BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 175
A
AUTHOR: Galgiani
B
AMENDED: April 21, 2009
HEARING DATE: June 17, 2009
1
REFERRAL: Business, Professions and Economic
Development 7
CONSULTANT:
5
Dunstan/cjt
SUBJECT
Medical telemedicine: optometrists
SUMMARY
Expands the definition of "teleophthalmology and
teledermatology" by store and forward to include the
services of an optometrist.
CHANGES TO EXISTING LAW
Existing law:
Establishes the Medi-Cal program, administered by the
Department of Health Cares Services (DHCS), which provides
comprehensive health benefits to low-income children; their
parents or caretaker relatives; pregnant women; elderly,
blind or disabled persons; nursing home residents; and
refugees who meet specified eligibility criteria.
Establishes the Telemedicine Development Act of 1996, which
broadly defines telemedicine as the use of information
technology to deliver medical services and information from
one location to another, and imposes several requirements
governing the delivery of health care services through
telemedicine.
Continued---
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Defines, in the Medical Practice Act, telemedicine as the
practice of health care delivery, diagnosis, consultation,
treatment, transfer of medical data, and education using
interactive audio, video or data communications.
Allows the use of telemedicine in the Medi-Cal program,
when those services would be otherwise covered by the
program when appropriate, and when the contact between the
health care provider and the patient is real time or near
real time.
Defines, for the purposes of Medi-Cal, "teleophthalmology
and teledermatology by store and forward" as transmission
of medical information to be reviewed at a later time and
at a distant site by a physician who is trained in
ophthalmology or dermatology, where the physician at the
distant site reviews the medical information without the
patient being present in real time and allows these
telemedicine services to be reimbursed under the Medi-Cal
program. Existing law provides a sunset date of January 1,
2013 for these provisions.
Authorizes optometrists to engage in the practice of
telemedicine in California.
This bill:
Expands the definition of teleophthalmology and
teledermatology by store and forward to include the
services of an optometrist. Requires that if the
reviewing optometrist identifies a disease or condition
requiring consultation or referral, as specified, that
consultation shall be with an appropriate physician and
surgeon or ophthalmologist.
FISCAL IMPACT
According to the Assembly Appropriations Committee
analysis, there would be major savings of $2,500 (General
Fund) per digital retinal screening to Medi-Cal and other
publicly funded health and human services programs. The
analysis estimates that $1.3 million (General Fund) will
accrue if 500 screenings prevent blindness. Savings will
be greater to the extent more screening for diabetic
STAFF ANALYSIS OF ASSEMBLY BILL 175 (Galgiani) Page
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retinopathy reduces visual impairments, blindness, and
associated dependence on public benefits. According to
information from the California Health Interview Survey,
there are approximately 112,000 people in the target
population, namely adult diabetics, enrolled in Medi-Cal,
but who have not had the proper eye exam within the last
year.
BACKGROUND AND DISCUSSION
According to the author, that although optometrists are
able to provide telemedicine services, they are restricted
from providing these services to Medi-Cal recipients using
store and forward technology. The author states that this
bill would allow optometrists to provide teleophthalmology
services by store and forward, and authorize the Medi-Cal
program to reimburse optometrists the service, to the
extent that federal participation is available, until
January 1, 2013. The author argues that this bill will
increase the number of providers able to perform
teleophthalmology services by store and forward, thereby
improving access in medically underserved rural and other
areas that pose geographic barriers to receiving these
services. The author states that since the majority of the
claims for teleophthalmology by store and forward will be
for the diagnosis of diabetic retinopathy, this change will
potentially decrease the risk of blindness in diabetic
Medi-Cal recipients through early detection and prevention
in underserved areas.
Increasing use of telemedicine
The 1996 Telemedicine Development Act declared the lack of
primary care and specialty providers, combined with
inadequate transportation are significant barriers to
access to health services in medically underserved rural
and urban areas. The Act also declares that parts of
California have difficulty attracting and retaining health
professionals, as well as supporting local health
facilities to provide a continuum of health care.
Telemedicine is increasingly being seen as part the
approach to address the problem of inadequate access to
providers, especially specialists, and the development of
health systems in medically underserved areas.
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Telemedicine can improve communication capabilities and
provide convenient access to up-to-date information,
consultation and other forms of support. Telemedicine can
result in consumers benefiting from expanded access to
providers, faster and more convenient treatment, better
continuity of care, reduction of lost work time and travel
costs, and the ability to receive care while they remain
with support networks. In traditional telemedicine, a
physician at a distant site is able to interview and
examine the patient via closed circuit television. Store
and forward telemedicine allows video recording with
viewing of the recording at a later time by a health care
provider at a distant location. Store and forward is
especially applicable to the fields of dermatology and
ophthalmology where visual examination is important in
diagnosis.
Diabetes and vision problems in rural areas
According to the National Eye Institute, diabetic
retinopathy, which is damage to the blood vessels at the
back of the eye, is a leading cause of blindness in
American adults. The California HealthCare Foundation
(CHCF), in a March 2009 report on its diabetic retinopathy
program, states 24,000 diabetics become legally blind each
year in the United States, but clinical trials demonstrate
that early detection and treatment can prevent 90 percent
of vision loss. The National Eye Institute recommends that
everyone with diabetes - whether type I or type II - get an
annual comprehensive dilated eye exam.
According to CHCF, residents of California's Central Valley
face the challenges of high rates of diabetes, high rates
of poverty, low insurance rates, lack of regular sources of
care, health provider shortages, and a rural setting that
poses transportation obstacles. CHCF funded a pilot project
to implement screening for diabetic retinopathy using
EyePACS, which is open-source telemedicine software that
the University of California, Berkeley School of Optometry
developed specifically for exchanging eye-related clinical
information. Providers in the 13 primary care sites in the
pilot project screened over 12,000 patients, of whom 15
percent required referrals for further eye care. CHCF
subsequently expanded the project to help 43 more clinics
throughout the state to acquire digital retinal cameras,
telemedicine software and/or expert consultation. CHCF's
STAFF ANALYSIS OF ASSEMBLY BILL 175 (Galgiani) Page
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goal for this program is 100 clinics and 100,000 patients.
Prior legislation
AB 1224 (Hernandez), Chapter 507, Statutes of 2007, adds
optometrists to the list of health professionals authorized
to practice telemedicine.
AB 354 (Cogdill), Chapter 449, Statutes of 2005) authorized
the practice of teledermatology and teleophthamology using
store and forward technology for the Medi-Cal program.
Arguments in support
The Department of Health Care Services, the sponsor of the
bill, argues that this bill would enable the Medi-Cal
program to recognize optometrists as an additional provider
for teleopthalmology services by store and forward
technology. They noted that optometrists are already
authorized to use telemedicine but are restricted from
providing these services to Medi-Cal patients. The
California Optometric Association states that passage of AB
175 will assure that more patients at risk of becoming
blind from diabetes or glaucoma will be diagnosed and
treated sooner. They point out that optometrists are now
the first line of defense against debilitating eye disease;
data show that seven out of ten eye care patients visit an
optometrist first, where threats to visual health and
eyesight are first diagnosed.
PRIOR ACTIONS
Assembly Floor: 77-0
Assembly Appropriations: 16-0
Assembly Business and Professions: 10-0
Assembly Health: 19-0
COMMENTS
1. Provisions of the health budget trailer bill for the
2009-2010 budget, resulted in the
elimination of certain optional Medi-Cal benefits,
including optometry for adults, by July 1, 2009.
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Optional benefits are those that states are not required
under federal law to offer. By eliminating the optometry
benefits for the adult Medi-Cal population, this action
reduced the potential benefit of this bill, but optometry
is still an available benefit for juveniles.
Technical amendment
Page 2, beginning line 27
If the reviewing optometrist identifies a disease or
condition requiring consultation or referral pursuant to
Section 3041 of the Business and Professions Code, that
consultation or referral shall be with an ophthalmologist
or other appropriate physician and surgeon or
ophthalmologist , as required.
POSITIONS
Support: Department of Health Care Services (sponsor)
American Federation of State, County and Municipal
Employees
California Optometric Association
California Primary Care Association
Medical Board of California
Oppose: None received
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