BILL ANALYSIS
AB 1542
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 1542 (Jones)
As Amended August 27, 2010
2/3 vote. Urgency
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|ASSEMBLY: |72-0 |(May 14, 2009) |SENATE: |28-9 |(August 31, |
| | | | | |2010) |
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Original Committee Reference: HEALTH
SUMMARY : Enacts the Patient-Centered Medical Home Act of 2010.
Defines "medical home" to mean, in part, a health care delivery
model in which a patient establishes an ongoing relationship
with a physician or other licensed health care provider acting
within his or her scope of practice, working in a
physician-directed practice team to provide comprehensive,
accessible and continuous evidence-based primary and
preventative care and to coordinate the patient health care
needs across the health care system..
The Senate amendments revise the Assembly approved version as
follows:
1)State that nothing in the bill shall be construed to:
a) Permit a medical home to engage in the unlicensed
practice of medicine;
b) Change the scope of practice of any health care
provider;
c) Affect the ability of a nurse to operate under standard
procedures as allowed by law;
d) Apply to activities of local Coverage Expansion and
Enrollment Demonstration (CEED) projects, managed care
plans or county alternative plans that are participating in
the Medicaid Section 1115 Demonstration Waiver; and,
e) Prevent participation in the Patient Protection and
Affordable Care Act of 2010 (PPACA).
2)Clarify that the definition of a medical home includes the
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term: "patient-centered medical home;" "advanced practice
primary care;" "health home;" "person-centered health home;"
and, "primary care home."
3)Revise the characteristics of a medical home by making the
medical team the entity responsible for the providing and
arranging all of the patient's health care needs instead of a
personal provider.
4)Clarify that care coordination includes mental health and
substance use disorder care.
5)Delete the requirements applicable to a payment structure
framework.
6)Delete the requirement that a medical home meet the National
Committee for Quality Assurance (NCQA) standards.
7)Make other technical and clarifying amendments.
AS PASSED BY THE ASSEMBLY , this bill defined a "medical home" as
a team approach to providing health care that fosters
partnerships among the patient, other health professionals, and
the patient's family, where appropriate, to promote coordinated
care, ensure quality and access to care, and to improve health;
required a medical home to have specified characteristics and
meet specified standards, including those established by the
NCQA; and, required payment systems to recognize the added value
by allowing for payments as specified.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
Fiscal Impact (in thousands)
Major Provisions 2010-11 2011-12 2012-13 Fund
Potential increased costs cost pressure likely in the
millions General/
to Medi-Cal, Healthy of dollars commencing upon thisFederal/
Families, CalPERS, bill's enactment Special
and other publicly-funded
health care coverage
COMMENTS : The author contends that high-cost, low-quality
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compartmentalized care, combined with a growing shortage of
physicians and a shrinking primary care infrastructure,
highlight the need to implement medical homes in California.
According to the author, this bill defines what is known as a
patient centered medical homes (PCMHs), which is a medical
practice that consists of a physician-directed team of health
care professionals who collectively take responsibility for the
ongoing care of the patient. The author notes, that in the PCMH
model, the patient actively participates in decision making and
care is coordinated across the patient's community, including
hospitals, home health agencies, nursing homes, consultants, and
other components of the health care system, to assure that
patients get the indicated care when and where they need it.
The PCMH uses evidence-based medicine and information
technology, including clinical decision-support tools, guided
decision making to improve quality and safety and support
optimal patient care, performance measurement, patient education
and communication. The author states that developing a
standard, uniform definition of a PCMH could pave the way to
reducing health disparities, reining in costs, and improving
quality and outcomes
The concept of "medical home." was first used by the American
Academy of Pediatrics (AAP) in 1967 to describe pediatric
practices that provide primary care and coordinate all care for
children with special health care needs. It has evolved to the
concept of a PCMH with a whole person orientation. In 2007, the
AAP, American Academy of Family Physicians, the American College
of Physicians and the American Osteopathic Association released
the "Joint Principles of the Patient-Centered Medical Home."
The principles of this model include: 1) personal physician; 2)
physician directed medical practice; 3) whole person
orientation; 4) coordinated and/or integrated care; 5) quality
and safety; 6) enhanced access; and, g) adequate payment. The
model has been further adapted to include elements of chronic
care management for treating individuals with chronic illnesses
such as disease management and quality improvement.
Studies of PCMH projects have shown savings from reduction in
emergency room visits and hospital admissions. For instance,
the Geisinger Health System in Pennsylvania reported a 20%
reduction in hospital admissions and a 7% reduction in cost at
the end of the first year of a pilot project. The Group Health
Cooperative of Puget Sound reported a 29% reduction in emergency
room visits, improvements in diabetes and heart disease care and
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was cost neutral after one year. The PCMH model that is the
basis of these projects includes payment reform such as a
monthly care coordination payment, risk adjusted payments and
bonus payments based on quality goals, cost and utilization
reductions.
According to a 2007 Commonwealth Fund report, when adults have
health insurance coverage and a medical home, racial and ethnic
disparities in access and quality tend to disappear. The report
reveals that linking minority patients to a medical home helps
them manage chronic conditions and obtain preventive care.
In 2005, California obtained a five-year Section 1115 Medicaid
waiver entitled the Medi-Cal Hospital/Uninsured Care
Demonstration Project, or the hospital waiver that included,
among other things, a Health Care Coverage Initiative (HCCI)
demonstration project to provide health care coverage to
low-income, uninsured residents of 10 selected counties for
federal fiscal years 2007-08 through 2009-10. A fundamental
feature of the HCCI program was the assignment of individuals to
a medical home.
The hospital waiver was due to expire on September 1, 2010. (A
request for a 60 day extension was submitted on August 19,
2010). On June 4, 2010 the state submitted a Section 1115
Comprehensive Demonstration Project Waiver Proposal, "A Bridge
to Reform" requesting a new five-year waiver. The new waiver
request expands on the HCCIs and creates CEED projects to
provide health care benefits to uninsured adults 19 to 64 with
incomes up to 200 percent of the federal poverty level and who
are not eligible for Medicare or Medi-Cal. Designation of a
medical home is retained as a key element. In addition, the new
waiver proposes to require the mandatory enrollment of Seniors
and People with Disabilities (SPD) in a Medi-Cal managed care
plan or a county alternative organized system of care. SB 208
(Steinberg) and AB 342 (John A. Perez), contain the legislative
authority to implement the new waiver proposal. SB 208 and AB
342 require, prior to exercising its authority to enroll SPDs,
the Department of Health Care Services to ensure that all
managed care health plans or county alternative models of care
are able to establish medical homes that meet specified
criteria. However, this bill expressly exempts these waiver
entities.
PPACA, the federal health care reform bill, also recognizes the
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concept of medical homes. Effective January 2011, states may
implement a Medicaid Health Home State Option for enrollees with
two or more chronic conditions, one conditions and the risk of
developing another, or at least one serious and persistent
mental health condition. Health home related services, such as
comprehensive care management, care coordination, health
promotion and use of health information technology to link
services will be matched with federal funs at 90%.
The new law will also create the following patient-centered
medical home demonstration projects designed to create and
reinforce a strong primary care foundation for the health care
delivery system:
1)Grants for medication management services provided by
pharmacists to treat patients with multiple chronic diseases
and those who take several, or high-risk, prescribed
medications.
2)Grants to states to establish community health teams working
in collaboration with providers in the community to support
primary care physicians, with capitated payments to qualified
primary care providers.
3)A Medicare demonstration program to test a model of care that
uses physician and nurse practitioner directed home-based
primary care teams. Provides an incentive payment to qualified
groups of providers who come in under target spending levels.
A new CMS Innovation Center to test innovative payment and
service delivery models, reduce health care hosts and enhance
quality.
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097
FN: 0006822