BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 217
A
AUTHOR: Beall
B
AMENDED: June 1, 2009
HEARING DATE: July 8, 2009
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CONSULTANT:
1
Dunstan/sh
7
SUBJECT
Medi-Cal: alcohol and drug screening and brief intervention
services
SUMMARY
Establishes a screening and brief intervention (SBI)
services program within the Medi-Cal program, to be
administered by the Department of Health Care Services
(DHCS), in collaboration with the State Department of
Alcohol and Drug Programs (DADP), for the purpose of
allowing local funds to be used to secure federal matching
funds for these services.
CHANGES TO EXISTING LAW
Existing federal law:
Establishes the Medicaid program, which provides basic
health care coverage for low-income individuals and their
families; pregnant women; elderly, blind, or disabled
persons; nursing home residents; and refugees who meet
specified eligibility criteria. Requires states that
participate in the Medicaid program to offer certain
benefits and allows states the option of providing other
specified benefits, including substance abuse programs.
Provides that states can obtain Medicaid reimbursement if
they choose to offer SBI in their Medicaid program.
Continued---
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Existing state law:
Establishes the Medi-Cal program, the state's version of
Medicaid, and provides that the program will be
administered by DHCS. Names DADP as the lead state agency
for alcohol and drug programs and establishes the Drug
Medi-Cal program which is administered by DADP. Requires
Drug Medi-Cal to provide defined modes of treatment for
Medi-Cal eligible persons with drug or alcohol abuse
problems.
This bill:
Establishes an alcohol and drug SBI program in Medi-Cal, to
be administered by DHCS, in consultation with DADP for the
purpose of making available alcohol and drug screening and
brief intervention services for Medi-Cal beneficiaries who
are pregnant women or women of childbearing age. Makes
specific findings concerning the benefits of the SBI
program and maximizing the use of federal funds. Provides
that participation in the screening and intervention
program shall be voluntary for a Medi-Cal beneficiary and
that the results shall be maintained in the beneficiary's
confidential medical records and subject to all
confidentiality requirements applicable to medical records.
Defines "public entity" to mean a county, or other local
governmental entity designated by DHCS, that elects to
provide or contract for SBI services for Medi-Cal
beneficiaries pursuant to this bill. Requires a public
entity that participates in the program to do all of the
following:
a. Certify that the claimed expenditures for SBI
services for Medi-Cal beneficiaries are eligible for
federal financial participation (FFP);
b. Provide evidence supporting the certification, as
specified by DHCS; and,
c. Submit data, as specified by DHCS, to determine the
appropriate amounts to claim as expenditures
qualifying for FFP; and maintain records as specified
by DHCS and the federal Centers for Medicare and
Medicaid Services (CMS).
Requires DHCS to administer this bill in accordance with
the certified public expenditure requirements described in
applicable federal regulations. Requires DHCS to seek any
federal approvals necessary to implement this bill.
STAFF ANALYSIS OF ASSEMBLY BILL 217 (Beall) Page
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Requires DHCS to submit claims for FFP, and submit, on an
annual basis, necessary materials to the federal
government, to provide assurances that claims for FFP will
include only those expenditures that are allowable under
federal law. Directs DHCS to develop an appropriate
mechanism to enable a public entity to pay the nonfederal
share of the cost of providing services under this bill.
Requires DHCS to pass the federal reimbursement on to the
claiming public entity. Requires that the states share of
the reimbursement submitted to CMS for purposes of claiming
FFP, must be comprised of only those funds that are
certified expenditures by a public entity. Directs a
public entity that participates in the SBI program to
reimburse the state for any costs of creating and
administering the program. Mandates that this bill would
be implemented only if federal funds are available. Allows
DHCS to implement this bill by means of all county letters,
provider bulletins, and similar instructions.
FISCAL IMPACT
According to the Assembly Appropriations Committee
analysis, this bill will result in a one-time cost
estimated to be $150,000 (50 percent General Fund) to DHCS
to develop and manage a federal waiver to qualify local SBI
expenditures for matched funding. They also estimate
annual costs to manage the waiver and related approval of
certify public expenditures (CPE) of $50,000 (50 percent
General Fund). On-going costs could be less depending on
how many counties take advantage of the federal funding
opportunity created by this bill. They estimate unknown
additional federal funding to the extent SBI activities are
funded by Medi-Cal with a federal share of cost and unknown
treatment costs and future savings to the extent SBI
reduces or prevents substance abuse.
BACKGROUND AND DISCUSSION
According to the author, this bill will help address the
problem of prenatal exposure to alcohol, tobacco, and other
drugs, all of which can severely damage the development,
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structure and functioning of the fetal brain. The author
reports that one in twelve pregnant women, nationwide,
reported they consume alcohol and one in thirty pregnant
women said they had engaged in binge drinking, and that
this behavior has led to fetal alcohol syndrome being one
of the leading known preventable causes of birth defects
and developmental disabilities. The author argues that
effective prevention, intervention and screening can reduce
this needless suffering while significantly reducing
long-term health care costs. However, the author notes
that, despite the evidence of their benefits, SBI services
have not yet been widely used in primary care settings,
emergency rooms, state licensed facilities and clinics.
According to the author, in order for providers to receive
Medicaid reimbursement for SBI services, the state must
activate two new billing codes and appropriate funds for
these services. The author reports that, according to
DHCS, these codes have not been activated in California,
mainly due to the state's budgetary shortfall, but this
bill addresses the lack of state funds for SBI services by
allowing county expenditures to serve as the state match to
draw down federal Medicaid dollars. According to the
author, due to the absence of state action, 20 counties
have chosen to begin their own county-funded prenatal SBI
programs. The author reports that an evaluation of those
counties found a sharp decline, both in rates of substance
use during pregnancy, and in low birth-weight newborns.
Background
Alcohol and other drug abuse is a major factor in chronic
disease, the spread of infectious diseases, hospital
emergency room visits, newborn health problems, violence,
and auto fatalities. According to a 2004 DADP survey of
alcohol and drug use in the month prior to the survey,
found that an estimated 18.5 million persons had used
alcohol, 7.5 million had engaged in binge drinking
(drinking four or more drinks in a row), and 3.5 million
had used illicit drugs. DADP estimated that the 2005 cost
to society of alcohol and drug abuse in California was over
$44 billion, including loss of productivity, health care
costs, prevention and treatment costs, criminal justice
costs, and losses due to crimes. DADP reported that in
2004, 308,683 Californians were arrested on alcohol-related
charges and 431,769 on drug-related charges.
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Fetal alcohol syndrome (FAS), caused by drinking during
pregnancy, is a major cause of developmental disabilities
and birth defects in the United States and is completely
preventable. While the exact incidence is unknown, such
defects and disabilities are more common than Down's
syndrome or spina bifida and are the leading cause of
mental retardation, a specific developmental disability, as
defined by the American Psychiatric Association. While
prenatal alcohol exposure does not automatically result in
FAS, the U.S. Surgeon General advises pregnant women to
abstain from alcohol use due to the risk of the syndrome.
Alcohol and other drug dependency is a treatable condition
and treatment is widely considered to save money by
combating the problems associated with substance abuse.
The benefit cost analysis done in conjunction with the
evaluation of the Substance Abuse and Crime Prevention Act
of 2000, which was Proposition 36 on the ballot, found
that, for every $1 invested in substance abuse treatment,
state and local governments have saved $2.50 from reduced
health costs, crime and other impacts. Other studies have
found that the per capita cost of treatment is
significantly less than the cost of incarceration.
According to the Institute of Medicine, the cost of
incarceration is about $40,000 per year, compared to
$12,500 and $3,100 for residential and outpatient
treatments, respectively. Despite the cost effectiveness
of substance abuse treatment programs, a substantial gap
exists between the number of people who need treatment and
the number who receive treatment.
Drug Medi-Cal
Currently, most substance abuse programs in Medi-Cal are
offered through Drug Medi-Cal. These benefits are optional
Medi-Cal benefits that the state has decided, as allowed by
federal law, to offer in Medi-Cal. Drug Medi-Cal provides
medically necessary alcohol and drug treatment services to
at least some eligible Medi-Cal recipients. Services
include outpatient drug free treatment, methadone and
naltrexone treatment, day-care rehabilitative treatment and
residential treatment. Under the program, all pregnant and
postpartum women receive the broadest array of services
related to drug and alcohol abuse. Other recipients
receive varying levels of services. DADP receives funding
from DHCS for eligible services provided to Medi-Cal
beneficiaries through an interagency agreement.
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Drug Medi-Cal is one of several major sources of support
for substance abuse treatment services. Among the other
major sources of support for treatment are the state
Substance Abuse and Crime Prevention Act, the CalWORKs
program for welfare recipients, discretionary state grants,
federal grants and contributions of county funds. The U.S.
Department of Veterans Affairs operates a separate health
care system that includes an array of substance abuse
treatment services for qualified veterans.
Use of SBI
SBI is a verbal screening tool by which a person is
questioned about their substance use and their answers are
evaluated for the possibility of substance abuse. If the
patient screens positive, indicating they are at risk for
alcohol or other substance abuse, the provider will
recommend a brief intervention that usually involves one or
more short counseling sessions. Individuals who are
considered high risk for abuse or addiction are given the
brief intervention counseling session and are also
scheduled for a brief treatment appointment.
A number of evaluations, including one conducted by the
World Health Organization, has shown that even this
scripted, brief intervention significantly reduces
substance use, accidents, trauma, other adverse events, as
well as health care costs. According to other researchers,
brief alcohol interventions are among the top five most
cost-effective preventive measures, and are at least as
effective as Pap smears or colon cancer screenings. A
recent review of multiple studies found that screening was
credited with reducing problem drinking by an average of
17.4 percent over time periods ranging from six months to
two years.
The federal Substance Abuse and Mental Health Services
Administration (SAMHSA) has initiated a pilot project for
SBI in 17 states. Preliminary data from the pilot project
has shown that the approach is successful in modifying the
use patterns of those who consume five or more alcoholic
beverages in one sitting, and those who use illegal
substances. Pilot project grantees have implemented SBI in
trauma centers/emergency rooms, community clinics,
federally qualified health centers, and school clinics.
Under California's pilot project, DADP received a grant to
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implement SBI in 36 in hospital emergency and trauma
settings across 4 counties.
Effective January 2007, CMS allows Medicaid reimbursement
for SBI services. According to the White House Office of
National Drug Control Policy, the impetus behind the
Medicaid decision to reimburse for SBI services was the
recognition of the number of people who are in need of
treatment and who go unidentified.
Prior legislation
AB 2124 (Beall) of 2008 would have established a SBI
program within the Medi-Cal program, to be administered by
DHCS for the purpose of allowing local funds to be used to
secure federal matching funds for these services. AB 2124
was held on the Senate Appropriations suspense file.
AB 2129 (Beall) of 2008 would have required the Department
of Public Health to collaborate with DADP in developing a
model program for the screening and treatment of pregnant
women who are suffering from drug and alcohol abuse. This
bill was held in the Assembly Appropriations Committee.
Arguments in support
Supporters argue that effective screening and intervention
services are a vital tool that can lower the risk of
substance abuse during pregnancy and prevent birth defects
in infants and this measure would allow counties to provide
these services to Medi-Cal beneficiaries by drawing down
federal dollars to match scarce county funds. They note
that under existing law, counties must provide the full
cost of services and, because of the cost factor, not all
counties provide these vital services to expectant mothers.
Supporters argue that accessing federal funds would
provide more money to counties to provide these programs
and help mothers give birth to healthy babies.
PRIOR ACTIONS
Assembly Floor: 78-0
Assembly Appropriations:17-0
Assembly Health: 19-0
POSITIONS
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Support: American College of Obstetricians and
Gynecologists, District IX
California Medical Association
California State Association of Counties
Commission on the Status of Women
National Association of Social Workers
Santa Clara County Board of Supervisors
Oppose: None received
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