BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 22
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|AUTHOR: |Roth |
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|VERSION: |April 21, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Melanie Moreno |
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SUBJECT : Residency training.
SUMMARY :1. Requires the Office of Statewide Health Planning and
Development (OSHPD) to establish a non-profit public benefit
corporation to be known as the California Medical Residency
Training Foundation (Foundation), as specified. Requires the
Foundation to be governed by a board of trustees consisting of
a total of 13 members, as specified. Specifies the duties of
the Foundation and OSHPD for the purposes of establishing and
funding new residency positions in medically underserved areas
of the state.
Existing law:
1.Establishes the California Healthcare Workforce Policy
Commission (Commission) and requires the Commission to, among
other things, identify specific areas of the state where unmet
priority needs for primary care family physicians and
registered nurses exist; establish standards for family
practice training programs, family practice residency
programs, primary care physician assistants programs, and
programs that train primary care nurse practitioners; and
review and make recommendations to OSHPD concerning the
funding of those programs that are submitted to the Health
Professions Development Program for participation in the state
medical contract program.
2.Establishes the Health Professions Education Foundation (HPEF)
within OSHPD. Requires the HPEF to solicit and receive funds
from Foundations and other private and public sources and to
provide financial assistance in the form of scholarships or
loans to students in the health professions who are from
underrepresented groups. Provides that HPEF governed by a
board consisting of 13 members appointed by the Governor,
SB 22 (Roth) Page 2 of ?
Speaker of the Assembly, and Senate Rules Committee.
3.Establishes, under the HPEF, scholarship, loan, and loan
repayment programs for registered nurses, vocational nurses,
geriatric nurse practitioners, clinical nurse specialists, and
mental health professionals who agree to practice for
specified periods of time in underserved areas and in
designated practice settings, as specified.
4.Establishes, under HPEF, the Steven M. Thompson Physician
Corps Loan Repayment Program (STPCLRP), which provides for the
repayment of educational loans for licensed physicians and
surgeons who practice in medically underserved areas of the
state, as defined. Requires HPEF, in administering the
STPCLRP, to use and develop guidelines for applicants that
give preference to applicants who are best suited to meet the
cultural and linguistic needs of patients in medically
underserved populations, as specified, and who agree to
practice in geriatric care settings. Also allows HPEF to
appoint a selection committee to provide policy direction and
guidance to the STPCLRP. Requires funds for loan repayment
under the STPCLRP to have a funding match from a Foundation or
other private source. Establishes a Medically Underserved
Account for Physicians within the Fund, the primary purpose of
which is to provide funding for the STPCLRP.
5.Establishes within OSHPD the Health Professions Education Fund
to receive funds for scholarships and loans to students from
underrepresented groups who are enrolled in or accepted to
schools of medicine, dentistry, nursing, and other health
professions. Provides that moneys in the fund are
continuously appropriated.
6.Establishes the Song-Brown Health Care Workforce Training Act
of 1973 (Song-Brown Act), administered by OSHPD to provide
financial support to family practice residency programs, nurse
practitioner and physician assistant programs, and registered
nurse education programs to increase the number of students
and residents receiving education and training in family
practice and nursing. The Song-Brown Act also encourages
universities and primary care health professionals to provide
health care in medically underserved areas.
This bill:
1.Requires OSHPD to establish a non-profit public benefit
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corporation to be known as the Foundation, which is required
to be governed by a board of trustees consisting of a total of
13 members.
2.Requires nine members to be appointed by the Governor, one
member appointed by the Speaker of the Assembly, one member by
the Senate Committee on Rules, and two members of the Medical
Board of California (MBC) by the MBC. Permits the board
members appointed by the Governor, the Speaker of the
Assembly, and the Senate Committee on Rules to include
representatives of public and private hospitals, community
clinics, public and private health insurance providers, the
pharmaceutical industry, associations of health care
practitioners, and other appropriate members of health or
related professions.
3.Requires all persons considered for appointment to have an
interest in increasing the number of medical residencies in
the state, an interest in increasing access to health care in
underserved areas of California, and the ability and desire to
solicit funds for the purposes of this chapter, as determined
by the appointing power.
4.Requires the chairperson to be a non-voting, ex officio member
of the board. Requires the Governor to appoint the president
of the board from among those members appointed by the
Governor, the Assembly, the Senate, and the MBC. Requires the
initial terms to be as follows:
a. Governor appointees: three members to serve a
one-year term, three members to serve a two-year term,
and three members to serve a three-year term;
b. Assembly and Senate appointees: four-year
terms;
c. MBC appointees: four-year term; and,
d. Upon expiration of the initial appointments:
four-year terms.
5.Permits the OSHPD director, after consultation with the
president of the board, to appoint a council of advisers
comprised of up to nine members, to advise the director and
the board on technical matters and programmatic issues related
to the Foundation.
6.Requires board and council members to serve without
SB 22 (Roth) Page 4 of ?
compensation, but to be reimbursed for any actual and
necessary expenses incurred in connection with their duties as
a board or council member. Requires members appointed by the
MBC to be reimbursed by the MBC for any actual and necessary
expenses, as specified.
7.Prohibits any board member from being considered to be engaged
in activities inconsistent and incompatible with his or her
duties solely as a result of membership on the MBC.
8.Makes the Foundation subject to the Non-profit Public Benefit
Corporation Law, except that if there is a conflict with this
bill and that law, this bill prevails.
9.Requires the Foundation to:
a. Solicit and accept funds from business,
industry, Foundations, and other private or public
sources for the purpose of establishing and funding
new residency positions in medically underserved areas
of the state;
b. Encourage public and private sector
institutions, including hospitals, colleges,
universities, community clinics, and other health
agencies and organizations to identify and provide
locations for the establishment of new residency
positions in the medically underserved areas of the
state;
c. Make recommendations to the OSHPD director on
the establishment of new residency positions,
including the locations, fields of practice, and
levels of funding in order to fulfill the goals of
this bill;
d. Recommend to the OSHPD director the
disbursement of moneys deposited in the California
Medical Residency Training Fund to establish and fund
residency positions;
e. Recommend to the OSHPD director that a portion
of the funds solicited from the private sector be used
for the administrative requirements of the Foundation;
and,
f. Prepare and submit an annual report to the
Legislature documenting the amount of money solicited
from the private sector, the amount of money deposited
from the Foundation into the fund, the recommendations
SB 22 (Roth) Page 5 of ?
for the location and fields of practice of future
residency positions, and the prospective fundraising
goals.
10.Requires OSHPD to:
a. Provide technical and staff support to the
Foundation in meeting all of its responsibilities;
b. Provide financial management for the
Foundation;
c. Establish, with the recommendation of the
board, criteria for ranking the geographical areas of
the state that have the highest need for primary care
residencies, and give preference to proposals that
would establish residency positions in these areas.
Requires the criteria to be based the size of an
area's population that is enrolled in, or eligible
for, Medi-Cal and the shortage of primary care
physicians in the area;
d. Solicit proposals for new residency positions
from public and private sector institutions, including
hospitals, colleges, universities, community clinics,
and other health agencies and organizations that train
primary care residents;
e. Establish a uniform process that requires that
these proposals contain all necessary and pertinent
information, including, but not limited to, the
location of the proposed residency position; the
medical practice area of the proposed residency
position; information that demonstrates the area's
need for the proposed residency position and for
additional primary care practitioners; and, the amount
of funding required to establish and operate the
residency position;
f. Enter into contracts with public and private
sector institutions, including hospitals, colleges,
universities, community clinics, and other health
agencies and organizations in order to fund and
establish residency positions at, or in association
with, these institutions. Requires the OSHPD director
to seek the recommendations of the Commission and
Foundation as to which proposals best fulfill this
bill's objective;
g. Prior to the first distribution of funds for
any new residency position, ensure that the residency
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position has been, or will be, approved by the
Accreditation Council for Graduate Medical Education;
h. Provide the following information to the
board:
i. The areas of the state that are
deficient in primary care services;
ii. The areas of the state that have
the highest number of Medi-Cal enrollees and
persons eligible to enroll in Medi-Cal, by
proportion of population;
iii. The proposals received from
institutions that train primary care physicians
pursuant d) above;
iv. Other information that OSHPD or the
board finds relevant to assist the board in
making its recommendations on possible locations
for new residency positions;
i. Monitor the residencies established pursuant
to this chapter; and,
j. Prepare and submit an annual report to the
Foundation and the Legislature documenting the amount
of money contributed to the fund by the Foundation,
the amount of money expended from the fund, the
purposes of those expenditures, the number and
location of residency positions established and
funded, and recommendations for the location of future
residency positions.
11.Establishes the Medical Residency Training Fund is hereby
created within the State Treasury. Specifies that the primary
purpose of the fund is to allocate funding for new residency
positions throughout the state and requires money in the fund
to also be used to pay for the cost of administering the goals
of the Foundation, and for any other purpose authorized by
this bill.
12.Makes the level of expenditure by OSHPD for the
administrative support of the Foundation is subject to review
and approval annually through the State Budget process.
13.Permits OSHPD and the Foundation to solicit and accept public
and private donations for deposit in the fund, and makes all
money in the fund continuously appropriated to OSHPD for the
purposes of this chapter. Requires OSHPD to manage this fund
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prudently in accordance with applicable laws.
14.Requires any regulations adopted to implement this to be
emergency regulations, as specified.
FISCAL EFFECT :
This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, California has a
critical shortage of primary care physicians. In order to
maintain our current rate of utilizations, we must train 8000
more primary care physicians by 2030. Our statewide shortage
is further aggravated by misdistribution. Only 16 of
California's 58 counties meet the recommended 60-80 primary
care physicians per 1,000 people. With an increasing Medi-Cal
population, these already underserved areas will see their
services stretched even thinner. SB 22 will create a voluntary
public-private partnership to fund additional primary care
physician residency positions to be placed in these
underserved areas of California. By providing a state match of
up to $20 million for private contributions, SB 22 would
create a fund to provide additional residency positions while
allowing a state sanctioned but privately run non-profit
organization have a say in the distribution of the positions
within these areas. By working closely with private and public
stakeholders, the bill aims to create a consensus based
solution to meet the need for more doctors in California as
access to healthcare continues to grow.
2.Primary Care in California. California is home to the largest
number of primary care physicians and nurse practitioner in
the country. However, the state ranks 23rd in the number of
primary care physicians per resident. An August 2014 report
by the California HealthCare Foundation states that California
has only 35 to 49 primary care physicians per 100,000 Medi-Cal
enrollees. Federal guidelines call for the state to have 60
to 80 doctors per 100,000 patients. The supply of primary
care physicians also varies substantially across California's
counties. The number of primary care physicians actively
practicing in California counties is, in too many cases, at
the bottom range of, or below, the state's need. According to
2011 Health Resources and Services Administration (HRSA) data,
29 of California's 58 counties fall at the lower end, or
below, the needed supply range for primary care physicians.
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In other words, half of Californians live in a community where
they do not have adequate access to the health care services
they need.
3.The Affordable Care Act (ACA). Under the ACA, about five
million Californians have enrolled in either private insurance
or Medi-Cal. There are now 12 million Medi-Cal enrollees,
about one third of California's population. The newly insured
will increase demand for health care from an already strained
system. Furthermore, the ACA will change how care is
delivered. It provides incentives for expanded and improved
primary care, which may affect demand for some health care
professionals more than others, and encourages the creation of
team-based models of service delivery. Research indicates
that health care reform will place higher skill demands on all
members of the health care workforce as systems try to improve
quality while limiting costs. The scale of change with health
care reform is unlike anything that California has previously
faced. Studies have found that persons with health insurance
use more health care services than uninsured persons,
particularly in primary care and preventive services. This
was found in Massachusetts, which experienced a substantial
increase in demand for primary care services as a result of
its 2006 health reform. A February 2, 2015 article in the San
Jose Mercury News reported that the primary care physician
shortage combined with the millions of newly insured has
resulted in significant delays in seeing a doctor and crowded
emergency rooms. According to the Mercury News article, "?
many experts say the problems are so widespread they shouldn't
be ignored."
4.Current workforce development programs. The state currently
operates a number of programs designed to increase the number
of health care professionals practicing in medically
underserved areas:
a. Health Professions Education Foundation (HPEF)
Established in 1987 and housed within OSHPD non-profit,
HPEF is a non-profit Foundation statutorily created to
provide financial incentives to aspiring and practicing
health professionals. The Foundation offers six
scholarships and seven loan repayment programs in several
allied health professions, including nursing, mental
health, dentistry, and medicine. Scholarship programs
provide financial assistance to healthcare students who
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are attending a California accredited college or
university and agree to practice in California's
underserved communities upon graduation. Loan repayment
programs are offered to working health professionals to
assist in repayment of their education debt in exchange
for a service obligation. Service obligations are
typically one to three years, and vary depending on the
program. Awards range from $4,000 to $105,000 dependent
on profession and length of service obligation. HPEF has
increased access to care in the state's underserved areas
via 6,693 awards totaling more than $60 million to health
practitioner awardees serving in 57 of the state's 58
counties.
b. California State Loan Repayment Program (SLRP)
Provides educational loan repayment assistance to primary
health care professionals who provide health care
services in federally designated Health Professional
Shortage Areas (HPSAs). Eligible health professionals
include physicians specializing in primary care fields,
nurse practitioners, certified nurse-midwives, general
practice dentists, registered dental hygienists, clinical
or counseling psychologists, clinical social workers,
licensed counselors, pharmacists, physician assistants,
psychiatric nurse specialists, and marriage and family
therapists. Eligible health professionals must be
employed by or have accepted employment at a SLRP
Certified Eligible Site (which includes rural health
clinics, community health clinics, county facilities, and
federally qualified health centers) and must commit to
providing full-time or half-time primary care services in
a HPSA for a minimum of two years. Health professionals
may receive up to $50,000 in exchange for a two year
full-time service obligation and/or $25,000 for a two
year half-time service obligation; individuals can
receive up to $150,000 over six years at full-time and
$75,00 for half-time. SLRP award amounts are matched by
the site(s) in which the health professional is
practicing, on a dollar-for-dollar basis, in addition to
salary. The SLRP is funded through a grant from the HRSA,
Bureau of Clinician Recruitment and Service, National
Health Service Corps (NHSC) and is administered by OSHPD.
c. Song-Brown Program The Song-Brown Program was
established in 1973 under Health and Safety Code Section
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128200-128241 to increase the number of family physicians
in the state and increase the number of family medicine
residency programs. Currently, Song-Brown provides
financial support to family medicine and primary care
residency (Internal Medicine, OB/GYN and Pediatric)
programs, family nurse practitioner programs, primary
care physician assistant training programs, and
registered nurse education programs. Funding is provided
to institutions that provide clinical training and
education in underserved areas, and healthcare to the
state's underserved population.
d. Mini Grants Program (Mini Grants) Provides grants
to organizations supporting underrepresented and
economically disadvantaged students in pursuit of careers
in health care. Organizations receive grants of up to
$15,000 to engage in health career conferences,
workshops, and/or career exploration activities. Since
2005, over $2.2 million has been awarded to support
organizations engaging in these activities serving nearly
56,000 students statewide. In 2014 to2015, via partial
funding from Mental Health Services Act (MHSA) Workforce
Education and Training, the California Endowment, and the
California State Office of Rural Health, OSHPD awarded 46
Mini Grants to organizations for a sum of $603,706. This
will help support 16,555 students from demographically
underrepresented groups to pursue healthcare careers.
e. California Student/Resident Experiences and
Rotations in Community Health (CalSEARCH) Provides grants
to organizations that support student and resident
rotations from primary care and mental health disciplines
in community clinics, health centers, and public mental
health system sites which expose students, residents and
practitioners to underserved communities. Organizations
awarded receive funding to administer the program and to
provide students, residents, and preceptors and mentors a
small stipend for completing the program. In addition to
completing a rotation in an underserved area,
participants are also required to complete a community
project. From 2009 to 2012, 150 students and residents
were supported via an American Recovery and Reinvestment
Act grant. In 2014 to2015, via funding from the MHSA
Workforce Education and Training and The California
Endowment, OSHPD granted 12 awards to organizations for a
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sum of $317,000 which will help support 92 participants
statewide.
f. MHSA Workforce Education and Training (WET) Program
Funded by Proposition 63, this program remedies the
shortage of mental health practitioners in the public
mental health system (PMHS) via: career awareness; PMHS
rotations; retention grants; stipends; loan repayments;
grants to expand capacity of education and residency
programs; grants to increase and retain consumer and
family member employment; and grants to support regional
partnerships.
5.Prior legislation. SB 1416 (Rubio and Hernandez) of 2012 would
have created the Graduate Medical Education Trust Fund for the
purpose of funding grants to graduate medical education
residency programs in California, and would have required
OSHPD to develop criteria for distribution of available
moneys. SB 1416 was held in the Assembly Appropriations
Committee
SB 635 (Hernandez) would have required funds deposited in the
Managed Care Administrative Fines and Penalties Fund in excess
of $1 million be transferred each year to OSHPD for the
purposes of the Song-Brown Program. SB 635 was held in the
Assembly Appropriations Committee.
AB 589 (Perea), Chapter 339, Statutes of 2012, establishes the
Steven M. Thompson Medical School Scholarship Program and
would provide that the program is open to persons who agree in
writing, prior to entering an accredited medical or
osteopathic school, to serve in an eligible practice setting,
as defined, for at least three years.
AB 2551 (Hernandez), of 2010, would have established the
Health Workforce Development Fund, consisting of moneys
received from federal and private sources, as specified; would
have authorized the Fund to be used, upon appropriation by the
Legislature, for prescribed purposes relating to health
workforce development, and would have required the California
Workforce Investment Board and OSHPD to report specified
information to the Legislature annually, as specified. AB 2551
failed passage on the Senate Floor.
AB 657 (Hernandez) of 2009 would have required OSHPD, in
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collaboration with the California Workforce Investment Board,
to establish the Health Professions Workforce Task Force,
composed of specified members, to assist in the development of
a health professions workforce master plan for the state and
would have prescribed the functions and duties of the task
force in that regard. AB 657 was vetoed by the Governor, who
stated, in part, that the bill was unnecessary and duplicative
of efforts already underway.
AB 2375 (Hernandez), of 2008, would have required OSHPD to
establish the Health Professions Workforce Task Force, as
specified, to assist in the development of a health
professions workforce master plan. AB 2375 was held in the
Senate Appropriations Committee on suspense.
AB 2439 (De La Torre), Chapter 640, Statutes of 2008, requires
the Medical Board of California (MBC) to assess an additional
$25 fee for the initial license and license
renewal of a physician or surgeon to support the STPCLRP.
Requires up to 15 percent of the funds collected from the
additional $25 fee to be dedicated to loan assistance for
physicians who agree to practice in geriatric care settings,
as specified.
AB 327 (De La Torre), Chapter 293, Statutes of 2005, requires
the MBC to assess an applicant a $50 fee for the issuance and
renewal of a physician and surgeon's certificate. Specifies
that payment of the fee is voluntary and directs the fees to
the Medically Underserved Account for the STPCLRP.
AB 920 (Aghazarian), Chapter 317, Statutes of 2005, provides
for the transfer of the
STPCLRP and the Physician Volunteer Program from the MBC to
the California Physician Corps Program within the Foundation,
effective July 1, 2006.
AB 1403 (Nunez), Chapter 367, Statutes of 2004, renames the
California Physician Corps Loan Repayment Program of 2002 as
the STPCLRP.
AB 982 (Firebaugh), Chapter 1131, Statutes of 2002, creates
the California Physician Corps Loan Repayment Program of 2002.
This program is administered by the Division of Licensing of
MBC for the purpose of granting loan repayment awards to
physicians and surgeons working in medically underserved
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communities.
6.Support. The Association of California Healthcare Districts
writes that funding graduate medical residency programs will
make it financially more feasible for students to afford
higher quality education and training. In turn, this would
increase the number of residents in the area who are able to
provide higher quality healthcare services for those in need.
The Community Clinic Association of Los Angeles County
believes this is important legislation that supports the
primary care workforce necessary to serve underserved
communities. The AARP believes that significant legislation
is needed to deal with shortages and unequal geographic
distribution of health care professionals, most notably
primary-care physicians and nurses.
7.Support in concept. The MBC supports the concept of
increasing funding for residency programs and positions in
California, as this would help promote MBC's mission of
increasing access to care for consumer. However, this bill
does not specify which public-private partnerships would be
funding the California Medical Residency Training Fund.
8.Support if amended. The California Medical Association writes
that it is not appropriate to suggest that the various
appointing authorities consider an individual or
organization's ability to fundraise as a factor in making
appointments to the Foundation board and that it is not in the
public interest to have corporations and other wealthy
interests having "significant control over the geographic
dispersion of funds," as stated by the author's office.
9.Author's amendments. The author request the Committee approve
an amendment to add the following language to the bill:
SECTION 7: Section 128596 is added to the Health and Safety
Code to read:
128596. Notwithstanding any other law, the office may exempt
from public disclosure any document in the possession of the
office that pertains to a donation made pursuant to this
chapter if the donor has requested anonymity.
SECTION 8: Section 128597 is added to the Health and Safety
Code to read:
128597.
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(a) This chapter shall become operative only upon
certification by the Director of the Department of
Finance that sufficient private funds have been made
available from private sources to implement this chapter.
(b) Upon this chapter becoming operative, the State
General Fund shall annually deposit into the Fund an
amount equal to the contribution received by the Fund
from the Foundation in the preceding fiscal year, not to
exceed 20 million dollars annually.
SUPPORT AND OPPOSITION :
Support: AARP
Association of California Healthcare Districts
California Academy of Physician Assistants
California Physical Therapy Association
California Primary Care Association
Community Clinic Association of Los Angeles County
Oppose: None received.
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