BILL ANALYSIS Ó
AB 1771
Page 1
Date of Hearing: April 29, 2014
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1771 (V. Manuel Pérez) - As Amended: March 11, 2014
SUBJECT : Telephonic and electronic patient management services.
SUMMARY : Requires health plans and insurers to cover physician
telephonic and electronic patient management services and to
reimburse the services at the same level as face-to-face patient
encounters, as specified. Specifically, this bill :
1)Requires health plans and insurers, in health coverage issued,
amended or renewed on or after January 1, 2015, to,
notwithstanding any other law, cover physician telephonic and
electronic patient management services and to reimburse the
services at the same level and amount as face-to-face patient
encounters with similar complexity and time expenditure.
2)Defines "telephonic and electronic patient management
services" to mean the use of electronic communication tools,
such as the telephone and electronic mail, to enable treating
physicians to evaluate and manage existing patients in a
manger recognized by the American Medical Association (AMA),
Current Procedural Terminology (CPT) codes.
3)Specifies that this bill not be construed to alter the scope
of practice of a health care provider or authorize the
delivery of services in a setting or manner not otherwise
authorized by law, or to authorize a health plan or insurer to
require the use of telephonic and electronic patient
management services when the physician determines those
services are not medically appropriate.
4)Applies all laws regarding the confidentiality of health
information and a patient's rights to his or her medical
information to telephonic and electronic patient management
services.
5)Exempts from this bill patients under the jurisdiction of the
Department of Corrections and Rehabilitation.
6)Makes legislative findings regarding the lack of primary and
specialty care physicians and declares that telephonic and
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electronic patient management is an effective strategy to
address the shortage which will benefit consumers in many
ways, as specified.
EXISTING LAW :
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans and the California Department of
Insurance (CDI) to regulate health insurers.
2)Prohibits a health plan or insurer from requiring in-person
contact between a health care provider and patient before
payment is made for covered services appropriately provided
through telehealth.
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. Telehealth facilitates patient self-management and
caregiver support for patients and includes synchronous
interactions and asynchronous store and forward transfers.
4)Defines "synchronous interaction" as a real-time interaction
between a patient and a health care provider located at a
distant site and defines "asynchronous store and forward" as
the transmission of a patient's medical information from an
originating site to the health care provider at a distant site
without the presence of the patient.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
necessary because even though physicians can bill for
telephone and online evaluations, payer policies differ, with
some reimbursing for the services while others deny payment.
The author views providing coverage for these services as an
effective strategy to address access to care issues, and
increase efficiency and productivity through the reduction of
unnecessary office visits, allowing physicians to treat more
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patients.
2)BACKGROUND .
a) California Health Benefits Review Program. The
California Health Benefits Review Program (CHBRP) reviewed
this bill at the request of this Committee. CHBRP found
that the requirements in this bill do not represent a
mandate above essential health benefits (EHBs) because EHBs
already require coverage for physician services and would,
therefore, not require the state to defray the costs of
this mandate for enrollees in the exchange.
Existing California law recognizes two forms of telehealth:
live videoconference and "store-and-forward," that capture
medical information (e.g. photo, recording) and
transmission of that information to physicians for review
later. Current California law does not require coverage or
specify a level of reimbursement for live videoconference
or store-and-forward. CHBRP interpreted this bill to
require reimbursement for all telehealth modalities defined
in current law as well as those being added by this bill,
and therefore, analyzed the impact of mandated
reimbursement for four modalities: telephone, e-mail, live
videoconference, and store-and-forward. CHBRP limits
analysis of services delivered via telephone and e-mail
where an established patient first contacted the physician.
According to CHBRP, this bill would make California the first
state in the country to require health insurance carriers
to cover and reimburse physicians for patient-initiated
evaluation and management (E/M) via telephone and e-mail.
The key findings of the CHBRP report are as follows:
i) Medical effectiveness. Advances in technology
have been outpacing the publication of studies on these
technologies, limiting the research literature on
telephone, e-mail, live videoconference, and
store-and-forward.
ii) Telephone and e-mail. There is insufficient
evidence to determine whether E/M services provided via
telephone or e-mail are as effective as medical care
provided in-person.
iii) Live videoconference and store-and-forward. For
the diseases and conditions studied, the evidence
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suggests that medical care provided by live
videoconferencing and store-and-forward is at least as
effective as medical care provided in person.
iv) Benefit coverage. Approximately 49% of
California's 23.4 million enrollees with
state-regulated health insurance currently have some
form of benefit coverage for telephone and e-mail
patient management; 79% of enrollees currently have
some form of benefit coverage for live videoconference
and store-and-forward technology.
v) Capacity and access. CHBRP estimates that this
bill would result in an overall increase of between
2.3% and 9.9% physician encounters, which includes both
in-person, and telephonic or electronic visits.
vi) Utilization -Telephonic and electronic visits.
CHBRP estimates that between 6.2% and 25.1% of all E/M
visits would occur using telephone, e-mail, live
videoconference, or store-and-forward.
vii) Impact on expenditures. CHBRP estimates this
bill would increase overall health expenditures -
premiums and out-of-pocket expenses - by between $55.3
million and $240.7 million.
(1) Premium per member per month (PM/PM) impact.
CHBRP estimates premium increases to range from $0.19
PM/PM to $0.81 PM/PM for DMHC-regulated plans in the
large-group market, depending on the rate of adoption
and $0.49 PM/PM to $2.13 PM/PM for CDI-regulated
policies in the small-group and individual markets,
depending on the rate of adoption.
(2) Financial burden of copayments for telephonic
and electronic visits for enrollees. CHBRP assumes a
$20 copayment for telephone, e-mail, live
videoconference, or store-and-forward visits, thereby
increasing enrollees' overall out-of-pocket expenses
by between $9.4 million and $41.3 million collectively
for additional visits.
viii) Patient experience. If enacted, CHBRP predicts
that patient experience would improve as physicians
increase e-mail and telephone responses to patient
inquiries, increased convenience, and reduce or
eliminate travel times to in-person visits.
ix) Long-term impacts. Technology will continue to
drive changes in telehealth. Electronic health records,
online patient portals, and increased use of smart
phones, will increase demand for these types of
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services.
CHBRP found limited evidence that this bill would
increase the capacity of physicians to see additional
patients because this bill: (1) limits coverage and
reimbursement to encounters with "similar complexity
and time expenditure." Based on this language, CHBRP
assumed that most visits that occur via telephone,
e-mail, live videoconference, or store-and-forward
would be displacing (supplanting) a similarly timed
in-person visit, thereby having a limited impact on
capacity, and therefore access; and, (2) limits
coverage and reimbursement to physicians, and does not
include nonphysicians who are part of a practice. CHBRP
assumes that physicians' personal bandwidth to respond
using any of the telehealth modalities is also limited
and that newly covered telehealth visits under this
bill would fall into two categories: (1) substitute (or
replace) current in-person visits with e-mail,
telephone, live videoconference, or store-and-forward
for patient-initiated evaluation and management
encounters; and, (2) supplement current in-person
visits with added services via telehealth, and include
both services that would previously not have been
delivered in person due to distance, inconvenience, and
time, and services that physicians have already been
providing via telephone and e-mail, but were previously
not billed or reimbursed because they were not covered.
Because this bill constrains the covered evaluation
and management services to those that are
physician-provided only, CHBRP assumed that the
capacity to add supplemental services is limited based
on each physician's capacity.
b) CPT Codes. Physicians are reimbursed for their
professional services through the use of standardized
billing codes, CPT. The CPT code set is a medical code set
maintained by the AMA through the CPT Editorial Panel
(copyright protected by the AMA), which describes medical,
surgical, and diagnostic services, and is designed to
communicate uniform information about medical services and
procedures among physicians, coders, patients,
accreditation organizations, and payers for administrative,
financial, and analytical purposes. This bill requires
coverage of telephonic and electronic services used to
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evaluate and manage existing patients (which includes
e-mail, store-and-forward, and live videoconferencing).
According to CHBRP, this bill targets non face-to-face CPT
codes 99441-99443 for telephone services and 99444 for
electronic mail, and a number of in-person E/M codes that
can be further defined by modifier codes GT (for
interactive audio and video telecommunications systems
[live videoconferencing]) and GQ (for asynchronous
telecommunications system such as store-and-forward
technology). With a few exceptions, the federal Centers
for Medicare and Medicaid (CMS) does not reimburse for
telephone and e-mail communications; most commercial
insurance carriers follow CMS reimbursement decisions.
Therefore, most physicians are not currently reimbursed for
services they provide by e-mail and telephone, and to a
lesser extent for other electronic services. CHBRP
concluded that the utilization of telehealth, specifically
email and telephone, is difficult to ascertain, in part
because of the lack of reimbursement that would document
the frequency of services.
3)SUPPORT . California Medical Association (CMA), sponsor of
this bill, writes that inconsistent policies among health
plans and insurers in their willingness to reimburse for the
services covered by this bill deprive patients of a reasonable
alternative to face-to-face physician evaluations. CMA states
that telephonic and electronic patient management services can
include contacting consultants, sending orders to labs or
X-rays, transmitting emails and prescriptions, answering quick
medical questions, monitoring patients with chronic
conditions, and returning patient calls to confirm or adjust
treatment plans. According to CMA, such services facilitate
the diagnosis, consultation, treatment, education, care
management and self-management of the patient's health as well
as providing caregiver support. California Chapter of the
American College of Emergency Physicians supports this bill as
an important measure to strengthen access-to-care and points
out that without adequate reimbursement for physicians for
these innovative treatment methods, the services will not be
available to patients. California Academy of Family
Physicians state that when doctors are able to answer patient
questions over the phone or electronically it improves the
patient experience, reducing unneeded office visits and wait
times, increasing the capacity of doctors to see more
patients. California Primary Care Association (CPCA) and
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Planned Parenthood Affiliates of California support this bill
as a way to support member clinic efforts to better serve
patients through the development and expansion of telehealth
capabilities, especially in underserved and remote rural
areas. CPCA states that maximizing the efficient use of
physician time is especially important since only 16 of
California's 58 counties have the federal government's
recommended supply of primary care providers.
4)OPPOSITION . Health plans and insurers oppose this bill
because they are concerned that the mandated reimbursement
will dramatically and significantly increase the costs of
coverage and reimburse physicians for a basic and fundamental
communication tool that every provider should be using
regardless of coverage or reimbursement status. Health plans
acknowledge telemedicine as a resource that plays a critical
role in providing access to patients in key areas such
dermatology, radiology, behavioral health and ophthalmology,
especially in underserved areas of the state. However, health
plans are concerned that this bill would establish a much more
general definition of telehealth and could double or triple
the reimbursement to providers with no demonstrated increase
in access or quality of care. Local Health Plans of
California also point out that this bill does not recognize or
address the situation where providers are paid through
negotiated, capitated contracts and not on a fee-for-service
basis. America's Health Insurance Plan opposes this bill and
states that reimbursing providers for each and every service
provided to a patient including phone calls and e-mails will
subject patients to multiple copayments and other cost sharing
responsibilities for every such encounter. Health plans and
insurers are also concerned about the requirement in this bill
that emails and telephone calls be reimbursed at the same
level as face-to-face visits and sets potentially vague and
subjective standards, including "similar complexity and time
expenditure." Association of California Life and Health
Insurance Companies points out that it is difficult to
envision an email or telephone conversation that would be of
similar complexity and time expenditure as an in-person
physical examination. California Chamber of Commerce opposes
this bill stating that it will add new costs for services
already being provided, driving up costs and health insurance
premiums, along with consumer cost sharing charges, just for
patients to be able to communicate with their doctors.
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5)RELATED LEGISLATION . AB 2484 (Gordon) allows a health care
provider to obtain written consent from the patient, as an
option in addition to verbal consent, before telehealth may be
used and requires that written consent to be documented in the
patient's medical record. AB 2484 is currently before the
Assembly Business, Professions and Consumer Protection and is
double-referred to Assembly Health Committee.
6)PREVIOUS LEGISLATION .
a) AB 318 (Logue) of 2013 would have provided that, to the
extent federal financial participation is available,
face-to-face contact between a health care provider and a
patient shall not be required under the Medi-Cal program
for teledentistry by store and forward. AB 318 was never
heard and died in the Assembly Health Committee.
b) AB 809 (Logue) of 2013 would have allowed the verbal
consent for the use of telehealth to apply in the present
instance and for any subsequent use of telehealth and
require the health care provider initiating the use of
telehealth at the originating site to obtain verbal or
written consent from the patient for the use of telehealth,
as specified, and document the consent in the patient's
medical record, as specified. AB 809 died in the Senate
Health Committee.
c) AB 1174 (Bocanegra and Logue) of 2013 would have
provided face-to-face contact between a health care
provider and a patient is not required under the Medi-Cal
program for teledentistry by store and forward, as defined.
AB 1174 died in the Senate Business, Professions and
Economic Development.
d) AB 1231 (V. Manuel Pérez) of 2013 would have required
the state Department of Developmental Services to inform
all regional centers that any appropriate health care
service and dentistry for consumers of regional center
services may be provided through the use of telehealth, as
defined. AB 1231 passed the Legislature and was vetoed by
the Governor.
e) AB 1733 (Logue), Chapter 782, Statutes of 2012, updates
several code sections to replace the term "telemedicine"
with "telehealth" and expands the potential for the use of
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telehealth in additional health care programs administered
by the Department of Health Care Services and amends
licensed professional clinical counselor licensing laws to
subject practitioners to telehealth requirements and
definitions.
f) AB 415 (Monning), Chapter 547, Statutes of 2011
establishes the Telehealth Advancement Act of 2011 to
facilitate the advancement of telehealth as a service
delivery mode in managed care and the Medi-Cal program and,
among other things, prohibits health plans and insurers
from requiring in-person contact of from limiting the type
of setting for covered services appropriately provided
through telehealth, as specified.
7)POLICY COMMENT. By reimbursing physicians for communications
with patients, this bill also creates the opportunity for
health plans and insurers to impose consumer cost sharing in
the form of copayments or coinsurance for services patients
may already be getting in the patient-physician relationship.
Since patients must initiate the communication for the
physician to be reimbursed, depending on how this new
requirement is implemented, patients may limit reaching out to
their doctors to avoid incurring the cost sharing potentially
associated with the communications. If that occurs, this bill
could actually reduce the level of communication between some
patients and their doctors.
8)RECOMMENDED AMENDMENT . This bill would require coverage for
email and telephone patient management, "notwithstanding any
other provision of law." It is not possible to evaluate the
impact of this broad and all-encompassing language. Given the
robust and detailed statutory framework for health coverage in
state and federal law, including extensive consumer
protections, this language could result in unintended
consequences, legal conflicts and lack of clarity on the
context for these benefits. This language should be deleted
from this bill.
9)AUTHOR'S AMENDMENTS . The author intends to offer amendments
in Committee to clarify the intent of this bill as follows:
a) Remove the findings and declarations, including
references to the existing broad statutory definition of
telehealth;
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b) Narrow the definition of telephonic and electronic
patient management services that must be reimbursed under
this bill to "non-face-to-face telephone services and
online medical evaluation as recognized by the AMA CPT
codes;" and,
c) Delete the requirement that reimbursement for services
under this bill be "at the same level and amount as
face-to-face patient encounters" and instead require that
reimbursement for the services be "based on their
complexity and time expenditure."
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Association (sponsor)
California Academy of Family Physicians
California Chapter of the American College of Emergency
Physicians
California Primary Care Association
Osteopathic Physicians and Surgeons of California
Planned Parenthood Affiliates of California
Opposition
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Chamber of Commerce
California Association of Health Plans
Local Health Plans of California
Analysis Prepared by : Deborah Kelch / HEALTH / (916) 319-2097