BILL ANALYSIS Ó
AB 2325
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Date of Hearing: May 7, 2014
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
AB 2325 (John A. Perez) - As Introduced: February 21, 2014
Policy Committee: HealthVote:13-6
PERSS Vote: 5-1
Urgency: No State Mandated Local Program:
No Reimbursable: No
SUMMARY
This bill establishes the Medi-Cal Patient Centered
Communication (CommuniCal) program at the Department of Health
Care Services (DHCS) to provide and reimburse for certified
medical interpretation services to limited English proficient
(LEP) Medi-Cal enrollees. Establishes a certification process
and registry of CommuniCal certified medical interpreters (CCMI)
at the California Department of Human Resources (CalHR) and
grants CCMI collective bargaining rights with the state.
Specifically, this bill:
1)Requires CommuniCal to offer medical interpreter services
beginning July 1, 2014 and permits providers and health plans
to utilize CommuniCal to provide medical interpreter services
to Medi-Cal beneficiaries, as specified.
2)Requires DHCS to pursue federal funding and seek any necessary
federal approvals.
3)Requires CommuniCal to include in-person, telephonic, and
video medical interpretation services, with in-person
designated as the preferred mode whenever possible, as
specified.
4)Requires DHCS to create and administer a competitive Request
for Proposal (RFP) and to execute a contract for CommuniCal to
be administered by a patient-centered communication broker, as
specified.
5)Includes, among the CCMI certification requirements, an exam
to be administered by a nonprofit organization selected by
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CalHR. Requires CalHR to select an examination for
Spanish-language medical interpretation within 120 days of
this bill's implementation and provides a process by which
testing, training, and experience standards for interpreters
of other languages can be assessed so that interpreters of
those languages may be placed on the registry.
6)Grants CCMIs the right to form, join, and participate in the
activities of a labor organization of their own choosing for
collective bargaining with the state on matters of mutual
concern, as specified, and requires the Public Employment
Relations Board (PERB), to certify a labor organization and
undertake related activities if specified requirements are
met. Provides CCMIs are not public employees.
FISCAL EFFECT
1)One-time administrative costs in the range of $1 million
(GF/federal) to DHCS to seek federal approvals, create system
protocols, develop an IT infrastructure, design communications
and guidance, promulgate regulations, and other initial
program development activities.
2)An exact estimate of the cost of language services is
difficult given a lack of accurate projections about how, by
whom, and with what frequency a centralized system would be
used. Assuming 1.5 million LEP individuals receive one
additional office visit annually with interpretive services
provided through this program at a cost of $20 per visit,
additional costs would be about $30 million annually. This
overall cost increase would be experienced as direct costs in
the case of fee-for-service Medi-Cal, and cost pressure on
rates in the case of Medi-Cal managed care. The majority of
enrollees are now in managed care plans.
3)Medi-Cal costs would be at a 50% GF, 50% federal funds
matching rate except for:
a) Costs associated with services used by children, subject
to federal approval. Pursuant to the Children's Health
Insurance Program Reauthorization Act of 2010 (CHIPRA) and
subsequent federal guidance, language services for children
can be claimed at a 25% GF, 75% federal funds matching
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rate.
b) Costs associated with individuals found newly eligible
for Medi-Cal pursuant to the expansion related to the
Patient Protection and Affordable Care Act and subsequent
2013 state legislation, which expanded Medi-Cal to
childless adults. Costs for these individuals are funded
at a rate of 100% federal funds until 2017, after which the
federal matching rate gradually decreases to 90% for 2020
and beyond.
1)Improved access to high-quality interpretive services is
likely to improve access to care and increase overall medical
costs to the Medi-Cal program for LEP beneficiaries. It would
also likely result in some offsetting cost savings associated
with the provision of higher-quality care and fewer medical
errors. The magnitude of savings as compared to costs is
unknown, but evidence suggests that, on balance, the Medi-Cal
program would experience increased medical costs if
centralized, high-quality interpretive services were
available.
2)Potential one-time GF costs of $140,000 and ongoing annual
costs of $50,000 per year to PERB.
3)Periodic GF costs up to $1 million for negotiating a
memorandum of understanding with the established bargaining
unit and overseeing the implementation by CalHR.
COMMENTS
1)Rationale . Various federal and state laws require health
providers and health plans receiving federal funding to
provide interpreter services to patients. Despite these
requirements in law, there are indications not all Medi-Cal
beneficiaries receive care in a linguistically appropriate
manner. The author notes, "Language barriers can contribute to
inadequate patient evaluation and diagnosis, lack of
appropriate and/or timely treatment or other medical errors
than can jeopardize patient safety." Enhanced federal
funding opportunities allow California to develop a more
comprehensive language assistance program.
2)Background . It is well-documented that limited proficiency in
English is a risk factor for reduced access to health
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services, decreased satisfaction with care, poor understanding
of instructions, longer hospital stays, and increased risk of
medical errors and misdiagnoses. A recent study found LEP
hospital patients are more likely than their English-speaking
counterparts to experience adverse events that result in harm,
and the severity of that harm is often greater.
Title VI of the federal Civil Rights Act of 1964 requires that
any health care provider accepting federal funds must provide
linguistically accessible services to all patients. Linguistic
accessibility standards have been upheld and further clarified
through a number of related court decisions, regulations,
guidance, and executive orders. However, these standards
appear flexible and do not appear adequate to ensure
high-quality services are available everywhere. For example,
HHS guidance indicates smaller recipients with more limited
budgets are not expected to provide the same level of language
services as larger recipients with larger budgets. The
provision of language services in current practice appears to
be highly variable across the state, varying based on the
proportion of LEP persons served, health care
provider/facility priorities, and available resources.
This bill intends to establish medical interpreter services as
a separate program that would be made uniformly available to
all LEP Medi-Cal beneficiaries.
3)Prior legislation .
a) AB 1263 (John A. Pérez) of 2013 and AB 2392 (John A.
Pérez) of 2012 were similar to this bill. AB 2392 passed
both houses of the legislature but was not taken up for
concurrence in the Assembly. AB 1263 was vetoed by the
governor, citing his concern about introducing yet another
complex element as the state embarks on an unprecedented
expansion of Medi-Cal.
b) AB 505 (Nazarian) codifies existing Medi-Cal MCP
requirements to provide language assistance, translation,
and interpretation services when populations reach
specified thresholds. AB 505 is on the Senate Inactive
File.
c) SB 853 (Escutia), Chapter 713, Statutes of 2003,
requires the Department of Managed Health Care and the
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California Department of Insurance to adopt regulations to
ensure enrollees have access to language assistance in
obtaining health care services.
1)Staff Comments .
a) Potential Cost Shift . The program envisioned in this
bill may increase the availability and improve the quality
of language services to Medi-Cal enrollees, but it also
would encourage a significant cost shift from private
providers, who are currently required to provide these
services under federal law and/or managed care plan
contracts. In addition, some of the providers that do
offer quality interpretive services already receive
indirect reimbursement for these services. For example,
public hospitals have well-established interpretive
networks. These hospitals have unique funding arrangements
whereby they do not receive direct reimbursement from the
state, but instead certify their own expenditures for
language services as eligible for federal matching dollars.
Many federally qualified health centers (FQHCs) also
provide interpretive services, and receive reimbursement
for these services as part of an all-inclusive per-visit
rate that is based on the FQHC's total costs.
b) Increased Access = More Medical Costs . Increasing access
to high-quality language services in the Medi-Cal program
would likely reduce health disparities, improve LEP patient
satisfaction, improve the quality of care provided to LEP
patients, and increase the use of preventative care.
However, it is also likely to increase total medical
expenditures for LEP patients.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081