BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 485
S
AUTHOR: Hernandez
B
AMENDED: April 14, 2011
HEARING DATE: May 4, 2011
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CONSULTANT:
8
Bain
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SUBJECT
Health facilities: emergency department
SUMMARY
This bill requires the Department of Health Care Services
(DHCS) to establish a pilot program to facilitate
collaboration between providers and hospitals within two
geographic locations, to provide a Medi-Cal beneficiary or
an uninsured patient with an alternative to the use of the
hospital emergency department (ED) if the individual does
not have an emergency medical condition. Under this bill,
the individual would be provided the name and address of an
available and accessible provider of non-emergency medical
care and a referral from the hospital, if necessary, to
coordinate the scheduling of treatment prior to his or her
discharge from the hospital ED.
CHANGES TO EXISTING LAW
Existing law:
Establishes the Medi-Cal program, administered by DHCS,
which provides health benefits to low-income children,
their parents or caretaker relatives, pregnant women,
elderly, blind or disabled persons, and refugees who meet
specified eligibility criteria.
Continued---
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Establishes a schedule of benefits under the Medi-Cal
program, which includes physician services and hospital
inpatient and outpatient services, subject to utilization
controls. Federally qualified health center (FQHC) services
and rural health clinic (RHC) services described in federal
law are also a covered benefit under Medi-Cal.
This bill:
Requires DHCS to establish a pilot program to facilitate
collaboration between an available and accessible provider
of non-emergency medical care and a general acute care
hospital (hospital), within two geographic locations, to
provide a Medi-Cal beneficiary, an uninsured patient, or
both, with an alternative to the use of the ED of a
hospital for care and services, if the individual is
determined by a physician, or other health care provider
who acts within his or her scope of practice, to not have
an emergency medical condition and the individual is
provided the following information, in writing, before the
patient is discharged from the ED:
� The name and address of an available and accessible
provider of non-emergency medical care.
� A referral from the hospital if necessary to coordinate
the scheduling of treatment.
Requires DHCS to submit any necessary application to the
federal Centers for Medicare and Medicaid Services (CMS)
for a waiver to implement the pilot project described in
this bill. Requires DHCS to determine the form of waiver
most appropriate to achieve the purposes of this bill, and
requires the waiver request to be included in any waiver
application submitted within 12 months after the effective
date of this bill, or to be submitted as an independent
application within that time period.
Requires DHCS to implement the waiver within 12 months of
the date of federal approval.
Requires DHCS to develop a request for proposal process for
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available and accessible providers of non-emergency medical
care and hospitals that want to participate in the pilot
project.
Requires DHCS to develop a timeline and process for
monitoring and evaluating the pilot project, and provide
this timeline and process to the appropriate fiscal and
policy committees of the Legislature.
Defines, for purposes of this bill, "an available and
accessible provider of non-emergency medical care" to
include the office of a physician, health clinic, community
health center, and hospital outpatient department, provided
that the provider of non-emergency medical care is able to
diagnose or treat contemporaneously within the same amount
of time that a physician within the ED of a hospital would
have taken to provide the same non-emergency services.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
According to the author, this bill has a two-fold purpose to
address the overcrowding of EDs by non-emergent cases, and to
find medical homes for those who do not have access to regular,
preventative health care and/or health care providers. The
author cites several studies on the use of hospital EDs for
non-urgent conditions. To address this issue, this bill would
set up a pilot program between a hospital and a clinic(s), to
find a permanent medical home for patients who utilize EDs for
non-emergency care. The author argues community health
centers/federally qualified health centers (CHCs/FQHCs) are an
ideal place for these patients to find consistent care in the
medical home model. The author states this bill is modeled on a
program in San Diego where hospital discharge personnel work
with patients who have been treated in a hospital ED for
non-emergency conditions to find a clinic close to the patient's
home, make them an appointment, provide them a personalized
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printout listing the clinic address, the doctor with whom they
have the appointment, and if needed, directions. The clinic
then follows up with the patient to confirm the appointment, and
to encourage the patient to come in to receive care. Although
San Diego has no data yet, the author states the individuals
involved are so certain the pilot project was a success that
they are extending it county-wide.
Background
Hospital EDs provide 24-hour access to emergency health
care services and, in some cases, serve as a point of entry
for inpatient hospital care. In 2009, there were 376
licensed general acute care hospitals in California with
6,636 ED treatment stations (beds). There were 11.4
million ED encounters in these hospitals in 2009, of which
1.6 million resulted in an admission to the hospital.
According to a July 2009 issue brief from the California
HealthCare Foundation (CHCF), from 2002 through 2007,
between 17 percent (in 2002) and 9 percent (in 2007) visits
to the hospital ED were for non-urgent conditions that
could be treated on an out-patient basis. In addition,
between 31 percent and 24 percent of ED visits were for
urgent conditions. Non-emergency ED visits rose by more
than 50 percent between 2002 and 2007, from 578,000 to
891,000. In 2009, the ED visits in 2009 by acuity are as
follows:
Emergency Department Visits in 2009 by Acuity
---------------------------------------------------------------
|Patient Level* | ED |Percentag| EMS |Admission |
| | Visits | e of | Visits |Percentage|
| | | Total |Resulting | by |
| | | | in | Acuity |
| | | |Admission,| Level |
| | | | by | |
| | | | Acuity | |
|----------------------+--------+---------+----------+----------|
|Minor EMS Visits |871,973 | 7.6%| 21,799 | 2.5%|
| | | | | |
|----------------------+--------+---------+----------+----------|
|Low/Moderate EMS |2,307,35| 20.2%| 28,771 |1.2% |
|Visits | 2 | | | |
|----------------------+--------+---------+----------+----------|
|Moderate EMS Visits |4,050,85| 35.4%| 184,593 | 4.6%|
| | 5 | | | |
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|----------------------+--------+---------+----------+----------|
|Severe w/o threat EMS |2,604,29| 22.8%| 563,042 | 21.6%|
|Visits | 2 | | | |
|----------------------+--------+---------+----------+----------|
|Severe w/ threat EMS |1,464,23| 12.8%| 835,915 | 57.1%|
|Visits | 6 | | | |
|----------------------+--------+---------+----------+----------|
|Unspecified Acuity |144,487 | 1.3%| 0 | 0.00%|
|Levels | | | | |
|----------------------+--------+---------+----------+----------|
|Total EMS Visits |11,443,1| 100.00%|1,634,120 | |
| | 95 | | | |
---------------------------------------------------------------
*Excludes patients who left without being seen.
In 2007, Medi-Cal patients accounted for 24 percent of ED
visits, self-pay payments accounted for 16 percent, 34
percent of visits were from private insured patients, and
19 percent were Medicare patients.
Patients seek care in the hospital ED for several reasons.
According to a CHCF-funded study in October 2006, the factors
that trigger ED use that may prevent patients from obtaining
care from their regular physician or other sources include:
� Lack of access to medical care outside the ED (such as
same-day appointments with a primary care physician, or
evening and weekend appointments);
� Lack of advice on how to handle sudden medical problems;
� Lack of alternatives to the ED (such as nurse advice
lines or urgent care clinics); and
� Positive attitudes about the ED as a site of care.
When patients use the ED for non-urgent conditions, it
contributes to ED overcrowding by requiring ED personnel to
screen and treat patients who could have been seen in
locations other than the ED. This can result in patients
leaving the ED without being seen, and ambulances being
forced to travel greater distances when hospital
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overcrowding results in ambulances being diverted to
neighboring facilities. In addition, non-urgent care
provided in the hospital ED is more expensive than care in
a physician's office. A Legislative Analyst Office (LAO)
analysis of the 2006-07 Budget Act stated that where
Medi-Cal patients receive their health care services can
have significant fiscal ramifications for the state
because, in many cases, Medi-Cal pays different rates for
the same medical procedure depending on the setting in
which that service is provided. The LAO stated, as an
example, Medi-Cal payment rates for many procedures are 24
percent higher when the procedure is performed in an ED
rather than a physician's office, and Medi-Cal must
typically also pay a facility charge for care obtained in
an ED, in addition to the payment for the health care
practitioner's services.
In San Diego, several hospitals with EDs participate in a
program where the hospitals are linked electronically with
clinics so that patients lacking their own doctors can move
seamlessly from the hospitals' ED into the clinic system
for follow-up care. In participating hospitals and
clinics, when insured patients are treated and discharged
from the ED, an electronic patient charting system
automatically refers them to their regular primary care
doctor. If a patient is uninsured and lacks a regular
doctor, the system routes him or her to a local clinic,
where the patient is contacted by the clinic's staff for a
follow-up appointment. At one San Diego clinic, an
electronic system installed in 2007 resulted in clinic
referrals increasing from 75 a month to more than 1,000.
According to the clinic CEO, about 30 percent of those
referrals are actually seen at the clinics, while the
remaining patients do not show up for additional care.
Health Affairs study
A September 2010 study in the health policy journal Health
Affairs entitled "Many ED Visits Could Be Managed at Urgent
Care Centers and Retail Clinics" states that Americans seek
a large amount of non-emergency care in EDs, where they
often encounter long waits to be seen. Urgent care centers
and retail clinics have emerged as alternatives to the ED
for non-emergency care. The study's authors estimate that
13.7 to 27.1 percent of all ED visits could take place at
one of these alternative sites, with a potential cost
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savings of approximately $4.4 billion annually. The
primary conditions that could be treated at these sites
include minor acute illnesses, strains, and fractures. The
authors of the study state there is some evidence that
patients can safely direct themselves to these alternative
sites. However, more research is needed to ensure that
care of equivalent quality is provided at urgent care
centers and retail clinics compared to EDs.
Related bills
AB 97 (Committee on Budget), Chapter 3, Statutes of 2011,
the heath budget trailer bill of 2011, contained a number
of provisions that will affect utilization of health care
services and hospital EDs by Medi-Cal beneficiaries. AB 97
limits the total number of physician office and clinic
visits for physician services provided by a physician to
seven visits per beneficiary per fiscal year, unless there
is a physician's certification. The physician's
certification must specify that the services will prevent
deterioration in a beneficiary's condition that would
otherwise foreseeably result in admission to the ED, or
that the services will prevent deterioration in the
beneficiary's condition that will otherwise result in an
inpatient admission. In addition, AB 97 increased
co-payments for Medi-Cal services, including establishing a
co-payment of up to $50 for outpatient emergency room
services, subject to federal law.
Prior legislation
AB 1076 (Jones) of 2009 would have required DHCS to expand
the Medical Case Management (MCM) Program to include
Medi-Cal beneficiaries who have two or more chronic
conditions and have used the hospital ED four or more times
in the previous twelve months. AB 1076 also specified the
type of services which must be included in case management
services. In addition, AB 1076 would have required the
Medi-Cal disease management benefit to include the
designation of a primary care provider as a patient's
medical home. AB 1076 was gutted and amended and used for
a non-health purpose.
SB 1738 (Steinberg) of 2008 would have required DHCS, by
July 1, 2009, to establish, in consultation with specified
stakeholders, the Frequent Users of Health Care Pilot
Program. This bill was vetoed by Governor Schwarzenegger
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who stated that he could not sign the bill in the current
fiscal environment, but noted that he supported the
concepts, in particular, a statewide proposal promoting
primary care and comprehensive coordinated care management.
Arguments in support
The California Hospital Association (CHA) states that
one-third of patient visits to ED are non-urgent. CHA
cites a recent national report that found that ED capacity
is strained, with almost all EDs report rising volumes due
to inadequate access to primary care among the insured and
uninsured, rising numbers of uninsured, and the growing
inability of patients to afford out-of- pocket costs
(co-payments and deductibles), among other factors. CHA
states that many ED patients are unaware of non-ED options
for their non-urgent care, and argues that connecting
patients with options for non-urgent care will help them
find a medical home and lessen their reliance on ED care.
COMMENTS
1. Discouraging inappropriate use of the hospital ED. How
to discourage inappropriate ED usage is a long-standing
concern of policymakers and third party payors. To
discourage inappropriate ED use, third-party payors and
Medicaid programs have tried multiple strategies, including
requiring higher cost-sharing (co-payments and deductibles)
for the non-urgent use of the hospital ED, providing
extended urgent care and clinics hours, providing intensive
case management services to frequent users of hospital EDs
for patients who have multiple chronic conditions, and
providing written notices to patients who have used the ED
for non-urgent services that inform patients of the
availability of primary care services. The pilot program
established by this bill would emphasize patient education,
by furnishing information to patients upon discharge about
available and accessible non-emergency outpatient services.
2. DHCS involvement in pilot program. This bill
establishes a two geographic location pilot program to
facilitate collaboration between providers and hospitals to
provide a Medi-Cal beneficiary or an uninsured patient with
an alternative to the use of hospital EDs if the individual
does not have an emergency medical condition. Establishing
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this bill through Medi-Cal within DHCS will likely require
DHCS to seek a federal waiver to operate such a program
within a limited part of the state because of the federal
"statewideness" requirement. An alternative approach to
having this bill established in Medi-Cal law under DHCS
that may not require federal approval is to instead make
the pilot program a regulatory requirement within the
state's health facility licensing laws (which are enforced
by the Department of Public Health). Federal approval may
not be required because the proposed pilot program is not
extending Medi-Cal coverage to a new population or enhanced
Medi-Cal payments to providers participating in the
program.
3. Definition of available and accessible provider of
non-emergency medical care.
This bill defines "an available and accessible provider of
non-emergency medical
care" to include the office of a physician, health clinic,
community health center, and hospital outpatient
department, provided that the provider of non-emergency
medical care is able to diagnose or treat contemporaneously
within the same amount of time that a physician within the
ED of a hospital would have taken to provide the same
non-emergency services. It is not clear that outpatient
providers would be able to meet the standard in this bill
of being able to "diagnose or treat contemporaneously
within the same amount of time that a physician within the
emergency unit of a hospital would have taken to provide
the same non-emergency services," or whether this standard
should apply to providers treating patients who do not have
an emergency medical condition.
POSITIONS
Support: California Hospital Association
Oppose: None on file.
-- END --
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