enrollees (federal funds  
                 and drug rebate funds).

           Unknown long-term cost savings to Medi-Cal due to earlier  
            medical intervention for HIV-positive Medi-Cal enrollees. To  
            the extent that HIV-positive Medi-Cal enrollees are diagnosed  
            earlier and begin treatment earlier, it is likely that the  
            long-term health status of those individuals will improve and  
            some of the health effects of HIV will be delayed or avoided.  
            There are indications that untreated HIV causes long-term  
            health impacts such as elevated risk of diabetes and heart  
            disease, even before the effects of compromised immune system  
            function associated with HIV infection become evident. Earlier  
            diagnosis and treatment for HIV-positive individuals may to  
            reduce long-term Medi-Cal expenditures for those individuals.  
            However, to some unknown extent the improvement in health  
            status and reduction in health care needs will be offset by  
            longer lifespans, potentially offsetting cost savings.

           Unknown cost savings due to reduced HIV infections in the  
            state, including amongst Medi-Cal beneficiaries. There are  
            academic findings that diagnosis of HIV significantly reduces  
            the likelihood that an HIV positive individual will infect  
            others. This is due both to a reduction in risky behavior by  
            those aware of their HIV positive status and reductions in  
            viral loads in the blood due to antiretroviral treatments. To  
            the extent that the bill results in new diagnoses of HIV and  
            that newly diagnosed individuals are able to access  
            appropriate medical care, the bill is likely to prevent future  








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            HIV infections.


          Background:  Under current law, patients who have blood drawn at primary  
          care clinics must be offered an HIV test by the clinic.
          Under state and federal law, the Department of Health Care  
          Services operates the Medi-Cal program, which provides health  
          care coverage to low income individuals, families, and children.  
          Medi-Cal provides coverage to childless adults and parents with  
          household incomes up to 138% of the federal poverty level and to  
          children with household incomes up to 266% of the federal  
          poverty level. The federal government provides matching funds  
          that vary from 50% to 90% of expenditures depending on the  
          category of beneficiary.


          In addition, the Department of Public Health manages the Aids  
          Drug Assistance Program which offers coverage for treatment of  
          HIV to those who do not qualify for Medi-Cal. 


          Current law mandates that all individual and group health plans  
          and insurance policies provide coverage for HIV testing.




          Proposed Law:  
            AB 2439 would create a pilot project to assess the  
          effectiveness of routinely offering HIV tests in the emergency  
          department of a hospital.
          Specific provisions of the bill would:
           Establish a pilot project to assess and make recommendations  
            regarding the effectiveness of routinely offering an HIV test  
            in the emergency department of a hospital;
           Require the Department of Public Health to administer the  
            pilot project;
           Require the Department to select four hospitals to voluntarily  
            participate;
           Require participating hospitals to offer an HIV test to any  
            patient in the hospital emergency department who has consented  
            to the test, with certain exceptions;
           Require participating hospitals to report specified data to  
            the Department;








          AB 2439 (Nazarian)                                     Page 3 of  
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           Make the term of the pilot project March 1, 2017 to February  
            28, 2019;
           Require the Department to report to the Legislature by July 1,  
            2019 on the results of the pilot project;
           Authorize the Department to seek or use private funding to  
            support the pilot project.


          Related  
          Legislation:  
           AB 2640 (Gipson) would require a medical provider  
            administering an HIV test to provide information on pre- and  
            post-exposure prophylaxis to individuals with a negative  
            result who are at high risk of HIV infection. That bill will  
            be heard in this committee.
           AB 521 (Nazarian, 2015) would have required a general acute  
            care hospital to offer an HIV test to any individual who has  
            been admitted to the hospital through the emergency department  
            and who has blood drawn after admission to the hospital. That  
            bill was vetoed by Governor Brown.


          Staff  
          Comments:  Current law requires health plans and health insurers  
          to cover HIV testing. However, the enrollee cost sharing for  
          such testing will vary based on the individual's plan and the  
          network status of the hospital providing the HIV test. An  
          individual with commercial health insurance may be required to  
          pay a deductible or copay associated with the test required in  
          the bill. In addition, if the hospital is not in the enrollee's  
          plan network, the enrollee may be required to cover a larger  
          share of cost, potentially the entire cost of the test,  
          depending on the terms of coverage.
          The state's Medi-Cal program covers HIV testing with no cost  
          sharing for beneficiaries. Because HIV screening has been  
          recommended for individuals between 15 and 65 years of age by  
          the United States Preventative Services Taskforce, the  
          Department of Health Care Services indicates that the cost of  
          the screening provided under the bill would be covered by  
          Medi-Cal.


          This bill is narrower than AB 521, in that this bill would  
          require a pilot project limited to four hospitals. However,  








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          under AB 521 an HIV test would have been offered only to an  
          individual who was admitted to the hospital through the  
          emergency department. This bill would require an HIV test to be  
          offered as part of any encounter in an emergency department  
          (with some limitations). Because a small portion of emergency  
          department encounters lead to hospital admissions, staff  
          estimates that the overall number of HIV tests that would be  
          offered under this bill would be roughly 25% of those that would  
          have been offered under AB 521.




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