BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 289
---------------------------------------------------------------
|AUTHOR: |Mitchell |
|---------------+-----------------------------------------------|
|VERSION: |April 6, 2015 |
---------------------------------------------------------------
---------------------------------------------------------------
|HEARING DATE: |April 29, 2015 | | |
---------------------------------------------------------------
---------------------------------------------------------------
|CONSULTANT: |Teri Boughton |
---------------------------------------------------------------
SUBJECT : Telephonic and electronic patient management services
SUMMARY : Requires a health plan or health insurer to cover telephonic
and electronic patient management services provided by a
physician or non-physician health care provider and reimburse
those services based on their complexity and time expenditure,
as specified.
Existing law:
1.States legislative intent to recognize the practice of
telehealth as a legitimate means by which an individual may
receive health care services from a health care provider
without in-person contact with the health care provider.
2.Prohibits a health plan or health insurer from requiring
in-person contact between a health care provider and a patient
before payment is made for the covered services appropriately
provided through telehealth, subject to the terms and
conditions of the contract entered into between the enrollee
or subscriber and the health plan or the insured and health
insurer, and between the health plan or health insurer and its
participating providers or provider groups.
3.Prohibits a health plan or health insurer from limiting the
type of setting where services are provided for the patient or
by the health care provider before payment is made for the
covered services appropriately provided through telehealth,
subject to the terms and conditions of the contract entered
into between the enrollee or subscriber and the health plan or
the insured and the health insurer, and between the health
plan or health insurer and its participating providers or
provider groups.
SB 289 (Mitchell) Page 2 of ?
4.Applies 2) and 3) above to health care and Medi-Cal managed
care plan contracts with the State Department of Health Care
Services (DHCS).
5.Prohibits existing law from being interpreted to authorize a
health plan or health insurer to require the use of telehealth
when the health care provider has determined that it is not
appropriate.
6.Establishes the Department of Managed Health Care (DMHC) to
regulate health plans and the California Department of
Insurance (CDI) to regulate health insurers, and other
insurance carriers and insurance agents.
7.Defines "Telehealth" as the mode of delivering health care
services and public health via information and communication
technologies to facilitate the diagnosis, consultation,
treatment, education, care management, and self-management of
a patient's health care while the patient is at the
originating site and the health care provider is at a distant
site. Telehealth facilitates patient self-management and
caregiver support for patients and includes synchronous (real
time) interactions and asynchronous store and forward
transfers.
This bill:
1.Requires a health plan or health insurer, with respect to plan
contracts or insurance policies issued, amended or renewed on
or after January 1, 2016, to cover telephonic and electronic
patient management services provided by a physician or
non-physician health care provider and reimburse those
services based on their complexity and time expenditure.
2.Requires all laws regarding the confidentiality of health
information and a patient's rights to his or her medical
information to apply to telephonic and electronic patient
management services.
3.Prohibits a plan or insurer from requiring the use of
telephonic and electronic patient management services when
those services are not medically appropriate, and, the
altering of the scope of practice of a health care provider,
or, authorizing the delivery of services in a setting, or in a
manner, that is not otherwise authorized by law.
SB 289 (Mitchell) Page 3 of ?
4.Excludes a patient under the jurisdiction of the Department of
Corrections and Rehabilitation or any other correctional
facility.
5.Excludes from 1) above separate reimbursement for a telephonic
or electronic visit:
a. That is related to a service or procedure
provided to an established patient within a reasonable
period of time prior to the telephonic or electronic
visit, as recognized by the American Medical
Association (AMA), Current Procedural Terminology
(CPT) codes;
b. That leads to a related service or procedure
provided to an established patient within a reasonable
period of time, or within an applicable postoperative
period, as recognized by the AMA, CPT codes;
c. Provided as part of a bundle of services for
which reimbursement is provided for on a prepaid
basis, including capitation, or for which
reimbursement is provided for using an episode-based
payment methodology; and,
d. That is not initiated by the established
patient, or the parents or guardians of a minor who is
an established patient, or an established patient's
legally recognized health care decision-maker.
6.Permits a health plan or health insurer to require
documentation reasonably relevant to a telephonic or
electronic visit, as recognized by the AMA, CPT codes.
7.Defines "established patient" as a patient who, within three
years immediately preceding the telephonic or electronic
visit, has received professional services from the provider or
another provider of the exact same specialty and subspecialty
who belongs to the same group practice.
8.Defines "telephonic and electronic patient management
services" as the use of electronic communication tools to
enable treating physicians to evaluate and manage established
patients in a manner that does not require an in-person visit
with the physician or non-physician health care provider; are
initiated by the established patient, the parents or guardians
of a minor who is an established patient, or an established
patient's legally recognized health care decision-maker; and,
SB 289 (Mitchell) Page 4 of ?
are recognized by the AMA CPT codes.
9.Excludes a visit for which a provider or staff contacts a
patient to initiate services.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, while all states
define telehealth differently, 40 states mandate some kind of
Medicaid telehealth coverage and 21 states mandate telehealth
coverage by private payors. California has limited allowances for
telehealth coverage within Medi-Cal, but it does not mandate
coverage for private payors. Is it important that payors recognize
that they may not deny coverage simply on the basis that the
serviced was provided via telehealth, if it would have been
covered if provided through an in-person consultation. This bill
will require health insurance companies licensed in California to
reimburse physicians for telephone and electronic patient
management telehealth services. This bill also clarifies that
insurance companies must reimburse physicians for telephone and
electronic patient management telehealth services and ensures that
all patients can receive the care they need in an accessible and
efficient way.
2.California Health Benefits Review Program (CHBRP) analysis.
AB 1996 (Thomson), Chapter 795, Statutes of 2002, requests the
University of California to assess legislation proposing a
mandated benefit or service and prepare a written analysis
with relevant data on the medical, economic, and public health
impacts of proposed health plan and health insurance benefit
mandate legislation. CHBRP was created in response to AB 1996.
As indicated in its report of SB 289, CHBRP assumes that
coverage and reimbursement would apply to four telehealth
modalities: Telephone, email, live videoconferencing, and
store-and-forward technology (capture and storage of medical
information such as x-ray, photograph, sound that is forwarded
for evaluation).
a. Medical effectiveness. CHBRP indicates there is
insufficient evidence to determine whether services
provided via telephone or e-mail is as effective as
medical care provided in person. Furthermore, it is
SB 289 (Mitchell) Page 5 of ?
unknown whether diagnoses made using these technologies
are as accurate as diagnoses made during in-person
visits. The studies of the effect of telephone
consultations or email communication on subsequent
utilization are inconsistent. However, in diabetes,
there is a preponderance of evidence from moderately
strong studies that email communication within a
multifaceted web portal is associated with better
glycemic control. For the disease and conditions
studied, there is a preponderance of evidence that
medical care provided by live videoconferencing and
store-and-forward is at least as effective as medical
care provided in-person for both physical and mental
health conditions. In particular, there is clear and
convincing evidence that live videoconferencing is
equivalent to in person care in psychiatric health
outcomes. The evidence suggests that store-and-forward
technology reduces wait times for specialty outpatient
care.
b. Benefit coverage. Approximately 48 percent of
California's 24.6 million enrollees with state-regulated
health insurance currently have some form of benefit
coverage for telephone and email evaluation and
management visits, while 78 percent have benefit coverage
for live videoconferencing and store-and-forward
evaluation and management visits. Post mandate all 24.6
million enrollees will have coverage. California's
Medi-Cal managed care plans include coverage for live
videoconferencing and store-and-forward but do not
reimburse separately for telephone and e-mail encounters.
c. Capacity and access. CHBRP finds limited evidence
that this bill would increase the capacity of physicians
and non-physicians to see additional patients because the
bill limits coverage and reimbursement to encounters with
similar complexity and time expenditure as in-person
visits, and physicians and non-physicians who are part of
a practice with an existing relationship with the
patient.
d. Utilization and cost. CHBRP estimates overall
encounters would increase between 4.5 percent and 20
percent. Telehealth, as a share of all visits would
range between 7.4 percent to 29.2 percent, while
in-person visits would decrease by .9 percent to 15
percent. CHBRP estimates that in-person visits would
SB 289 (Mitchell) Page 6 of ?
decline slightly in all scenarios modeled, but overall
patient-provider encounters would increase. In the low
take up scenario 40 percent of the increase is
substitution of telehealth services for in-person visit
and 60 percent of the increase is supplemental. In the
low-enhanced take up scenario, CHBRP assumes that of the
seven percent increase in year one, 90 percent of the
increase is supplemental. CHBRP indicates average costs
per visit are as follows: Telephone: $67.62 ($0-$10
copayment), E-mail: $57.71 ($0-$10 copayment), Live
Videoconferencing: $101.66 ($0-$20 copayment),
Store-and-Forward: $82.75 ($0-$20 copayment).
e. Impact on expenditures. According to CHBRP,
depending upon the scenario, total expenditures are
estimated to increase by $46.7 million to $207.3 million.
The percent change of premium expenditures by payer
ranges from a low of .03 percent ($16 million for private
employers for group insurance) based on low take up to a
high of .13 percent ($75 million for private employers
for group insurance) for high take up. Enrollees for
individual purchased insurance would have a percent
change of premium expenditure of between .07 percent ($15
million based on low take up) to .32 percent ($69 million
based on high take up). Enrollee out-of-pocket expenses
for covered benefits are expected to increase .05 percent
($7.5 million) to .21 percent ($33.1 million). The
estimated increases in expenditures under the low take up
scenario equate to per member per month premium (pmpm)
increases ranging from a low of $0 for Medi-Cal managed
care to a high of $.40 for CDI regulated individual and
small group market. The estimated increases in
expenditures under the high take up scenario equate to
pmpm premium increases ranging from a low of $0 Medi-Cal
managed care pmpm to a high of $1.77 for CDI regulated
individual and small group market.
f. Public health impacts. CHBRP estimates that
positive mental health and dermatologic outcomes could
occur for some newly covered enrollees with these
conditions. CHBRP estimates patient experience would
improve as physicians increase their email and telephone
responses to patient-initiated inquiries. The
improvement is partly attributable to increasing the
overall convenience for patients, such as reducing wait
times for some visits. CHBRP also estimates travel costs
and loss of productivity for some enrollees would
SB 289 (Mitchell) Page 7 of ?
decrease but is unable to quantify the impact.
g. Interaction with EHB. CHBRP indicates that this
bill does not appear to exceed EHBs. This bill does not
add services health insurers must cover, but affects the
setting in which already covered services are provided.
3.CPT Codes. CPT codes are used to report episodes of patient
care initiated by an established patient or guardian of an
established patient. If the telephone service ends with a
decision to see the patient within 24 hours or next available
urgent visit appointment, the code is not reported; rather the
encounter is considered part of the pre-service work of the
subsequent evaluation and management service, procedure, and
visit. If the telephone call refers to an evaluation and
management service reported within the previous seven days or
within the postoperative period of the previously completed
procedure, then the services is not reported. There are also
CPT codes for telephone services provided by a qualified
non-physician who may report telephone assessment and
management services with similar criteria as described above.
CHBRP included any billable services that do not require a
physical examination by a physician or non-physician and are
considered either evaluation or management of established
patients. CHBRP included CPT codes for evaluation and
management services performed at hospitals, nursing
facilities, custodial care facilities, assisted living
facilities, or at home, and specifically excluded CPT codes
that require a physical exam.
4.Telehealth complaints. CHBRP contacted DMCH and CDI and
identified that there have been 55 complaints since 2009
against health plans and insurers denials of claims related to
telehealth. Most cases relate to coverage for remote patient
monitoring (not addressed in this bill). However, in 2010,
one complaint was filed related to speech therapy via
interactive videoconferencing, and in 2014 two complaints were
related to telephonic treatment with non-physicians: a
nutritionist and mental health professional.
5.Other states, Medicare and Medicaid. Approximately half of
states require reimbursement of live videoconferencing, and
half a dozen states require reimbursement of
store-and-forward. Telephone and email reimbursement is only
required in Oregon, but only in cases where live
videoconferencing is unavailable. According to the CHBRP
SB 289 (Mitchell) Page 8 of ?
analysis, with a few exceptions, the Centers for Medicare and
Medicaid Services (CMS) do not reimburse for telephone and
email communications. Medicare will reimburse for live
videoconferencing in all 50 states if patients are in a rural
Health Professional Shortage Area or in an area with a
shortage of health professionals; and physically located in a
physician office, rural health clinic, or hospital while
receiving live videoconferencing services. Medicare covers
store-and-forward for demonstrations in Alaska and Hawaii, or
teleradiology and remote EKG applications. Most commercial
insurance carriers follow CMS reimbursement decisions.
Forty-five states recognize either live videoconferencing
and/or store-and-forward in their Medicaid programs, primarily
reimbursing for live videoconferencing. Only two state
Medicaid programs require reimbursement for telephone
interactions: Nevada for crisis interactions and Oregon if
live videoconferencing is not available.
6.Prior legislation. AB 1771 (Perez), of 2014, would have
required health plans and health insurers, with respect to
plan contracts and insurance policies issued, amended, or
renewed on or after January 1, 2016, to cover telephone visits
provided by a physician. AB 1771 was held in the Senate
Appropriations Committee.
AB 415 (Logue), Chapter 547, Statutes of 2011, among other
provisions, prohibits DHCS from requiring that a health care
provider document a barrier to an in-person visit prior to
paying for services provided via telehealth to a Medi-Cal
beneficiary. Repeals the prohibition of paying for a service
provided by telephone or facsimile and would instead prohibit
DHCS from limiting the type of setting where services are
provided for the patient. Prohibits health plans and insurers
from requiring that in-person contact occur between a health
care provider and a patient before payment is made for the
services appropriately provided through telehealth, subject to
the terms of the relevant contract. Repeals the prohibition
for paying for a service provided by telephone or facsimile
and would instead prohibit health plans and insurers from
limiting the type of setting where services are provided for
the patient or by the health care provider.
SB 1665 (Thompson), Chapter 864, Statutes of 1996, established
the Telemedicine Development Act (TDA) to set standards for
the use of telemedicine by health care practitioners and
SB 289 (Mitchell) Page 9 of ?
insurers. TDA specifies, in part, that face-to-face contact
between a health care provider and a patient shall not be
required under the Medi-Cal Program for services appropriately
provided through telemedicine, when those services are
otherwise covered by the Medi-Cal program, and requires a
health care practitioner to obtain verbal and written consent
prior to providing services through telemedicine.
7.Support. According to the California Medical Association
(CMA) payors in the state vary in reimbursing for these
telehealth services and often deny provider requests for
coverage of this time spent providing substantive medical
advice, depriving patients of a reasonable alternative to
in-person provider evaluations. Telephone and electronic
patient management services include a provider giving medical
advice in response to a patient communication, potentially
making a new diagnosis, or providing self-care or patient
education information for a new health problem. These
services are intended to facilitate the diagnosis,
consultation, treatment, education, care management and
self-management of the patient's health care and caregiver
support. These services ensure better continuity of care,
faster and more convenient treatment, as well as reduce lost
work time. The Occupational Therapy Association of California
supports this bill because it will allow OTs to utilize
telephone interaction for patient services where appropriate.
The California Association of Physician Groups (CAPG ) writes
that this bill clarifies that coverage is provided for these
services because some health plans have not kept up with
physician group's technological capabilities to provide
patient visits through electronic means, even when conducted
within capitated payment models, at no additional cost to the
health plan. CAPG groups have experienced problems with
health plans using telephonic and telehealth systems to
provide care access to their enrollees through out-of-state
physicians that are not part of the health plan's contracted
network. The California Chronic Care Coalition writes that
electronic services are especially convenient in rural and
remote areas as they allow a patient the ability to avoid long
and unnecessary trips to the medical provider's office.
8.Opposition unless amended. The California Association of
Health Plans and the Association of California Life and Health
Insurance Companies (ACLHIC) request amendments that patients
be notified at the time of the phone call or electronic
SB 289 (Mitchell) Page 10 of ?
monitoring that the service is subject to any share of cost
that would otherwise apply for an office visit, allow a health
plan to request prior authorization for the services that
qualify as a separately billable service, permit an adjustment
of the Medi-Cal managed care rate, amend the Insurance code to
exempt a carrier from making a separate payment to a provider
for telephone calls if the carrier pays the provider according
to a negotiated rate, and clarification on what is considered
"electronic patient management services." ACLHIC also
requests the bill include a delayed effective date of January
1, 2017.
9.Opposition. The California Chamber of Commerce writes that
all coverage mandates, even ones that can improve outcomes or
efficiencies for some patients are less valuable for others,
and most are apt to increase the cost of premiums. For some,
a lower premium might allow better access to care than the
availability of video teleconferencing. The Chamber also
indicates that they are opposed to the imposition of new
mandates on health care coverage beyond what is required under
the ACA, particularly since the growth of health care costs
has started to pick up again and many are struggling to afford
coverage and growing out-of-pocket costs.
10.Amendments.
a. The definition of "telephonic and electronic patient
management services" needs to be amended to enable
treating physicians "and non-physician providers" to
evaluate and manage established patients?
b. Subdivision (a) needs to be amended to ensure that
telephonic and electronic patient management services
that are covered under this bill are provided by a
"contracted" physician or "contracted" non-physician
health care provider?
SUPPORT AND OPPOSITION :
Support: California Medical Association (sponsor)
California Academy of Family Physicians
California Association of Physician Groups
California Chronic Care Coalition
California Healthcare Institute
California Physical Therapy Association
Occupational Therapy Association of California
Oppose:Association of California Life and Health Insurance
SB 289 (Mitchell) Page 11 of ?
Companies (unless amended)
California Association of Health Plans (unless
amended)
California Chamber of Commerce
-- END --