BILL ANALYSIS Ó SB 613 Page 1 Date of Hearing: July 14, 2015 ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE Cheryl Brown, Chair SB 613 (Allen) - As Amended July 6, 2015 SENATE VOTE: 40-0 SUBJECT: State Department of Public Health: dementia guidelines: workgroup. SUMMARY: Makes legislative findings describing the public costs of Alzheimer's disease (AD), and the public benefits of peer-reviewed, evidence-based research to inform Alzheimer's disease management; directs the Department of Public Health (DPH) to convene a "workgroup" to update the physician " Guidelines for Alzheimer's Disease Management (April, 2008);" and, requires the Department to report those updates to the Legislature by March 1, 2017. Specifically, this bill: 1)Makes Legislative findings and declarations that: a. Approximately 60,000 to 85,000 people enrolled in the Coordinated Care Initiative (CCI) pilot project suffer from dementia; b. The costs of individuals who are dually eligible for SB 613 Page 2 Medicare (aged 65+ or disabled for 2+ years) and Medi-Cal (generally, income below 138% of the Federal Poverty Level/FPL) is nineteen times higher than average spending for all others on Medi-Cal who are 65 years of age or older; c. The three overlapping goals of the CCI, the Patient Protection and Affordable Care Act/P.L. 111-148 (ACA), and Medicaid (Medi-Cal) are improved health, better care, and lower costs; and, d. Peer-reviewed and evidence-based research proves that dementia care management achieves each of the three goals. 2)Directs DPH to convene a workgroup consisting of members determined by the department, including but not limited to experts in Alzheimer's disease detection, diagnosis, treatment and support. 3)Sunsets the provisions of the bill on January 1, 2018. EXISTING LAW: 1)Designates the Secretary of California Health and Human Services to be responsible for the oversight and coordination of programs serving people living with Alzheimer's disease and related disorders and their families, including, but not limited to state level support and assistance to all programs within the Health and Human Services Agency and member departments. SB 613 Page 3 2)Establishes DPH, which oversees various public health programs, including programs related to genetic diseases such as AD, and requires DPH to provide public and professional education on AD to educate consumers, caregivers, and health care providers, and to increase public awareness. 3)Establishes geographically dispersed diagnostic and treatment centers for Alzheimer's disease within every postsecondary higher educational institution with a medical center to encourage research to discover the cause of, and a cure for, Alzheimer's disease, and: a. To provide diagnostic and treatment services and improve the quality of care to victims of Alzheimer's disease. b. To increase research by faculty and students in discovering the cause of, and a cure for, Alzheimer's disease. c. To provide training, monitoring, consultation, and continuing education to the families of those who are affected by Alzheimer's disease. d. To increase the training of health care professionals with respect to Alzheimer's disease and other acquired brain impairments to the extent that the centers have the requisite expertise. SB 613 Page 4 4)Establishes the Alzheimer's Disease Program (ADP) in DPH to relieve the human burden and economic costs associated with AD and related dementias, and to assist in ultimately discovering the cause, treatment, and prevention of these diseases. 5)Requires the California Health and Human Services Agency to establish an Alzheimer's Disease and Related Disorders Advisory Committee consisting of 14 members to: a. Provide ongoing advice and assistance to the Administration and the Legislature as to program needs and priorities; and, b. Provide planning support to the Administration and the Legislature by updating recommendations of the 1987 California Alzheimer's Disease Task Force Report and regularly reviewing and updating recommendations as needed. FISCAL EFFECT: This bill has not yet been analyzed by the Assembly Committee on Appropriations. The Senate Committee on Appropriations identified "(M)inor costs to provide support to the workgroup. The Department has already begun the process for reviewing the available literature and updating the guidelines using an existing federal grant. The additional responsibilities in the bill should impose minor costs on the Department." COMMENTS: SB 613 Page 5 1)Author's Statement: "Alzheimer's disease is a public health crisis in California, but unlike other public health concerns there is no known cause, cure or prevention to reduce the impact on individuals, families, communities and our state's public programs such as Medi-Cal and In Home Supportive Services (IHSS). We've seen a 42% increase in just the last decade. Experts agree that managing the course of Alzheimer's disease after a diagnosis is the best public health strategy we have available today. SB 613 proposes a statewide working group under the leadership of the California Department of Public Health, drawing on the existing resources and expertise of our state's 10 university-affiliated Alzheimer's Disease Centers. Our own experts will update the physician Guideline for Alzheimer's Disease Management to systematically improve quality of care, better manage complex patient populations, and lower public costs associated with Medi-Cal-funded hospital stays and nursing home placements. When someone in California learns they have Alzheimer's, there should be evidence-based, up to date, guidelines for physicians to follow to ensure the patients receive the care and support they need." 2)Background on Alzheimer's Disease: An estimated 550,000 Californians have AD. Research supported by the National Institute of Aging and the Alzheimer's Association states that the nation's growing elderly population will drive a 300 percent increase in the number of AD cases over the next four decades. The organization's estimate that by 2050 there will be approximately 1.3 million Californians living with AD. Between 1990 and 2000, mortality rates of persons with AD increased 74 percent. AD was the 8th leading cause of death in the state in 2004, with a total of 6,962 deaths, a five percent increase from the death rate in 2000. Of these deaths, nearly 70 percent were women, and over 99 percent occurred among residents 65 years of age and older. In SB 613 Page 6 California, Caucasians comprised 84.4 percent of the deaths, followed by Latinos with 6.9 percent, African Americans with 5.1 percent and Asians with 3.4 percent. Data shows the proportion of deaths increased with age and that over 61 percent of these deaths occurred among residents 85 years of age and older. 3)State Plan on Aging: In 2003, the California Health and Human Services Agency issued a strategic plan to address issues facing the state's growing aging population. The plan cites a substantial growth in the need for long-term care options, including options for Alzheimer's patients, and recommends an expansion of community-based services including home health, adult day care and Alzheimer's Disease Diagnostic and Treatment Centers. The plan also cites greater needs for early diagnostic testing for Alzheimer's, recommends more support and respite programs for caregivers, and proposes dementia training for health professionals and others who interact with, and provide care to, persons with AD. 4)Alzheimer's State Plan: In 2011, DPH issued the " California State Plan For Alzheimer's Disease: An Action Plan for 2011-2021 " to promote person-centered care that is responsive to individual need, addresses the broad cultural, ethnic, racial, socio-economic and demographic diversity of California's population, provides recommendations to integrate the social and medical needs of this and other aging SB 613 Page 7 populations. According to the plan, "(T)he number of Californians living with Alzheimer's disease will nearly double, growing to over 1.1 million. Due to a rapidly aging population, the increase will be even more dramatic among California's Asians and Latinos, who will see a tripling in those affected by 2030. With the enormous growth in the number of Californians living with Alzheimer's disease there will be a substantial increase in family caregiving demands, both emotionally and financially. The economic value of unpaid care is expected to rise from $37.2 billion to $72.7 billion. Costs of formal services, including traditional medical and social supports, are expected to jump from $16 billion to $31.3 billion by 2030. Demographic data indicates that legions of older Californians are now living alone - without the support of a spouse, adult child or other relative - placing new demands on more costly, formal services. The care and support of people living with Alzheimer's and related disorders also impacts state and federal governments. Unless the State takes steps to provide better support in the home and community for those who are affected by this condition, volume alone will cripple public resources." 5)Senate Select Committee on Aging and Long-Term Care Findings: In January, the State Senate Select Committee on Aging and Long-Term Care released an exhaustive assessment of issues and challenges confronting the state of California. "A Shattered System: Reforming Long-Term Care in California" identified ten critical interrelated policy areas which have a critical impact upon the services delivery of services for older adults and people with disabilities. According to the report, AD incidence will exceed 1,100,000 people in California within 20 years, and that this demographic reality brings with it significant implications for the health care and long-term care services delivery system, including substantial increases in caregiving and service needs. SB 613 Page 8 6)Disease Management: According to the Disease Management Association of America, an effective working definition for Disease management is: "A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management: Supports the physician or practitioner/patient relationship and plan of care, Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. Disease management components include: Population identification processes, Evidence-based practice guidelines, Collaborative practice models to include physician and support-service providers, Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance), SB 613 Page 9 Process and outcomes measurement, evaluation, and management, and, Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)." Disease management strategies are often organized throughout health systems for a range of chronic conditions. In the "disease management" context, processes that deliver and provide services are often as important as the service itself, since the efficient delivery of those services assures the broadest and most beneficial impact. Health care systems say they benefit when they focus greater attention on the development of care processes for common conditions that afflict many people. Disease management has emerged as a strategy to enhance the quality of care. Success with cardio vascular disease management has improved patient outcomes and significantly reduced costs over time. Further interest in disease management strategies is due in part to the aging population, which is creating increasing demand for effective cost and quality care models. 1)Guidelines for Alzheimer's Disease Management: Since 2000, the state has overseen the development of, communication, distribution, and coordination of Alzheimer's Disease Management. The current report published in 2008 describes the rapid development of pharmacological interventions which occurred between 2002 and 2008. These pharmacological SB 613 Page 10 developments impacted the information primary care providers and health care providers used to make decisions about patient care, services and supports. Besides pharmacological advancements, additional advancements in the way cultural and linguistic factors impact Alzheimer's disease treatment and family care; the processes associated with legal capacity evaluations were impacted; and special needs were identified for early-stage and late-stage patients and their families. This year, the Assembly Committee on Aging and Long-Term Care heard a presentation by Dr. Dale Bredesen regarding breakthrough research demonstrating improved functioning for people with AD when a broad, multi-faceted strategy involving diet, exercise, sleep, and 33 other variables is implemented. Guidelines for Disease Management may ultimately inform all health care providers of such strategies in order to assure that the most people benefit from these and other developments. Related Legislation AB 1744 (Brown) of 2014 proposed to require, until January 1, 2018, the California Department of Aging to establish a blue-ribbon task force comprised of at least 13 members, as specified, to make legislative recommendations to improve services for unpaid and family caregivers. AB 1744 was vetoed by the Governor, who stated: "The California State Plan on Aging, the California Plan for Alzheimer's Disease, the significant reports and action plans developed by the 33 Area Agencies on Aging, SB 613 Page 11 the Alzheimer's Association, the AARP and so many others have produced ample evidence for knowledgeable and caring people to recommend ways to improve support for family caregivers. Establishing another task force in state law simply isn't necessary." SB 491 (Alquist), Chapter 339, Statutes of 2008, established California's State Plan for Alzheimer's Disease under the California Health and Human Services Agency. The State Plan called for an update to the 2008 physician Guideline and made physician education a top priority for California. SB 321 (Alquist) was passed by the Assembly Aging and Long-Term Care Committee in 2007, but subsequently held in the Assembly Appropriations Committee. SB 639 (Ortiz), Chapter 692, Statutes of 2001, required development of a strategic plan to improve access to mental health services for people with AD and related dementias. REGISTERED SUPPORT / OPPOSITION: Support Alzheimer's Association - Sponsor American Federation of State, County and Municipal Employees SB 613 Page 12 (AFSCME), AFL-CIO California Assisted Living Association (CALA) National Association of Social Workers, California Chapter (NASW) On Lok Senior Health Services Opposition None on file. Analysis Prepared by:Robert MacLaughlin / AGING & L.T.C. / (916) 319-3990