BILL ANALYSIS                                                                                                                                                                                                    



                                                                      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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          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