BILL ANALYSIS
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|Hearing Date:June 29, 2009 |Bill No:AB |
| |175 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Gloria Negrete McLeod, Chair
Bill No: AB 175Author:Galgiani
As Amended:June 24, 2009 Fiscal: Yes
SUBJECT: Medical telemedicine: optometrists.
SUMMARY: Expands, for purposes of Medi-Cal reimbursement, the
definition of teleopthalmology and teledermatology by store and
forward to include a asynchronous transmission of medical information
to be reviewed at a later time for teleopthalmology by a licensed
optometrist.
NOTE : Double-referral to Health Committee (first.) This bill was
double-referred. It was heard by the Senate Health Committee on June
17, 2009 and passed out on a 10-0 vote.
Existing law:
1)Defines telemedicine in the Medical Practice Act as the practice of
health care delivery, diagnosis, consultation, treatment, transfer
of medical data, and education using interactive audio, video, or
data communications. Excludes a telephone conversation and
electronic mail message between a health care practitioner and
patient from the definition of telemedicine.
2)Defines teleopthalmology and teledermatology by store and forward as
asynchronous transmission of medical information to be reviewed at a
later time by a physician at a distant site 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.
3)Requires, prior to the delivery of health care via telemedicine, a
licentiate to obtain verbal and written consent from the patient or
the patient's legal representative. States the information that
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must be contained in an informed consent procedure.
4)Requires that a patient receiving teleophthalmology or
teledermatology by store and forward be notified of the right to
receive interactive communication with the distant specialist
physician, and receive an interactive communication with the distant
specialist physician, upon request. If requested, communication
with the distant specialist physician may occur either at the time
of the consultation, or within 30 days of the patient's notification
of the results of the consultation.
5)Establishes the Medi-Cal program, administered by the Department of
Health Care Services (DHCS), which provides comprehensive health
benefits to low-income children, their parents or caregiver
relatives, pregnant women, elderly, blind or disabled persons,
nursing home residents, and refugees who meet specified eligibility
criteria.
6)States that commencing July 1, 2006, to the extent that federal
financial participation is available, face-to-face contact between a
health care provider and a patient shall not be
required under the Medi-Cal program for teleopthalmology and
teledermatology by store and forward.
7)Requires the DHCS, on or before January 1, 2008, to report to the
Legislature the number and type of services provided, and the
payments made related to the application of store and forward
telemedicine as provided, as a Medi-Cal benefit.
8)Establishes the Optometry Practice Act to regulate the practice of
optometry. Includes an optometrist in the definition of a
licentiate who could practice telemedicine.
This bill:
1)Expands, for purposes of Medi-Cal reimbursement, the definition of
teleopthalmology and teledermatology by store and forward to include
an asynchronous transmission of medical information to be reviewed
at a later time for teleopthalmology by a licensed optometrist.
2)States that if the reviewing optometrist identifies a disease or
condition requiring consultation or referral, as specified, the
consultation or referral will be with the appropriate
ophthalmologist, physician and surgeon.
3)Makes other technical, nonsubstantive changes.
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FISCAL EFFECT: According to the Assembly Appropriations Committee:
1)Major savings of $2,500 (GF) per digital retinal screening to
Medi-Cal and other publicly funded health and human services
programs; $1.3 million (GF) will accrue if 500 screenings prevent
blindness. According to data, there are approximately 110,000
Medi-Cal patients who may benefit from increased screening pursuant
to this bill. Savings will be greater to the extent more screening
for diabetic retinopathy reduces visual impairments, blindness, and
associated dependence on public benefits.
2)This estimate is based on preliminary research which relies on a
combination of caseload, clinical, cost, and modeling information to
identify significant per screening savings due to reduced Medi-Cal,
Social Security Program (SSP), In-Home Supportive Services (IHSS),
and California Food Assistance Program (CFAP) benefits. According to
the modeling information, reductions in visual impairments lead to
significant public savings by reducing disability and dependence.
COMMENTS:
1.Purpose. According to DHCS , the Sponsor of this bill, although
optometrists are able to provide telemedicine services pursuant to
AB 1224 (Chapter 507, Statutes of 2007), they are restricted from
providing these services to Medi-Cal recipients. This bill allows
optometrists to provide teleophthalmology services by store and
forward. DHCS points out that various studies have shown that
prevention programs aimed at early detection and treatment of
diabetic retinopathy and improving eye care for diabetic persons are
highly cost-effective and may prevent blindness. Medi-Cal data
indicates that the proportion of diabetic fee-for-service Medi-Cal
recipients who receive annual dilated eye examinations is
significantly lower (25 percent) than the target of 75 percent set
by the Centers for Disease Control and Prevention and the National
Institutes of Health in the Healthy People 2010 Project. 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. 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 these underserved areas.
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2.Background.
a) Telemedicine. Current law defines telemedicine as the
practice of health care delivery, diagnosis, consultation,
treatment, transfer of medical data, and education using
interactive audio, video, or data communications. This
definition of telemedicine excludes a telephone conversation and
electronic mail message between a health care practitioner and
patient from the definition of telemedicine. According to a July
2008 report by the California Healthcare Foundation entitled
Telemedicine in California: Progress, Challenges and
Opportunities , one of the major goals of telemedicine is to
overcome time and distance barriers, delivering health services,
and education to patients in their communities. This report
points out that the widespread adoption of telemedicine can link
diverse aspects of the health care system, increase patient
access to all types of care, enable services to be provided where
they are needed most and ameliorate the shortage of primary care
physicians and specialists in certain geographic areas. Examples
of entities that have adopted telemedicine include the University
of California Davis, Kaiser Permanente Sacramento, Blue Cross of
California and the California Department of Corrections and
Rehabilitation.
According to the Medical Board of California's website, there are
no legal prohibitions in the practice of medicine through
telemedicine technology as long as the practice is done by a
California licensed physician. The MBC points out that the
standard of care is the same whether the patient is seen
in-person, through telemedicine or other methods of
electronically enabled health care. Physicians practicing via
telemedicine are held to the same standard of care, and retain
the same responsibilities of providing informed consent, ensuring
the privacy of medical information, and any other duties
associated with practicing medicine.
b) Medi-Cal Reimbursement for Telemedicine. The Telemedicine Act
of 1996 (Act) set standards for the use of telemedicine by health
care practitioners and insurers. The Act specified, 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. The Act defined
telemedicine as the practice of health care delivery, diagnosis,
consultation, treatment, transfer of medical data, and education,
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using interactive audio, video, or data communications that
involve a real time (synchronous) or near real time
(asynchronous) two-way transfer of medical data and information.
AB 354 (Cogdill) Chapter 449, Statutes of 2005, expanded these
telemedicine provisions by providing that, from July 1, 2006
through December 31, 2008, face-to-face contact between a health
care provider and a patient shall not be required for the
Medi-Cal program for store and forward teleophthalmology and
teledermatology services. Store and forward teleophthalmology
and teledermatology is defined as transmission of medical
information to be reviewed at a later time by a physician at a
distant site 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.
These services are subject to billing and reimbursement policies
established by the DHCS. AB 354 also required DHCS, on or before
January 1, 2008, to report to the Legislature the number and type
of services provided, and the payments made related to the
application of store and forward teleophthalmology and
teledermatology as a Medi-Cal benefit. In this report DHCS
indicated that for the period January 2007 to November 2007,
there were 30 paid claims, all for dermatology services, that
amounted to $1,786.
c) Benefits of Expanding Telemedicine. This bill expands the
definition telemedicine for purposes of Medi-Cal reimbursement to
include optometrists aimed for the detection and treatment of
diabetic retinopathy and improving eye care for diabetic persons.
According to the California Healthcare Foundation, diabetic
retinopathy is the leading cause of blindness among working
adults, and that 24,000 diabetics become legally blind each year
in the United States. Clinical trials have demonstrated that
early detection and treatment of diabetic retinopathy can reduce
vision loss by 90%, and it is recommended that people with
diabetes receive an annual eye exam to screen for diabetic
retinopathy.
A study conducted by the Blue Sky Consulting Group, commissioned by
the California Healthcare Foundation on the impact of this bill
indicates that the State can expect significant cost savings with
the implementation of this bill, and the expansion of
telemedicine. The study indicated that store and forward
teleophthalmology is a screening method that has the potential to
both reduce costs for the state of California and improve access
to health care services, by preserving sight for many with
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diabetic retinopathy, a leading cause of blindness. The study
states that this technology provides a substitute for dilated
retinal exam, and relies on remote location review of digital
photographs of the retina to detect patients with
sight-threatening diabetic retinopathy. Using a special digital
camera, minimally trained technicians and health care providers
can take digital images of the affected retina and "store and
forward" the images to remote locations for review by
ophthalmologists or optometrists. Furthermore, the study pointed
out that for each patient examined for retinopathy with store and
forward telemedicine, state costs savings will total nearly
$2,500 over the patient's lifetime.
3.Prior Legislation.
a) SB 1341 (Kuehl) of 2004 would have expanded the definition of
telemedicine to include the use of "store-and-forward" technology
for two applications, teledermatology and teleophthalmology
services, and to allow Medi-Cal reimbursement for these two types
of services provided by health care practitioners via
telemedicine. SB 1341 was vetoed by Governor Schwarzenegger.
b) AB 354 (Cogdill) Chapter 449, Statutes of 2005, is similar to
the provisions of SB 1341 and authorized Medi-Cal reimbursements
for teledermatology and teleophthalmology services.
c) AB 1224 (Hernandez) Chapter 507, Statutes of 2007, added
optometrists to the list health care practitioners who could
practice telemedicine.
d) AB 2120 (Galgiani) Chapter 260, Statutes of 2008, extended the
Medi-Cal telemedicine reimbursement authorization until January
1, 2013.
4.Arguments in Support. The California Optometric Association writes
in support of this measure and states that passage of this bill will
assure more patients at risk of becoming blind from diabetes or
glaucoma will be diagnosed and treated sooner.
The Medical Board of California writes in support of this measure
and indicates that telemedicine is a very important aspect of
improving access to health care for consumers and is supportive of
increasing the methods and areas of health care where telemedicine
can be effective.
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SUPPORT AND OPPOSITION:
Support:
Department of Health Care Services (Sponsor)
California Optometric Association
Medical Board of California
Opposition:
None on file as of June 22, 2009
Consultant: Rosielyn Pulmano