BILL ANALYSIS Ó
SB 19
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Date of Hearing: August 19, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
SB 19
(Wolk) - As Amended July 16, 2015
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| |Judiciary | |10 - 0 |
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill requires the California Health and Human Services
Agency (CHHSA) to establish and operate a statewide registry
system to collect Physician Orders for Life-Sustaining Treatment
(POLST) forms, and disseminate the information in the form to
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authorized users, including health care providers.
FISCAL EFFECT:
1)Start-up costs of about $2.5 million over the first three
years to develop the system (non-state funds). The California
Health Care Foundation has commissioned a feasibility report
to examine the concept of a POLST registry. According to a
draft of the report, it will cost about $2.5 million to
develop the information technology system for an
online-accessible registry and set up the program.
2)Ongoing costs of about $1.3 million per year to staff,
maintain, and market the system (General Fund or other unknown
fund source).
3)Unknown potential cost savings due to avoided unwanted medical
care (various fund sources). The primary purpose of a POLST
and the POLST registry proposed in this bill is to document a
patient's preferences for end-of-life treatment. This can
either ensure that individuals receive all treatment possible
to prolong life, or ensure that people do not receive medical
care they do not wish to receive. According to experience in
other states, most people who fill out a POLST form indicate
their wishes for - and receive- much less intensive treatment.
By creating a registry of POLST forms, the bill will improve
access to POLST forms by emergency medical services and
hospitals. In turn, this will lead to fewer emergency health
care services for individuals who do not want those services.
The size of this impact is unknown.
COMMENTS:
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1)Purpose. This bill establishes an electronic POLST registry
that allows individuals and health care providers to update
and access information about an individual's end-of-life
treatment options.
2)POLST. The POLST form is a voluntary form that documents
patient preferences about medical interventions common in
end-of-life treatment, including cardiopulmonary resuscitation
(CPR), mechanical ventilation, intubation, and artificially
administered nutrition. It is completed and signed by a
patient or their authorized representative, and is also signed
by a physician. A signed POLST form, or copy thereof, is a
legally valid physician order that other health care
providers, such as emergency medical services (EMS) personnel,
can rely on to make treatment decisions. POLST is used widely
in health care settings, but nursing homes and hospitals
report problems with the flow of paper forms between settings.
3)POLST versus Advanced Health Care Directives (AHCD). POLST is
designed for use by seriously ill or medically frail
individuals who are close to the end of their lives. POLST
also includes very specific instructions about certain medical
interventions, is applicable to current treatment, and is a
legally valid physician order. In contrast, AHCDs are more
general legal documents that allow anyone 18 years or older to
designate future treatment preferences and to appoint a health
care representative. Unlike POLST, AHCDs do not carry the
legal weight of a valid physician order. This means AHCDs can
guide inpatient treatment by a physician who has reviewed the
AHCD, but do not provide a legal basis for EMS personnel to
follow a patient's treatment preferences.
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4)POLST Registry Supports Ongoing Policy Initiatives. This bill
aligns with goals devised by Let's Get Healthy California, a
public-private partnership coordinated by the CHHSA in 2012 to
improve the health of Californians. LGHC, as well as a
related 2014 California State Innovation Model (CalSIM) grant
proposal to the federal government, identified improving
end-of-life care, by reducing deaths in the hospital and
increasing advanced care planning, as a key initiative.
Although California was unsuccessful in the CalSIM grant
application, some work is ongoing to implement the proposed
initiative. This bill appears to be consistent with these
efforts.
5)Readiness for a POLST Registry in California. A brief
commissioned by the California Health Care Foundation (CHCF)
assessing California's readiness for a POLST registry found
support for the concept among health care providers involved
in using and completing POLST forms. Stakeholders interviewed
for the brief suggested piloting an electronic registry,
developing a modern technology platform, expanding education
about POLST, engaging state administrative leadership, and
identifying funding sources to build and maintain the
registry. It also notes both Oregon and New York have
successful electronic POSLT registries. CHCF is currently
exploring the idea of sponsoring a POLST pilot project and a
decision on moving forward with funding a pilot project is
pending.
6)Prior Legislation.
a) SB 1357 (Wolk) of 2014 was substantially similar to this
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bill, and was held on the Suspense File of the Senate
Appropriations Committee.
b) AB 2452 (Pan) of 2014 required the Secretary of State to
develop an online registry for advance health care
directives, and was held in the Senate Judiciary Committee.
1)Staff Comments.
a) Funding a POLST Registry. This bill specifies CHHSA
shall implement the registry only after determining that
sufficient nonstate funds have been received to allow for
the development of the registry and any related startup
costs. Interest from private foundations in establishing a
POLST registry indicates it may be possible to fund the
initial development cost with non-state sources.
However, the bill does not specify an ongoing fund source,
raising questions about an appropriate fund source for
ongoing customer service staffing and maintenance of an IT
system. Given the cost of providing aggressive and often
unwanted end-of-life medical interventions, both in dollars
and human terms, providing real-time access to POLST forms
through an electronic registry appears to be a reasonable
investment for the state. Some potential fund sources that
could be considered for ongoing support include:
GF. The benefits of a POLST registry would be
widespread and statewide, and the GF would also likely
incur savings in state-funded health programs from
making all patient's end-of-life wishes more
accessible, making the GF a reasonable long-term
funding source in absence of a more specific funding
source.
Federal funds may be available through federal
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financial participation (FFP) for serving the Medi-Cal
population or potentially through grants, though grant
funding may prove unreliable as an ongoing fund
source. Drawing down FFP to cover some of the cost
would likely only be available through a federal
waiver, and would generally require a nonfederal share
to match any federal dollars.
The Health Data and Planning Fund administered
by the Office of Statewide Health Planning and
Development is another non-GF source to consider.
Fees charged to health care facilities support OSHPD's
work in collecting and disseminating health care data,
and bolstering California's health care workforce
through improved training. Although the bill does not
specify OSHPD as an administering agency, this fund
would likely be a fiscally sound revenue source for a
program of this size, and offers a reasonable nexus
between the payers and the activities being funded.
Hospitals and skilled nursing facilities that provide
the majority of end-of-life care, which are the
primary users of a POLST system, are also the primary
payers into the fund. This fund received a GF loan
repayment of $12 million in 2015-16.
a) Pilot program? As mentioned above, the CHCF readiness
assessment suggested an electronic POLST registry start
with a pilot project, one that could be rapidly scalable
after success was proven. Though a statewide POLST
registry appears to be a reasonable long-term policy goal,
the committee may wish to consider whether starting with a
regional pilot may offer a better chance at success, and
minimize potential fiscal risk associated with statewide
implementation.
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Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081