BILL ANALYSIS
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| Hearing Date:August 9, 2010 |Bill No:AB |
| |1542 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Gloria Negrete McLeod, Chair
Bill No: AB 1542Author:Jones
As Amended:August 3, 2010Fiscal: No
SUBJECT: Medical homes.
SUMMARY: This is an urgency measure that enacts the Patient-Centered
Medical Home Act of 2010 which establishes a definition for a medical
home and prohibits health care providers from calling their practice a
medical home unless certain standards are met.
NOTE : This bill was double-referred. It was heard by the Senate
Health Committee on June 30, 2010 and passed out on a 6 - 2 vote.
Existing law:
1) Establishes the Medical Practice Act to regulate and govern the
practice of physician and surgeons. Provides that any person who
practices medicine must possess a valid license issued by the
Medical Board of California.
2) Specifies that the Department of Public Health shall license
specified primary care clinics and other specialty clinics.
Exempts from licensure any place or establishment owned or leased
and operated as a clinic or office by one or more licensed health
care providers and used as an office for the practice of their
profession, within the scope of their license, regardless of the
name used publicly to identify the place or establishment.
3) Establishes the Medi-Cal program, administered by the State
Department of Health Care Services and under which qualified
low-income persons receive health care benefits, as specified.
4) Provides that the Department of Health Care Services shall submit
an application to the federal Centers for Medicare and Medicaid
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Services for a waiver or a demonstration project to expand health
care coverage to low-income, uninsured residents, as specified.
Specifies that the waiver or demonstration project shall include
proposals to restructure the organization and delivery of services
to Medi-Cal enrollees, including proposals for the improved
coordination of care for children with significant medical needs
through the use of medical homes and specialty centers, as
specified.
This bill:
1) Enacts the Patient-Centered Medical Home Act of 2010 which
establishes standards for medical homes.
2) States the following Legislative intents:
a) To encourage licensed health care providers and patients
to partner in a patient-centered medical home that promotes
access to high-quality, comprehensive care, and ensure that
Californians have a medical home.
b) That a California practice or other entity calling itself
a medical home adhere to quality standards that will do all of
the following:
i) Reduce disparities in health care access,
delivery, and health care outcomes.
ii) Improve quality of health care and lower health care
costs, creating savings to allow more Californians to have
health care coverage and to provide for the sustainability
of the health care system.
iii) Integrate medical, mental health, and substance abuse
care.
iv) Remove barriers to receiving appropriate health care.
c) That payors recognize the added value of a medical home by
providing additional payment for the increased services and
overhead associated with this practice model, including, but
not limited to, all of the following:
i) Coordination of care within the practice and
between consultants, ancillary providers, and community
resources.
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ii) Adoption and use of health information technology for
quality improvement.
iii) Increased patient access through advanced appointment
systems, electronic patient portals, secure electronic
mail, remove access monitoring systems, and telephone
consultations.
iv) Risk adjustments based on the case mix, type and
severity of patient illness, and patient age for the
patient population.
v) Provision for monetary reimbursement for added
services among the various payment systems, including
fee-for-service, value-added global, shared savings, and
capitated payments.
3) Defines a medical home, patient-centered medical home advanced
practice primary care, health home and primary care home as a
health care delivery model in which a patient establishes an
ongoing relationship with a physician or other licensed health care
provider acting within the scope of his or her practice, working in
a physician-directed practice team to provide comprehensive,
accessible, and continuous evidence-based primary and preventive
care, and to coordinate the patient's health care needs across the
health care system in order to improve quality and health outcomes
in a cost-effective manner.
4) States that a health care delivery model described in this measure
shall stress a team approach to providing comprehensive health care
that fosters a partnership among the patient, the licensed health
care provider acting within his or her scope of practice, other
health care professionals, and if appropriate, the patient's
family.
5) Requires a medical home to include all of the following
characteristics:
a) Individual patients have an ongoing relationship with a
physician or other licensed health care provider acting within
his or her scope of practice, who is trained to provide first
contact and continuous and comprehensive care, or if
appropriate, provide referrals to health care professionals
that provide continuous and comprehensive care.
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b) A team of individuals at the practice level collectively
take responsibility for the ongoing health care of patients.
The team is responsible for providing for all of a patient's
health care needs or taking responsibility for appropriately
arranging health care by other qualified health care
professionals, including making appropriate referrals.
c) Care is coordinated and integrated across all elements of
the complex health care system and the patient's community.
Care is facilitated, if available, by registries, information
technology, health information exchanges, and other means to
ensure that patients receive the indicated care when and where
they need and want the care in a culturally and linguistically
appropriate manner.
d) All of the following quality and safety components.
i) The medical home advocates for its patients to
support the attainment of optimal, patient-centered
outcomes that are defined by a care planning process
driven by a compassionate, robust partnership between
providers, the patient, and the patient's family.
ii) Evidence-based medicine and clinical decision
support tools guide decisionmaking.
iii) Licensed health care providers in the medical
practice who accept accountability for continuous quality
improvement through voluntary engagement in performance
measurement and improvement.
iv) Patients actively participate in decisionmaking
and feedback is sought to ensure that the patients'
expectations are being met.
v) Information technology is utilized appropriately
to support optimal patient care, performance measurement,
patient education, and enhanced communication.
vi) The medical home participates in a voluntary
recognition process conducted by an appropriate
nongovernmental entity to demonstrate that the practice
has the capabilities to provide patient-centered services
consistent with the medical home model.
vii) Patients and families participate in quality
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improvement activities at the practice level.
e) Enhanced access to health care is available through
systems such as open scheduling, expanded hours, and new
options for communication between the patient, the patient's
personal provider, and practice staff.
6) Provides that this bill shall not be construed to do any of the
following:
a) Permit a medical home to enter into a contractual
relationship that may result in the unlicensed practice of
medicine.
b) Change the scope of practice of physician and
surgeons, nurse practitioners, or other health care
providers.
c) Affect the ability of a nurse to operate under
standard procedures, as specified.
d) Impede the ability of a practice or entity to call
themselves a medical home if specifically authorized by
statute and the use of the term medical home is for the
purposes of complying with that statute.
e) Prevent or limit the ability of a practice of entity
to participate in activities authorized by the federal
Patient Protection and Affordable Care Act, as specified.
States that nothing in this subdivision shall be construed
to change the scope of practice of physicians and surgeons,
nurse practitioners, or other health care providers.
FISCAL EFFECT: Unknown. This bill has been keyed nonfiscal by
Legislative Counsel.
COMMENTS:
1. Purpose. According to the Author , burgeoning health care costs,
severe budget problems, a shortage and mal-distribution of
physicians, and a shrinking primary care infrastructure all
highlight the need to implement medical homes in California. The
Author points out that more than three-quarters of national health
spending goes to treating chronic diseases. With the number of
Americans with a chronic disease projected to increase from 125
million in 2000 to 157 million in 2020, we can expect improved care
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management to have a real effect on health spending. Developing a
standard, uniform definition for the medical home could pave the
way to reducing health disparities, reining in costs, and improving
quality and outcomes in health care. Furthermore, the Author
points out that this bill addresses health disparities. According
to a 2007 report by the Commonwealth Fund, when adults have health
insurance coverage and a medical home, racial and ethnic
disparities in health care access disappear. The analysis reveals
that linking minority patients to a medical home can help them
better manage chronic conditions and obtain critical preventive
care.
2. Background.
a) Medical homes. Many states have adopted medical home
legislation and programs, mostly for Medicaid and Children's
Health Insurance Program (CHIP) enrollees. Some states, such
as Iowa, Oregon, Pennsylvania and Vermont, also allow or
encourage private sector participation. According to the
Author, Community Care of North Carolina, the state's Medicaid
program, is a working example of a patient centered medical
home. The goals of North Carolina's program are to improve the
care of the Medicaid population, control costs, develop
community-based networks to manage care of populations in
partnership with the state, and fully develop the medical home
model. Additionally, the program has demonstrated excellent
quality and cost outcomes through disease management,
evidence-based clinical practice, and an emphasis on a
physician-led team approach. Two evaluations of this program
indicate it saved the State of North Carolina $195 to $215
million in 2003, and between $230 and $260 million in 2004,
when compared to historical fee-for-service.
In California, the Administration, Legislature and stakeholders
are examining the issue of medical homes in an effort to
fashion a new Medicaid Section 1115 waiver on hospital
financing in the Medi-Cal program. Legislation being
considered for these purposes are discussed below.
Additionally, the federal health care reform (federal Patient
Protection and Affordable Care Act and the Health Care and
Education Reconciliation Act of 2010) also included provisions
relating to medical homes. For example, the federal health
care reform, among other provisions, would give states the
option to provide health homes for those with chronic diseases,
allow for increased payments to primary care physicians in
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Medicaid, and permit the establishment of community health
teams to support patient-centered medical homes.
b) Related Legislation this Session. AB 342 (John A. P?rez),
among its other provisions, defines a medical home and requires
seniors and persons with disabilities enrolled in Medi-Cal and
those enrolled in the health care coverage initiative to be
provided with medical homes. This bill is pending in the
Senate Appropriations Committee.
SB 208 (Steinberg and Alquist) is identical to the provisions of
AB 342. SB 208 is pending in the Assembly Appropriations
Committee.
SB 966 (Alquist) directs the Department of Health Care Services
to establish a definition of medical home, consistent with
specified guidelines and to establish a timetable for Medi-Cal
managed care plans to provide beneficiaries with a medical
home. SB 966 is on the Senate Appropriations suspense file.
3. Arguments in Support. According to the California Academy of
Family Physicians , the Sponsor of this measure, and other
supporters such as the Osteopathic Physicians and Surgeons of
California, the California Medical Association, and the Latino
Coalition for a Healthy California, the goal of a medical home is
to provide a patient with a broad spectrum of coordinated care.
With the growing popularity of this concept among consumers and
providers, this bill will ensure uniform standards of quality and
access.
4. Proposed Author's Amendments. The Author proposes to amend this
bill, as reflected in the attached mock-up, to do the following:
a) Provides for Legislative intent that payors take into
account the potential savings from better managing chronic
diseases and conditions through the utilization of medical
homes.
b) Provides that the care that has to be coordinated must
also include mental health and substance use disorder.
c) Clarifies that this bill shall not be construed to permit
a medical home to engage in or otherwise aid and abet in the
unlicensed practice of medicine, either directly or indirectly.
d) Provides that this bill shall not be construed to apply to
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activities of managed care plans, or their contracting
providers, or county alternative model of care, or their
contracting providers, when those activities are part of
demonstration projects, as specified.
e) Makes other clarifying, technical, and non-substantive
changes.
5. Policy Issue: Oversight of Medical Home Concept. This bill
establishes a framework for the delivery of health care through the
medical home model. Although this patient-centered model is
labeled as a medical home, it remains a physician directed
practice. In California, the physician's practice conducted within
their office(s) is exempt from licensure by the Department of
Public Health. However, physicians and surgeons who establish
physicians' offices continue to be licensed and regulated by the
Medical Board of California. As such, the Medical Board of
California has regulatory and enforcement authority only with the
physicians and surgeons, but not necessarily over the utilization
of the medical home model by the physician. It would appear that
if physicians and surgeons hold themselves out as providing medical
home services but do not meet the requirements of this health care
delivery model then it would most likely be a reimbursement issue.
SUPPORT AND OPPOSITION:
Support:
California Academy of Family Physicians (Sponsor)
American College of Physicians
American Congress of Obstetricians and Gynecologists, District IX
American Nurses Association/California
California Academy of Physician Assistants
California Association of Physician Groups
California Chiropractic Association
California Medical Association
California Psychiatric Association
Latino Coalition for a Healthy California
Osteopathic Physicians and Surgeons of California
Opposition: None on file as of August 4, 2010.
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Consultant:Rosielyn Pulmano