BILL ANALYSIS �
SB 393
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Date of Hearing: July 3, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 393 (Ed Hernandez) - As Amended: June 15, 2012
SENATE VOTE : 30-7
SUBJECT : Medical homes.
SUMMARY : Establishes the Patient-Centered Medical Home (PCMH)
Act of 2011 to define a PCMH as a health care delivery model
that conforms to the definition contained in the federal Patient
Protection and Affordable Care Act (ACA) and meets other
specified criteria consistent with providing patient-centered,
coordinated care. Specifically, this bill :
1)Defines PCMH, "medical home," "advanced practice primary
care," "health home," "person-centered health care home," and
"primary care home," all to mean a health care delivery model
as defined in the ACA, and any subsequent federal rules or
regulations, and that meets the following criteria:
a) Facilitates a relationship between a patient and his or
her personal physician or other licensed primary care
provider in a physician-directed practice team to provide
comprehensive and culturally competent primary and
preventive care; and,
b) Meets the criteria of, and participates in, a voluntary
recognition process conducted by a nongovernmental entity
to demonstrate that the practice has the capabilities to
provide patient-centered services consistent with the
medical home model.
2)Prohibits this bill from being construed to alter the scope of
practice of any health care provider, or to authorize the
delivery of health care services in a setting or manner
otherwise authorized by law.
EXISTING LAW :
1)Defines PCMH under the ACA and authorizes tests of innovative
Medicaid (Medi-Cal in California) and Medicare service
delivery models in federal fiscal years 2010 to 2019, to
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reduce program expenditures while preserving or enhancing
patient quality of care. Innovative models include PCMHs for
high-need patients and medical homes that address women's
unique health care needs.
2)Makes grants under the ACA 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.
3)Authorizes the waiving of specified Medicaid requirements for
demonstration projects, for care delivered through primary
care case-management systems, or for the provision of home- or
community-based services.
4)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income persons receive health care benefits.
FISCAL EFFECT : None
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill
establishes a definition for the set of best health care
practices known as PCMH 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 PCMH model of health care
delivery. The author maintains that establishing a definition
for this model in state law makes it more likely that
California will receive crucial federal health care dollars.
2)PCMH MODELS . According to the National Conference of State
Legislatures (NCSL), PCMH is a way to provide comprehensive
care that is designated and centered around the patient's
needs. In the PCMH model, a health care team (i.e. doctors,
nurses, physician assistants, medical assistants, mental
health providers, community health workers, and social
workers) works in partnership with one another, their
patients, and their patients' families to coordinate care and
navigate the complex and often confusing health care system to
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ensure that patients receive the right care at the right time.
The model aims to improve coordination of care, increase the
value of health care received, expand administrative and
quality innovations, promote active patient and family
involvement, and help control the rising costs of health care
for both individuals and payers, such as Medicaid and private
insurers. NCSL reports that PCMHs are serving as key aspects
in state health reform efforts. 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.
3)PCMH & ACA . The ACA includes provisions requiring the federal
Secretary of Health and Human Services to establish a program
to provide grants to, or enter into contracts with, eligible
entities to establish community health teams to support the
PCMH model. The ACA defines a PCMH as a mode of care that
includes personal physicians; whole person orientation;
coordinated and integrated care; safe and high-quality care
through evidence-informed medicine, appropriate use of health
information technology, and continuous quality improvements;
expanded access to care; and, payment that recognizes added
value from additional components of patient-centered care.
4)HEALTH HOME OPTION & ACA . The ACA authorizes a temporary,
two-year 90% federal match rate for care coordination provided
in conjunction with a health home. In November 2010, the
Centers for Medicare & Medicaid Services (CMS) issued
preliminary guidance describing the requirements, choices,
funding opportunities, and expectations for successful
implementation of the health home provision of the ACA. To be
eligible for health home services, Medi-Cal beneficiaries must
have at least two specified chronic conditions; one chronic
condition and be at risk for another; or, one serious and
persistent mental health condition. States are allowed to
target health home services to those with particular chronic
conditions or with higher numbers or severity of chronic or
mental health conditions. Services must be provided by a
designated health home provider arrangement.
CMS expects use of the health home service delivery model to
result in lower rates of emergency room use, reductions in
hospital admissions and re-admissions, reductions in health
care costs, less reliance on long-term care facilities, and,
improved experience of care and quality of care outcomes for
the individual. CMS adds that states that opt to provide the
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health homes benefit, and the health home providers with which
the states collaborate, are expected to operate under a "whole
person" philosophy that cares not just for an individual's
physical condition, but provides linkages to long-term
community care services and supports, social services, and
family services.
5)VOLUNTARY RECOGNITION STANDARDS . This bill requires a primary
care practice to meet the criteria of, and participate in, a
voluntary recognition process conducted by a nongovernmental
entity to demonstrate that it provides patient-centered
services consistent with a PCMH. Standards developed by the
National Committee for Quality Assurance (NCQA) are most often
used to identify which primary care practices have achieved
designation as a medical home. The NCQA standards allow for
recognition as a PCMH at three different levels and include 30
elements, of which 10 are considered mandatory or "must pass."
The must pass elements include standards related to patient
access and communication, patient tracking, care management,
test and referral tracking, and performance reporting and
improvement.
NCQA indicates on its Website that its PCMH 2011 standards offer
guidance on developing better chronic care management
programs, enhancing patient engagement and improving patient
outreach. According to NCQA, clinicians, patients, health
plans, employers, public entities, and other participants
across the country are actively testing the model to learn how
to transform and reward medical home practices. NCQA reports
that the evidence shows promising results in improving care
quality and lowering costs by increasing access to more
efficient, coordinated, and responsive care. There are over
200 NCQA-recognized PCMHs in California.
The California Academy of Family Physicians, a cosponsor of this
bill, notes that there are other organizations that also have
PCMH recognition programs, including the Joint Commission, the
Accreditation Association for Ambulatory Health Care, and the
Utilization Review Accreditation Commission. This bill
requires a practice to obtain PCMH recognition using any of
these multiple program options.
6)RELATED LEGISLATION . AB 2266 (Mitchell) requires DHCS to
design and administer a program to provide health homes to
eligible individuals with high-health needs in order to take
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advantage of enhanced federal matching funds available under
the ACA. AB 2266 is pending in the Senate Appropriations
Committee.
7)PRIOR LEGISLATION :
a) AB 1542 (Jones) of 2010, substantially similar to this
bill, 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. AB 1542 failed passage on concurrence on the
Assembly Floor.
b) SB 966 (Alquist) of 2010 would have directed DHCS to
establish a definition of medical home consistent with
specified guidelines and a timetable for Medi-Cal managed
care (MCMC) plans to provide beneficiaries with a medical
home. SB 966 died on the Senate Appropriations Committee
Suspense File.
c) SB 771 (Alquist) of 2010 would have required a health
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 PCMH. These
provisions were amended out of SB 771.
d) AB 342 (John A. P�rez), Chapter 723, Statutes of 2010,
revises and recasts provisions pertaining to the local
Coverage Expansion and Enrollment Demonstration projects.
Among other provisions, AB 342 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.
e) SB 208 (Steinberg), Chapter 714, Statutes of 2010, a
companion bill to AB 342, enacts provisions that relate to
hospital financing, mandatory enrollment of seniors and
persons with disabilities into MCMC plans, and pilot
projects to provide organized systems of care to California
Children's Services and Medi-Cal eligible children and to
Medicare and Medi-Cal dual eligible persons.
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f) SB 1738 (Steinberg) of 2008 would have required DHCS to
establish a three-year pilot program to provide intensive
multidisciplinary services to 2,500 Medi-Cal beneficiaries
identified as frequent users of health care. SB 1738 was
vetoed by Governor Schwarzenegger who stated in his veto
message that he could not support the bill because of the
state's ongoing fiscal challenges and asked the author and
stakeholders to work with his Administration to identify
strategies to ensure these beneficiaries receive the right
care, at the right time, in the right setting.
g) AB 1736 (Levine) of 2005 would have required the
Department of Health Services (DHS now DHCS) to
conduct a demonstration testing of the chronic care
model of providing disease management services in
community clinics and health center and public
hospital settings. AB 1736 was vetoed by Governor
Schwarzenegger who stated in his veto message that the
bill was duplicative of current efforts and would
impose significant costs.
8)SUPPORT . Supporters, representing various provider and
consumer advocacy groups, agree that a medical home serves as
a centralized hub to provide patients and their families with
coordinated services, such as preventive and wellness care,
referrals for specialty care, and help in coordinating care
across specialties. They state that the PCMH model is
particularly effective for children as it encourages a "whole
child" approach that increases the ability to avoid or
successfully manage chronic childhood conditions and, in doing
so, it could produce potentially significant cost savings over
a lifetime. Supporters write that, as the PCMH model
continues to evolve and grow in popularity, this bill will
ensure uniform application of the use of the PCMH in
California and provide clarity on the appropriate standards of
care for this model in the state. They add that this bill
ensures that all licensed providers are included as partners
in the medical home model and sends an important signal that
California supports health care that is comprehensive,
accessible, cost-effective, and evidence-based.
9)POLICY COMMENTS .
a) Role of the nongovernmental entity . The effect of
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requiring a nongovernmental entity in this bill to do a
voluntary review of a primary care practice is unclear.
The author may wish to explain the purpose of this
provision.
b) Potential for duplication . AB 2266 (Mitchell) directs
DHCS to take advantage of the health homes option in the
ACA by establishing a program to provide enhanced health
homes, as defined, to persons at high risk of avoidable and
frequent hospital use due to chronic health and behavioral
health conditions. The author may wish to address the
extent to which this bill, by defining a PCMH in statute,
may potentially conflict with the health home model
specified in AB 2266.
REGISTERED SUPPORT / OPPOSITION :
Support
American Academy of Pediatrics - California District
(co-sponsor)
American College of Physicians, California Chapters (co-sponsor)
California Academy of Family Physicians (co-sponsor)
California Academy of Physician Assistants (co-sponsor)
California Association of Physician Groups (co-sponsor)
California Primary Care Association (co-sponsor)
California Psychiatric Association (co-sponsor)
Osteopathic Physicians and Surgeons of California (co-sponsor)
American Congress of Obstetricians and Gynecologists, District
IX
California Black Health Network
California Department of Insurance
California Optometric Association
California Society of Health-System Pharmacists
Children Now
Planned Parenthood Affiliates of California
Opposition
None on file.
Analysis Prepared by : Cassie Royce / HEALTH / (916) 319-2097
SB 393
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