BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: ACR 62
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AUTHOR: Galgiani
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INTRODUCED: April 20, 2009
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HEARING DATE: July 8, 2009
CONSULTANT:
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Orr/cjt
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SUBJECT
Chronic obstructive pulmonary disease awareness
SUMMARY
Designates Chronic Obstructive Pulmonary Awareness Day and
Month, and makes legislative findings about the prevalence
of the disease. Commends the Department of Health Care
Services for implementing a pilot program for COPD Medi-Cal
beneficiaries.
CHANGES TO EXISTING LAW
Existing law:
Establishes the Medi-Cal program, administered by the State
Department of Health Care Services (DHCS), under which
basic health care services are provided to qualified
low-income persons.
Requires DHCS to apply for a waiver of federal law to test
the efficacy of a disease management program to specified
Medi-Cal beneficiaries. The program is to include use of
evidence-based practice guidelines, supporting adherence to
care plans, and providing patient education, monitoring,
and healthy lifestyle changes.
States that this waiver for disease management is to be
Continued---
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implemented only to the extent that federal financial
participation is available.
This resolution:
States findings related to the prevalence of Chronic
Obstructive Pulmonary Disease (COPD).
Commends the State Department of Health Care Services
(DHCS) for implementing a pilot program in August of 2006
to provide for the chronic disease management of COPD.
Designates November 2009, as COPD Awareness Month and
November 18, 2009, as COPD Awareness Day.
Encourages, but does not require, DHCS to provide interim
updates to the Legislature on the COPD pilot program, and
prepare a report of findings and recommendations in order
to evaluate the effectiveness of the program in reducing
Medi-Cal costs and in providing improved health and
well-being for affected patients.
FISCAL IMPACT
The Assembly Appropriations Committee estimates negligible
costs to the state.
BACKGROUND AND DISCUSSION
The author of this measure seeks to commend DHCS for
implementing this pilot program, and claims that DHCS is
recognizing the financial and clinical burden of this
illness upon the citizens of California. The author
contends that the use of disease management for COPD
presents a great opportunity to improve care for the COPD
population and to control costs.
COPD
COPD is a lung disease process characterized by difficulty
breathing, wheezing, and a chronic cough. It generally
refers to chronic bronchitis and emphysema, a pair of two
commonly co-existing diseases of the lungs in which the
airways become narrowed. This leads to a limitation of the
flow of air to and from the lungs causing shortness of
breath. It is caused by noxious particles or gases, most
commonly from smoking, which trigger an abnormal
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inflammatory response in the lungs. Risk factors also
include exposure to industrial dusts and chemicals,
second-hand smoke, history of childhood respiratory
infections, and heredity. In contrast to asthma, the
limitation of airflow is poorly reversible and usually gets
progressively worse over time. The natural course of COPD
is characterized by occasional sudden worsenings of
symptoms called acute exacerbations, most of which are
caused by infections or air pollution. Complications
include bronchitis, pneumonia and lung cancer.
Disease management programs
Disease management is not well-defined, but generally
refers to a system of coordinated health care interventions
and communications designed to improve patient health
outcomes for a particular disease. The types of
interventions can vary from specialists at a local hospital
hiring a nurse to educate patients about preventive care,
to large-scale programs reaching thousands of patients.
Disease management programs can be offered telephonically,
and/or require an extended series of interactions between
the patient and health professionals. Disease management
emphasizes prevention of exacerbations and complications
utilizing evidence-based practice guidelines and patient
empowerment strategies, and evaluates clinical, humanistic,
and economic outcomes on an on-going basis with the goal of
improving overall health. Patients are expected to play an
active role in managing their diseases.
Some programs may be better than others, but there has not
been enough research to properly assess which ones are the
most effective or what characteristics are associated with
more successful programs. Health insurance plans and
employers nationally in 2005 spent about $1.2 billion on
disease management programs, with 96 percent of the top 150
U.S. health insurance companies offering some form of
disease management service.
A 2007 RAND health study reviewed all past research on
disease management programs, and found consistent evidence
that these programs can improve health care quality,
improve disease control, and in some cases reduce hospital
admission rates. However there was little evidence about
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whether these programs improve health outcomes over the
long term, and no conclusive evidence that they can save
money.
DHCS pilot program
Under authorization of AB 1762 (Committee on Budget,
Chapter 230, Statutes of 2003), DHCS implemented the
Disease Management Pilot Project (DMPP) to test a Disease
Management health delivery model within the Medi-Cal
Fee-For-Service (FFS) system. One portion of the DMPP
focuses primarily on seniors and persons with disabilities
and those with these specific chronic disease conditions:
advanced atherosclerotic disease syndrome; congestive heart
failure; diabetes; asthma; coronary artery disease; and,
chronic obstructive pulmonary disease. The department also
has another pilot project to implement disease management
for Medi-Cal beneficiaries who have been diagnosed with
HIVor AIDS.
The pilot project dealing with COPD is an opt-out program
(eligible members are automatically enrolled and can then
choose to disenroll from the program) operating in Los
Angeles and Alameda Counties, and provides eligible
beneficiaries with a range of services that assist them in
their efforts to remain in the least restrictive, and most
homelike environment possible, while receiving the medical
care necessary to protect their health and well-being.
A private contractor was selected through a competitive bid
process and eventually began providing services to Medi-Cal
eligible members in August 2007, four years after the
statute was passed. The department receives on-going
quarterly updates relative to various program elements
including enrollment statistics and various performance
metrics. Funding for the disease management pilot, as
established by the Legislature, is $4 million per year for
three years. The Disease Management vendor contract
includes a cost-neutrality clause; thus, the contractor is
at risk for maintaining cost neutrality for the pilot
project.
The statute authorizing the waiver that allowed for the
program prescribed certain evaluation criteria that the
department was to utilize to determine the effectiveness of
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providing a Medi-Cal disease management benefit. These
include participant satisfaction, health and safety, the
quality of life of the participants receiving the disease
management benefit, and demonstration of the cost
neutrality of the waiver. The evaluation is also to
estimate projected savings, if any, in the budgets of state
and local governments if the waiver was expanded statewide.
The department secured $1.5 million for a contract for a
third-party evaluator to test the outcome and efficacy of
the DMPP. The University of California, Los Angeles,
Center for Health Policy Research, was selected as the
third-party evaluator.
Outcomes of the pilot
For the COPD portion of the pilot, DHCS uses the following
clinical outcomes metrics: 1) early recognition of COPD
exacerbation; 2) no problems with medications; 3) not a
current smoker; and, 4) receiving a flu vaccine. Early
recognition of exacerbation can prevent progression to
respiratory failure with resultant high cost emergency room
treatments and intensive care admissions which could
include the patient being placed on a ventilator with
subsequent long acute hospital stays. Medication compliance
is important because patients with COPD typically take
numerous medications to control their disease. Medication
side-effects and/or interactions is a common cause of
emergency room visits and hospitalizations in this
population. Additionally, due to unpleasant side-effects
of these medications, non-compliance can also be an issue.
Smoking is one of the primary causes of COPD and
exacerbates asthma. Smoking or continuation of smoking
defeats the treatment goals and increases damage to the
lungs; thereby, increasing debilitation of the disease.
Individuals with COPD are especially susceptible to
complications caused by influenza which can result in
costly hospital admissions or visits to the Emergency Room.
The administration of yearly Flu vaccine is a simple and
effective way to prevent COPD patients from contracting
influenza which can be life threatening in COPD patients.
So far, the pilot reports significant improvement in each
of these areas. At least 57 percent of the patients can now
recognize the early signs of COPD, up from 34 percent at
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the start of the pilot. 78 percent report no problems with
their medications, up from 63 percent at the initial
assessment. At least 66 percent of the patients reported
to have smoked sometime within the 3 months preceding the
initial assessment, but after 6 months that number
decreased to approximately 43 percent. More patients
reported receiving the flu vaccine, from 56 percent at the
start of the pilot, up to 65 percent after 6 months.
Related bills
SR 16 (Leno) 2009 recognizes March 12, 2009, as World
Kidney Day, and presents findings regarding the prevalence
of chronic kidney disease.
AB 1076 (Jones) 2009 would require DHCS to expand the
Medical Case Management (MCM) Program to include Medi-Cal
beneficiaries who have two or more chronic conditions, and
have used the hospital emergency department (ED) four or
more times in the previous twelve months, and specifies the
type of services which must be included in case management
services. Would require the Medi-Cal disease management
benefit to include the designation of a primary care
provider as a patient's medical home. Pending in the Senate
Health Committee.
Prior legislation
ACR 137 (Galgiani), Chapter 158, Statutes of 2008, is
nearly identical to this bill.
ACR 13 (Galgiani), Chapter 23, Statutes of 2007, is nearly
identical to this bill.
AB 1736 (Levine) of 2005 would have required DHCS to
conduct a demonstration testing of the chronic care model
of providing disease management services in community
clinics and health center and public hospital settings.
This bill was vetoed by Governor Schwarzenegger noting that
this bill is duplicative of current DHCS efforts and would
impose significant costs on the program.
AB 1762 (Committee on Budget), Chapter 230, Statutes of
2003, a budget trailer bill that authorized DHCS to apply
for a federal waiver to provide a disease management
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benefit to beneficiaries of the Medi-Cal program.
AB 2047 (Machado) of 2002 would have created the Chronic
Disease Prevention Council within the Department of Health
Services (now DHCS) to coordinate and prioritize disease
prevention programs. AB 2047 was vetoed by Governor Gray
Davis, who stated that committees similar to the Council
already existed within the department. The message
directed the department to utilize an existing advisory
committee or council to fulfill the objectives of the bill.
Arguments in support
Boehringer Ingelheim Pharmaceuticals, Inc. claims COPD is
now the fourth leading cause of death in the United States
and the only one of the top five causes of death whose
prevalence and death rate is rising. GlaxoSmithKline claims
COPD is a debilitating disease, and supports this measure
because they believe in the importance of global COPD
awareness. They acknowledge that even though COPD is not
curable, it is largely preventable, and claim that
management of the disease helps people improve their
quality of life.
PRIOR ACTIONS
Assembly Floor: 76-0
Assembly Appropriations:15-0
Assembly Health: 19-0
POSITIONS
Support: Boehringer Ingelheim Pharmaceuticals, Inc.
(sponsor)
American Lung Association
GlaxoSmithKline
Oppose: None received