BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 393
S
AUTHOR: Hernandez
B
AMENDED: As Introduced
HEARING DATE: May 4, 2011
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REFERRAL: Rules
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CONSULTANT:
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Tadeo
SUBJECT
Medical homes
SUMMARY
Establishes the Patient-Centered Medical Home Act of 2011
to encourage licensed health care providers and patients to
partner in a patient-centered medical home, as defined,
promoting access to high-quality, comprehensive care, in
accordance with prescribed requirements.
CHANGES TO EXISTING LAW
Existing federal law:
Defines, under the Patient Protection and Affordable Care
Act (PPACA) (Public Law 111-148), as amended by the Health
Care Education and Reconciliation Act of 2010 (Public Law
111-152), patient-centered medical homes and authorizes
tests of innovative Medicaid and Medicare service delivery
models in federal fiscal years 2010 to 2019, "to reduce
program expenditures while preserving or enhancing patient
quality of care." Innovative models include
patient-centered medical homes for high-need patients and
medical homes that address women's unique health care
needs.
Continued---
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Under the PPACA, makes grants available to states to
establish community-based interdisciplinary teams to
support medical homes and help primary care providers
implement them in federal fiscal years 2011 and 2012.
Existing state law
Defines a "medical home" as a "single provider or facility
that maintains all of an individual's medical information"
for the purposes of the Health Care Coverage Initiative, a
MediCal demonstration project which provides funding for
programs to expand health care coverage to low income,
uninsured residents in selected counties.
Provides for the licensure and regulation of clinics and
health facilities by the Department of Public Health.
Provides for the registration, certification, and licensure
of various health care professionals and sets forth the
scope of practice for these professionals.
This bill:
Establishes the Patient-Centered Medical Home Act of 2011.
Defines "medical home," "patient-centered medical home,"
"advanced primary home" and "primary care home" to mean 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, who works in a physician-directed team to provide
comprehensive, accessible, and continuous evidence-based
primary and preventive care that coordinates the patient's
health care needs across the health care system.
Requires a medical home model meet a variety of criteria,
including:
Individual patients have an ongoing relationship
with a physician or other licensed health care
provider acting within his or her scope of practice;
A team of individuals at the practice level
collectively takes responsibility for the ongoing
health care of patients;
Care is coordinated and integrated across all
elements of the health care system, including mental
health and substance use disorder care, and the
patient's community.
Care is facilitated, if available, by registries,
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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; and,
Quality and safety components are in place which
ensure the following:
o The medical home advocates for its
patients;
o Evidence-based medicine and clinical
decision support tools guide decision-making;
o Licensed health care providers in the
medical practice who accept accountability for
continuous quality improvement through voluntary
engagement in performance measurement and
improvement;
o Patients actively participate in
decision-making and feedback is sought to ensure
that the patients' expectations are being met;
o Information technology is utilized
appropriately;
o 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;
o Patients and families participate in
quality improvement activities at the practice
level; and,
o 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.
Provides that the bill does not:
Permit a medical home to engage in or otherwise aid
and abet in the unlicensed practice of medicine,
either directly or indirectly;
Change the scope of practice of physicians and
surgeons, nurse practitioners, or other health care
providers;
Affect the ability of a nurse to operate under
standard procedures pursuant to Section 2725 of the
Business and Professions Code;
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Apply to activities of managed care plans, or their
contracting providers, or county alternative models of
care, or their contracting providers, or local
Coverage Expansion and Enrollment Demonstration
projects, if those activities are part of established
demonstration projects, as specified.
Prevent or limit participation in activities
authorized by Sections 2703, 3024, and 3502 of the
federal Patient Protection and Affordable Care Act
(Public Law 111-148), as amended by the federal Health
Care and Education Reconciliation Act of 2010 (Public
Law 111-152), if the participation is consistent with
state law pertaining to scope of practice.
Declares Legislative intent to encourage licensed health
care providers and patients to partner in patient-centered
medical homes, and to adhere to quality standards that will
reduce disparities in health care access, delivery, and
health care outcomes, and improve the quality of health
care and lower health care costs.
FISCAL IMPACT
SB 393 is keyed nonfiscal.
BACKGROUND AND DISCUSSION
According to the author, SB 393 establishes a functional
definition for the set of best health care practices known
as the medical home, to ensure uniform standards of quality
and access. The author argues that out-of-control health
care costs, diminishing state revenue, a growing shortage
of primary care professionals, inadequate distribution of
health care providers, and a sharp increase in the demand
for services for those with chronic disease and mental
health disorders drive the need for the medical home model
of health care delivery. The author adds that
establishing a functional definition for this model of
delivery in law makes it more likely that California will
receive crucial federal health care dollars.
In the medical home model, a health care team (doctors,
nurses, physician assistants, medical assistants, mental
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health providers, community health workers, and social
workers) works in partnership with one another, their
patients and their patients' families to coordinate care,
navigate the complex and often confusing health care
system, and ensure that patients receive the right care at
the right time. The author points to a 2007 study by the
Commonwealth Fund which identifies fragmented care at the
national, state and community levels as the main cause of
the poor performance of the U.S. health care system. The
author adds that other states have leapt ahead in their
commitment to the medical home model and have already
proven that quality can improve, and costs can decrease
significantly using this set of best practices. The author
contends that adding a definition of "medical home" to
state law sends an important signal that California
supports health care that is comprehensive, accessible,
cost-effective and evidence-based.
Medical homes
According to a 2010 brief entitled "Health Cost Containment
and Efficiencies," published by the National Conference of
State Legislatures (NCSL), the medical home model is
designed to address several shortcomings in the current
health care system, especially uncoordinated care. Poor
care coordination is associated with duplicate procedures,
conflicting treatment recommendations, unnecessary
hospitalizations and nursing home placements, and adverse
drug reactions. In addition to uncoordinated care, medical
homes are designed to address lack of patient access to a
primary care doctor, inadequate physician payment for
primary care services, use of more expensive services when
less expensive care would be as effective, and poor care
management for patients with chronic conditions.
Research has shown that primary care makes significant
contributions to health. Primary care reduces deaths from
heart and lung disease, leads to longer lives, reduces
hospital and emergency room use, and reduces health
disparities. Researchers have linked the United States'
low scores on primary care to higher costs and poorer
health outcomes relative to other developed nations. In
addition, according to the Department of Public Health,
states find that a reliable medical home can magnify the
effect of disease management programs.
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According to a 2007 Commonwealth Fund report, "Closing the
Divide: How Medical Homes Promote Equity in Health Care,"
when adults have health insurance coverage and a medical
home, racial and ethnic disparities in access and quality
tend to disappear. The analysis, based on a Commonwealth
Fund survey of more than 2,830 adults nationwide, reveals
that linking minority patients to a medical home can help
them better manage chronic conditions and obtain critical
preventive care.
In a 2008 report to the U.S. Congress, the federal Medicare
Payment Advisory Commission recommended that Congress
establish a budget-neutral payment increase for primary
care services furnished by primary-care-focused
practitioners (defined as those whose specialty designation
is defined as primary care or whose pattern of claims meets
a minimum threshold of furnishing primary care services).
The commission also recommended that Congress initiate a
Medicare medical home pilot project, with stringent
specified criteria and a physician pay-for-performance
program.
Medical home model in other states
NCSL reports that, as of July 2010, at least 29 states had
enacted medical home legislation and 22 had one or more
public, private or public-private medical home pilot
programs.
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. Community Care of
North Carolina, the state's Medicaid program, is a working
example of a patient centered medical home. The goals of
the 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. 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
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compared to historical fee-for-service.
In the private sector, IBM also implemented a
"patient-centric medical home" which is similar to the
medical home defined in this bill. According to the
company, as a result, its injury and illness rates are
lower than the rest of the industry. IBM employees also
had nine to twenty-five percent fewer emergency room visits
and a sixteen percent reduction in medical and
pharmaceutical costs. These savings also led to lower
premiums and $100 million savings annually, including
through increased productivity.
Federal health care reform and medical homes
Federal health care reform legislation and earlier federal
legislation provide several provisions and incentives
related to medical homes including:
State options to provide health home for those with
chronic diseases;
Increased payments to primary care physicians in
Medicaid;
Grants for training in family medicine, general
internal medicine, general pediatrics and physician
assistantship;
Creation of a medical home pilot in Medicare for
physicians who elect to make their practice a medical
home;
Establishment of a state option to provide health
homes for Medicaid enrollees with chronic conditions
under which the federal government will provide 90
percent matching funds to states for over five years;
and,
Establishment of community health teams to support
the patient-centered medical homes.
Prior legislation
AB 1542 (Jones) of 2010, substantially similar to SB 393,
would have established the Patient-Centered Medical Home
Act of 2010 to encourage licensed health care providers and
patients to partner in a patient-centered medical home, as
defined, that promotes access to high-quality,
comprehensive care, in accordance with prescribed
requirements. AB 1542 included an urgency clause. This
bill died on the unfinished business file of the Assembly
Floor.
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SB 208 (Steinberg and Alquist) Chapter 714, Statutes of
2010, enacts statutory changes necessary for the Department
of Health Care Services and counties to implement a
proposed Section 1115 Comprehensive Demonstration Project
Waiver in the Medi-Cal Program.
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. This bill died in the
Senate Appropriations Committee.
SB 771 (Alquist) of 2010 would have required a health care
service plan or a health insurer, or a medical group that
contracts with a plan that uses a pay-for-performance
system for the payment of providers, to provide a
differential payment to providers who provide patients with
a patient-centered medical home. These provisions were
amended out of the bill.
AB 342 (John A. P�rez) Chapter 723, Statutes of 2010
revises and recasts provisions pertaining to the local
Coverage Expansion and Enrollment Demonstration (CEED)
projects. Among other provisions, the bill 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.
AB 1076 (Jones) of 2010 would have required DHCS to expand
the Medical Case Management Program and required the
Medi-Cal disease management benefit to include the
designation of a primary care provider as a patient's
medical home. These provisions were amended out of the
bill.
Arguments in support
The California Academy of Family Physicians (CAFP), one of
the six co-sponsors of SB 393, states that the goal of the
medical home model is to utilize a team of professionals to
provide to a patient and coordinate a broad spectrum of
coordinated care and that as this concept grows in
popularity among consumers and providers, SB 393 will
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ensure uniform standards of quality and access. Supporters
of SB 393 add that this bill will ensure inclusivity of all
licensed primary care providers in the medical home model.
POSITIONS
Support: American Academy of Pediatrics (co-sponsor)
California Academy of Family Physicians
(co-sponsor)
California Academy of Physician Assistants
(co-sponsor)
California Association for Nurse Practitioners
(co-sponsor)
California Primary Care Association (co-sponsor)
California Psychiatric Association (co-sponsor)
Osteopathic Physicians and Surgeons of California
(co-sponsor)
American College of Physicians, California
Chapter
American Congress of Obstetricians and
Gynecologists, District IX
American Nurses Association of California
California Association of Physician Groups
California Mental Health Directors Association
California Pharmacists Association
California Society of Health-System Pharmacists
Children Now
Planned Parenthood Affiliates of California
Six Rivers Planned Parenthood
Southern California Society of Health-System
Pharmacists
Four individuals
Oppose: None received.
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