BILL ANALYSIS �
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|SENATE RULES COMMITTEE | AB 415|
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THIRD READING
Bill No: AB 415
Author: Logue (R), et al.
Amended: 9/2/11 in Senate
Vote: 21
SENATE HEALTH COMMITTEE : 8-0, 06/29/11
AYES: Hernandez, Strickland, Alquist, Anderson, Blakeslee,
De Le�n, DeSaulnier, Wolk
NO VOTE RECORDED: Rubio
SENATE BUS., PROF. & ECON. DEVELOP. COMM. : 9-0, 07/06/11
AYES: Price, Emmerson, Corbett, Correa, Hernandez, Negrete
McLeod, Vargas, Walters, Wyland
SENATE APPROPRIATIONS COMMITTEE : 9-0, 08/25/11
AYES: Kehoe, Walters, Alquist, Emmerson, Lieu, Pavley,
Price, Runner, Steinberg
ASSEMBLY FLOOR : 76-0, 06/01/11 - See last page for vote
SUBJECT : Healing arts: telehealth
SOURCE : Author
DIGEST : This bill enacts the Telehealth Advancement Act
of 2011. This bill repeals and recasts existing laws
related to the delivery of health care services via
telemedicine and replaces the term telemedicine with
telehealth.
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Senate Floor Amendments of 9/2/11 allow a hospital where a
patient is receiving telehealth services to grant
privileges to, and verify and approve credentials for,
providers of telehealth services who are located at a
distant-site hospital or telehealth entity, pursuant to
federal regulations, and add Assemblymember Galgiani as a
principal coauthor.
ANALYSIS : Existing law:
1. Establishes the Medical Board of California to
exercise licensing, regulation and disciplinary
functions in accordance with the Medical Practice Act.
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.
2. Establishes the Telemedicine Development Act of 1996
(TDA), 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.
3. Requires the health care practitioner who has
ultimate authority over the care or primary diagnosis
of the patient to obtain verbal and written informed
consent from the patient or the patient's legal
representative prior to the delivery of health care via
telemedicine, except when the patient is not directly
involved in the telemedicine interaction (e.g., health
care practitioners consulting with one another), in an
emergency situation when a patient is unable to give
informed consent, and the patient is under the
jurisdiction of the California Department of
Corrections and Rehabilitation or any other
correctional facility.
4. Establishes an informed consent procedure
(specifically for telemedicine) that requires at least
all of the following information be given to the
patient or the patient's legal representative verbally
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and in writing: a) The patient or the patient's legal
representative retains the option to withhold or
withdraw consent at any time without affecting the
right to future care or treatment or program benefits;
b) A description of the potential risks, consequences,
and benefits of telemedicine; c) All existing
confidentiality protections apply; d) All existing laws
regarding patient access to medical information and
copies of medical information and copies of medical
records apply; and, e) Prohibits dissemination of any
patient identifiable images or information from the
telemedicine interactions to researchers or other
entities from occurring without consent.
5. Requires a patient or the patient's legal
representative to sign a written statement prior to the
delivery of health care via telemedicine, indicating
that the patient or the patient's legal representative
understands the written information provided pursuant
to 4) above and that this information has been
discussed with the health care practitioner, or his or
her designee.
6. Makes the patient's written consent statement part of
the patient's medical record.
7. Makes failure to comply with #3 to #6 above
unprofessional conduct, but not a misdemeanor, as
specified.
8. Establishes procedures for physicians to obtain
verbal and/or written informed consent for specified
treatments and procedures, such as hysterectomies,
psychosurgery, electroconvulsive therapy, and assisted
oocyte production.
9. Prohibits health plans and health insurers from
requiring face-to-face contact between a health care
provider and a patient for services appropriately
provided through telemedicine, subject to all terms and
conditions of the contract agreed upon between the
enrollee or subscriber and the plan or insurer. Applies
this prohibition to health plan contracts with the
Medi-Cal Managed Care Program only to the extent
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telemedicine services are covered by and reimbursed
under the Medi-Cal fee-for-service program, and
Medi-Cal contracts with health plans are amended to add
coverage of telemedicine services and make any
appropriate capitation rate adjustments.
10. Prohibits health plans and health insurers from being
required to pay for consultation provided by the health
care provider by telephone or facsimile machines.
11. 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.
12. Prohibits, under the Confidentiality of Medical
Information Act, licensed or certified health care
professionals, clinics and health facilities, health
plans, and contracting entities, as defined, from
disclosing or using a patient's medical information for
any purpose not necessary to provide health care
services to the patient and related administrative
functions, without first obtaining authorization from
the patient or the patient's representative, as
specified, with exceptions.
This bill:
1. Removes various requirements imposed by health care
service plans, health insurers, and Medi-Cal for
patients to receive health care services through
telehealth and would amend the informed consent
requirements prior to the delivery of health care via
telehealth.
2. Repeals the definition of telemedicine, which means
the practice of health care delivery, diagnosis,
consultation, treatment, transfer of medical data, and
education using interactive audio, video, or data
communications, not including by means of a telephone
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conversation nor an electronic mail message between a
health care practitioner and patient.
3. Defines telehealth as the mode of delivering health
care services and public health via information and
communication technologies to facilitate the diagnosis,
consultation, treatment, education, care management,
and self-management of a patient's health care while
the patient is at the originating site and the health
care provider is at a distant site.
4. Repeals the requirement that prior to the delivery of
health care via telemedicine, the health care
practitioner must obtain verbal and written informed
consent from the patient, as specified, and the
requirement that a patient must sign a written
statement prior to the delivery of health care via
telemedicine. The written statement is made part of the
patient's medical record. Instead, this bill would
require a health care practitioner to obtain verbal
consent from the patient prior to the provision of
health care services via telehealth and to document
that verbal consent was given in the medical record.
5. Prohibits the department from requiring that a health
care provider document a barrier to an in-person visit
prior to paying for services provided via telehealth to
a Medi-Cal beneficiary.
6. Repeals the prohibition for paying for a service
provided by telephone or facsimile and would instead
prohibit the department from limiting the type of
setting where services are provided for the patient.
7. Prohibits health plans and insurers from requiring
that in-person contact occur between a health care
provider and a patient before payment is made for the
services appropriately provided through telehealth,
subject to the terms of the relevant contract.
8. Repeals the prohibition for paying for a service
provided by telephone or facsimile and would instead
prohibit them from limiting the type of setting where
services are provided for the patient or by the health
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care provider. These provisions would apply to plans
contracting with DHCS to provide Medi-Cal managed care
and would repeal the requirements that telemedicine
could only be used (a) for telemedicine services that
are reimbursed by the Medi-Cal fee-for-service program
and (b) that Medi-Cal contracts with health plans are
amended to add coverage of telemedicine services and to
make any appropriate capitation rate adjustment.
9. Repeals the existing January 1, 2013, sunset date on
the use of teleopthalmology and teledermatology by
store and forward technology and would update and
define terminology related to telehealth and current
practice.
10. Allows the governing body of a hospital whose
patients are receiving telehealth services to grant
privileges to, and verify and approve credentials for,
providers of telehealth services, based on its medical
staff recommendations that rely on information provided
by the distant-site hospital or telehealth entity,
pursuant to federal regulations, as specified.
11. States legislative intent to allow hospitals to grant
privileges to, and verify and approve credentials for,
providers of telehealth services.
Background
Telehealth is a mode of delivering health care services and
public health using information and communication
technologies that enable the diagnosis, consultation,
treatment, education, care management, and self-management
of patients. It includes telemedicine, which is the
diagnosis and treatment of illness or injury, and
telehealth services can range from diagnosis, treatment,
assessment, monitoring, communications, and education.
Currently, telehealth services are primarily delivered in
three ways:
Video conferencing, which is used for real-time
patient-provider consultations, provider-to-provider
discussions, and language translation services;
Patient monitoring, in which electronic devices
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transmit patient health information to health care
providers; and
Store and forward technologies, which
electronically transmit pre-recorded videos and
digital images, such as X-rays, video clips, and
photos, between primary care providers and medical
specialists.
Telehealth is commonly used to address the problems of
inadequate provider distribution and is used in the
development of health systems in rural and medically
underserved areas. It has the potential to reduce costs,
improve quality, change the conditions of practice and
improve access to health care services.
In February 2011, the Center for Connected Health Policy
(CCHP) issued a report with 13 recommendations to update
California's TDA. The revisions to existing law that this
bill contemplates are based on the following
recommendations from the CCHP report:
Update the term "telemedicine" used in current law
to "telehealth," to reflect changes in technologies,
settings, and applications for medical and other
purposes;
Include the asynchronous application of
technologies in the definition of telehealth and
remove the 2013 sunset date for Medi-Cal reimbursement
of teledermatology, teleophthalmology, and
teleoptometry services;
Remove restrictions in the current telemedicine
definition that prohibit telehealth-delivered services
provided via email and telephone;
Eliminate the current Medi-Cal requirement to
document a barrier to an in-person visit for coverage
of services provided using telehealth;
Require private health care payers and Medi-Cal to
cover encounters between licensed health practitioners
and enrollees irrespective of the setting of the
enrollee and providers; and
Remove the requirement necessitating an additional
informed consent waiver be obtained prior to any
telehealth services being rendered.
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The CCHP indicates that telehealth is a mode of providing
services, not a treatment or procedure, but is treated in
California law in the same manner as highly invasive
procedures. The report states that by eliminating the
duplicative required written informed consent, more
patients can make more expedient choices regarding their
care.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
According to the Senate Appropriations Committee:
Fiscal Impact (in thousands)
Major Provisions 2011-12 2012-13
2013-14 Fund
DMHC $53 $105 $105 Special*
Potential increased unknown,
potentially significant
General/**
number of Medi-Cal visits
Federal/
Local
* Managed Care Fund
**50 percent federal funds, 50 percent non-federal funds
(usually General Fund, but would be local funds if
provided by designated public hospitals or paid for the
Low-Income Health Care Program)
SUPPORT : (Verified 9/6/11)
AgeTech California
Association of California Healthcare Districts
BayBio
California Association of Physician Groups
California Center for Rural Policy at Humboldt State
University
California Healthcare Institute
California Hospital Association
California Medical Association
California State Rural Health Association
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Continua Health Alliance
Del Norte Clinics, Inc.
Kaiser Permanente
Kings View Corporation
Latino Coalition for a Healthy California
Medical Board of California
National Multiple Sclerosis Society - California Action
Network
Occupational Therapy Association of California
Peach Tree Healthcare
Regional Council of Rural Counties
Rural Health Sciences Institute
The Children's Partnership
University of California
ARGUMENTS IN SUPPORT : The California State Rural Health
Association (CSRHA) states that telehealth and other health
information technologies (HIT) are critical tools for
California's rural health care safety net, and have the
potential to increase health care access, quality, and the
cost-effectiveness of care in rural communities, especially
for specialty care. Telehealth and other HIT can ensure
that rural patients receive timely care that otherwise
would be unavailable to them. CSRHA believes that the lack
of adequate care increases the costs of health care in
rural communities. Further, telehealth allows rural
communities to care for patients in their home community
rather than requiring them to travel to distant cities, and
allows more health care dollars to be spent in the rural
community where the patient's home is located. CSRHA also
asserts that telehealth and other advanced HIT applications
can alleviate chronic shortages of specialty care providers
and increase the ability of rural communities to attract
and retain health care providers.
The Children's Partnership (TCP) supports this bill because
low-income children living in medically underserved areas,
both rural and parts of urban areas, face geographic and
economic barriers to accessing health care. TCP states
that telehealth helps to overcome these barriers, such as
provider shortages, transportation costs, and lost time
from work and school, by using technology to bring the care
to where the children are located.
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According to the University of California (UC), which
supports this bill, there are three major initiatives
underway to expand the use of telehealth technologies and
expertise throughout the state. The first is the
California Telehealth Network (CTN), a recent statewide
broadband initiative to provide managed broadband access to
hundreds of primarily rural health care facilities
throughout California. The CTN expects to link more than
800 qualified sites, including the five UC academic health
systems, Stanford University, University of Southern
California, and Loma Linda University in a peer-to-peer
network which will be one of the largest in the nation. A
second initiative nables the expansion of existing
telemedicine programs at UC medical school campuses to
provide facilities and state-of-the-art equipment to expand
use of telemedicine across the state. Lastly, the
Specialty Care Safety Net Initiative is a collaborative
effort between UC medical school specialty departments and
safety net clinics in California. The initiative seeks to
identify barriers to adoption and sustainability of
telehealth programs in high-need specialties such as
dermatology, endocrinology, hepatology, neurology,
orthopedics and psychiatry.
ASSEMBLY FLOOR : 76-0, 06/01/11
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Beall, Bill
Berryhill, Block, Blumenfield, Bonilla, Bradford,
Brownley, Buchanan, Butler, Charles Calderon, Campos,
Carter, Cedillo, Chesbro, Conway, Cook, Davis, Dickinson,
Donnelly, Eng, Feuer, Fletcher, Fong, Fuentes, Furutani,
Beth Gaines, Galgiani, Gatto, Gordon, Grove, Hagman,
Halderman, Hall, Harkey, Hayashi, Roger Hern�ndez, Hill,
Huber, Hueso, Huffman, Jones, Knight, Lara, Logue, Bonnie
Lowenthal, Ma, Mansoor, Mendoza, Miller, Mitchell,
Monning, Morrell, Nestande, Nielsen, Norby, Olsen, Pan,
Perea, Portantino, Silva, Skinner, Smyth, Solorio,
Swanson, Torres, Valadao, Wagner, Wieckowski, Williams,
Yamada, John A. P�rez
NO VOTE RECORDED: Garrick, Gorell, Jeffries, V. Manuel
P�rez
CTW:nl 9/6/11 Senate Floor Analyses
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SUPPORT/OPPOSITION: SEE ABOVE
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