BILL ANALYSIS �
SB 1004
Page 1
Date of Hearing: June 17, 2014
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 1004 (Ed Hernandez) - As Amended: May 5, 2014
SENATE VOTE : 34-0
SUBJECT : Health care: palliative care.
SUMMARY : Requires the Department of Health Care Services (DHCS)
to request a federal Medicaid waiver to conduct a pilot project
and evaluate whether an adult palliative care benefit should be
offered in the Medi-Cal program. Specifically, this bill :
1)Requires DHCS to develop, as a pilot project for providing a
palliative care benefit to evaluate if such a benefit should
be offered in the Medi-Cal program. Requires the pilot
project to be implemented only to the extent that federal
financial participation is available.
2)Limits the pilot project to beneficiaries 21 years of age or
older, and authorizes DHCS to restrict participation in the
pilot project to a population sufficient to evaluate the
project.
3)Requires services covered under the palliative care benefit to
include those types of services that are available through the
Medi-Cal hospice benefit, and also include:
a) Hospice services that are provided at the same time that
curative treatment is available, to the extent that the
services are not duplicative;
b) Hospice services provided to individuals whose
conditions may result in death, regardless of the estimated
length of the individuals remaining period of life; and,
c) Any other services that DHCS determines to be
appropriate.
4)Requires DHCS to develop the pilot project in consultation
with interested stakeholders and determine the medical
conditions and prognoses that render a beneficiary eligible
for the benefit.
5)Requires the pilot project to include licensed hospice
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agencies and home health agencies licensed to provide hospice
care, subject to criteria developed by DHCS for provider
participation.
6)Requires DHCS within 12 months after the effective date of
this bill to submit an application to the federal Centers for
Medicaid and Medicare Services (CMS) for a waiver to implement
the pilot. Requires DHCS to implement the waiver within 12
months of the date of approval by CMS.
7)Requires the palliative care benefit in the pilot project to
be evaluated for medical necessity and cost-effectiveness and
requires the results be shared with the Legislature and
appropriate policy and fiscal committees to determine
effectiveness of the benefit.
8)Authorizes DHCS to implement the waiver by provider bulletin
and to notify the Legislature when the provider bulletin is to
be released.
9)Prohibits the provisions of this bill from resulting in
eliminating or reducing any covered benefits or services under
the Medi-Cal program, or affecting the ability of an
individual to concurrently receive any services the individual
is otherwise eligible to receive.
EXISTING LAW :
1)Establishes the Medi-Cal program, administered by DHCS, under
which low income individuals are eligible for medical
coverage.
2)Requires DHCS, in consultation with interested stakeholders, to
develop a pediatric palliative care pilot project to evaluate
whether and to what extent Medi-Cal beneficiaries under age 21
should be offered a pediatric palliative care benefit.
3)Establishes requirements for licensure as hospice, including that
the licensee provides the skilled nursing services, social
services/counseling services, medical direction, bereavement
services, volunteer services, inpatient care arrangements; and
home health aide services.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
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1)Likely costs of about $900,000 over two years to design the pilot
project and negotiate a waiver with the federal government
(General Fund and federal funds). Based on the workload to
engage with stakeholders, design the pilot project, and
negotiate an agreement with the federal government, staff
estimates that DHCS would need about three additional staff
positions for one to two years.
2)One-time costs, likely in the range of $150,000 to $300,000 to
conduct an evaluation of the pilot project once enough data
has been collected (General Fund and federal funds).
3)Unknown potential for cost savings from the pilot project
(General Fund and federal funds). The state created a pilot
project for pediatric palliative care in the Medi-Cal program
from 2009 to 2012. According to a preliminary analysis of the
pilot project, total spending for participants was about
$1,700 per month less than it would have been under standard
Medi-Cal pediatric benefits. Similarly, an analysis of a
pilot project to provide adult palliative care benefits in New
York State indicated that hospitalization costs were
substantially reduced for program participants.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, an abundance
of recent evidence suggests that an expansion of patient and
family centered palliative care has the potential to change
health outcomes for many Californians, while reducing costs
associated with inpatient care. Palliative care is designed
to better address patient preferences for patients facing
advanced illness. California has already demonstrated success
in Medi-Cal with pediatric palliative care where a preliminary
analysis indicates that the program improves quality of life
for the child and family, average days in the hospital fell by
one-third, and shifting care from the hospital to in-home
community based care resulted in cost savings of $1,677 per
child per month on average. With palliative care, patients
can live longer with a higher quality of life and fewer
hospitalizations. Establishing a Medi-Cal palliative care
program for patients with serious advanced illness is good
policy and promotes better health outcomes for patients with a
serious illness.
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2)BACKGROUND . Palliative care is specialized medical care for
people with serious illnesses. It is intended to provide
patients with relief from the symptoms, pain, and stress of a
serious illness. The goal is to improve quality of life for
both the patient and the family. Palliative care is provided
by a team of doctors, nurses, and other specialists who work
together with a patient's other doctors to provide an extra
layer of support. It is appropriate at any age and at any
stage in a serious illness and can be provided along with
curative treatment.
California was one of the first states to respond to the need
for comprehensive pediatric palliative care. Under the Nick
Snow Children's Hospice and Palliative Care Act of 2006,
established by AB 1745 (Chan), Chapter 330, Statutes of 2006,
eligible children receive in-home coordinated family-centered
care including pain and symptom management, access to a 24/7
nurse line, family education, respite care, expressive
therapies and family counseling. Eleven counties have been
part of the pilot: Monterey, San Diego, Santa Clara, Santa
Cruz, Marin, Alameda, Orange, San Francisco, Sonoma, Los
Angeles, and Fresno.
According to DHCS, this pilot was authorized under a 1915(c)
Home and Community Based Waiver, which originally ran from
April 2009 through March 2012. The waiver has been renewed
through March 2017. Since its inception 206 patients ages one
through 20 have been enrolled for an average of approximately
12 months. To be eligible, patients must face a life-limiting
or life-threatening medical disorder.
The pilot program was subject to a preliminary evaluation in
the August 2012, UCLA Center for Health Policy Research brief,
"Better Outcomes, Lower Costs: Palliative Care Program
Reduces Stress, Costs of Care for Children with
Life-Threatening Conditions." The preliminary findings
include a one-third reduction in hospital days per child, 11%
reduction in average costs, and survey data showed that
families and providers both reported high levels of
satisfaction with the program overall and with each of the
individual services. Seventy percent of patients have been
Latino/Hispanic. The brief concludes the preliminary results
need to be viewed with caution until a full analysis at the
end of the three-year program is conducted. The final
evaluation is due this summer.
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3)EFFECTIVENESS OF PALLIATIVE CARE . According to a 2011 article
published in Health Affairs, "Palliative Care Consultation
Teams Cut Hospital Costs for Medicaid Beneficiaries," which
examined data to determine the effect on hospital costs of
palliative care team consultations for patients enrolled in
Medicaid at four New York State Hospitals, on average,
patients who received palliative care incurred $6,900 less in
hospital costs during a given admission than a matched group
of patients who received usual care. These reductions
included $4,098 in hospital costs per admission for patients
discharged alive, and $7,563 for patients who died in the
hospital. Estimates suggest New York State could reduce
Medicaid hospital spending from $250 million to $75 million
annually if every hospital with 150 or more beds had a fully
operational palliative care consultation team. This article
highlights many benefits of palliative care, including
reducing intensive care expenses and the palliative care
team's contributions toward getting post-discharge care plans
right the first time. This is key to reducing readmissions,
emergency department visits, and unnecessary inpatient and
outpatient services. An August 2010 New England Journal of
Medicine article, "Early Palliative Care for Patients with
Metastatic Non-Small-Cell Lung Cancer," found that patients
assigned to early palliative care had a better quality of life
than did patients assigned to standard care, and median
survival was longer among patients receiving early palliative
care.
4)California's State Health Care Innovation Plan. The
California Health and Human Services Agency Let's Get Healthy
California Task Force set an overall target of bringing
California's health care expenditures growth rate in line with
that of the gross state product by 2022, along with
establishing targets for 38 health indicators. The State
Health Care Innovation Plan (SHIP) provides recommendations to
meet this target. SHIP centers around four initiatives, which
focus on different aspects of the health care system that
experience particularly high costs-uncoordinated care for
people with complex chronic conditions, maternity care, end of
life care, and accountable care communities. SHIP includes a
recommendation for a palliative care initiative, together with
a Health Homes for Complex Patients Initiative, which aims to
identify patients in hospitals, long-term care facilities, or
the community, who may benefit from and desire palliative care
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services, and offer them comprehensive palliative care by
people who are trained in this area. SHIP also describes
several health plan and hospital systems working to deliver
new models of care for people near end of life. As an
example, Sharp HealthCare in San Diego has a pre-hospice
program for patients with cancer, congestive heart failure,
cirrhosis, chronic obstructive pulmonary disease, and
dementia, which has reported savings on average of $27,000 per
patient.
5)SUPPORT . The Association of Northern California Oncologists
believes this bill proposes a meaningful solution to help ease
the pain and suffering of cancer patients who are seriously
and terminally ill, and will support curative treatment
concurrently with hospice services for all eligible
beneficiaries. The Alliance of Catholic Health Care writes
that catholic hospitals are leaders in the provision of
palliative care and pain management, helping improve the
quality of life for seriously ill patients. Among several
important provisions, this bill would include hospice services
that are provided at the same time that curative treatment is
available, to the extent the services are not duplicative, and
are provided regardless of the estimated length of time a
beneficiary may be expected to live. This bill proposes a
meaningful solution to help ease the pain and suffering of
patients who are seriously and terminally ill, and will
support curative/life prolonging treatment concurrently with
hospice services for all eligible beneficiaries. The
California Hospital Association supports this bill as an
excellent opportunity to evaluate the potential benefit of
access to palliative care for Medi-Cal beneficiaries.
6)PREVIOUS LEGISLATION . SB 1745 requires DHCS to develop, as a
pilot project, a pediatric palliative care benefit covered
under Medi-Cal.
REGISTERED SUPPORT / OPPOSITION :
Support
Alliance of Catholic Health Care
American Cancer society Cancer Action Network
Association of Northern California Oncologists
California Hospice and Palliative Care Association
California Hospital Association
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Children's Hospice
Medical Oncology Association of Southern California
Providence Health & Services, Southern California and Providence
TrinityCare Hospice
Tenet Healthcare
Opposition
None on file.
Analysis Prepared by : Roger Dunstan / HEALTH / (916) 319-2097